Gastroenterology - MTB Flashcards
Dysphagia
difficulty swallowing
Odynophagia
pain while swallowing
Alarm symptoms in which endoscopy should be done
Patient complains of dysphagia w/
- weight loss
- blood in stool
- anemia
Achalasia
- inability of lower esophageal sphincter (LES) to relax due to loss of nerve plexus within lower esophagus
- aperistalsis of the esophageal body
- Young patient (under 50)
- Progressive dysphagia to BOTH solids and liquids at the SAME TIME
- No association w/ alcohol and tobacco use
Achalasia
Most accurate test for achalasia
Manometry
Achalasia: diagnostic tests
- Barrium esophagram shows “bird’s beak”
- Manometry shows failure of LES to relax
- CXR shows abnormal widening of esophagus
- Upper endoscopy shows normal mucosa in achalasia but useful to r/o malignancy
Achalasia: Treatment
- Pneumatic balloon: inflatable balloon to enlarge esophagus
- Botulinum toxin: relaxes LES but only lasts for 3-6 months
- Surgical sectioning / myotomy: can help alleviate symptoms
Esophageal Cancer
- age 50 or olrder
- dysphagia FIRST FOR SOLIDS, LATER FOR LIQUIDS
- associated w. alcohol and tobacco use
- more than 5-10 years of GERD symptoms
Best initial test for esophageal cancer
- Barium esophagram
* * but cannot diagnose cancer, need biopsy**
Most accurate test for esophageal cancer
Biopsy
** only biopsy can diagnose cancer
Esophageal Cancer: Diagnostic Tests
- Endoscopy
- Barium testing
- CT and MRI scans to determine extent of spread to surrounding tissues
- PET scan to determine content of anatomic lesions
Esophageal Cancer: Treatment
- No resection = no cure
- Chemotherapy and radiation plus surgery
- Stent placement used for nonresectable lesions to keep esophagus open for palliation
Esophageal Spasm
- sudden onset of chest pain
- precipitate by drinking cold liquids
- EKG and stress test will be normal
Most accurate test to distinguish esophageal spasm and nutcracker esophagus
Manometry
Esophageal Spasm: Treatment
- Treated w/ calcium channel blockers and nitrates (similar to Prinzmetal angina)
43 y/o M recently diagnosed w/ AIDS comes to the ED w/ pain on swallowing that has become progressively worse over the last several weeks. There is no pain when not swallowing. His CD4 count is 43 mm^3. Patient is not currently taking meds. What is the most appropriate next step?
Oral fluconazole
- infectious esophagitis likely esophageal candidias
Pills that cause esophagitis w/ prolonged contact
- Doxycycline
- Alendronate
- KCl
Schatzki ring
- often from acid reflux and associated w. hiatal hernia
- scarring or tightening of distal esophagus (peptic stricture)
- associated w/ intermittent dysphagia
- detected on barium studies
- treated with pneumatic dilitation
Plummer Vinson syndrome
- associated w/ iron deficiency anemia
- glossitis
- can rarely transform in to squamous cell cancer
- seen on barium studies
- treated w/ Fe replacement which may lead to resolution
Zenker diverticulum
- outpocketing of posterior pharyngeal constrictor muscles
- dysphagia, hallitosis, and regurgitation of food
particles - diagnosed w/ barium studies
- repaired w/ surgery
Steakhouse syndrome
- dysphagia from solid food associated with Schatzki ring
Scleroderma
- presents with symptoms of reflux and clear hx of scleroderma or systemic sclerosis
- diagnosed w/ manometry which shows DECREASED LES pressure from inability to close LES
- treat w/ PPIs
Manometry is best test for which conditions?
- Achalasia
- Spasm
- Scleroderma
Mallory Weiss tear
- presents with upper gastrointestinal bleeding after prolonged vomiting or retching
- usually followed by hematemesis of bright red blood or black stool
- no dysphagia
- no specific treatment however, if there is persistent bleeding treat w/ epinepherine injections or electrocautery
Mallory Weiss tear
nonpenetrating tear of only mucosa
44 y.o woman comes to see you b/c of pain in her epigastric area for last several months. She denies nausea, vomiting, weight loss, or blood in her stool. On physical exam, you find no abnormalities. Likely diagnosis?
Non-ulcer dyspepsia
- common cause of epigastric pain
- never admit this patient to hospital
Pt c/o of epigastric pain and states pain is worse w/ food. Likely dx?
Gastric ulcer
Pt c/o epigastric pain and states pain is better w/ food. Likely dx?
Duodenal ulcer
Pt c/o epigastric pain and reports weight loss. Likely dx?
Cancer
Gastric ulcer
Pt c/o epigastric pain and reports bast tate, cough, hoarsness Likely dx?
GERD
Pt c/o epigastric pain and reports diabetes, bloating. Likely dx?
Gastroparesis
Pt c/o epigastric pain and reports no additional symptoms? Likely dx?
Non-ulcer dyspepsia
Best test to evaluate epigastric pain
Endoscopy
Epigastric pain: treatment
PPIs
H2 blockers - 2nd line therapy, not as effective as PPIs
GERD
inappropriate relaxation of LES, resulting in acid contents of stomach coming to esopagus
- worsened by nicotine, alcohol, caffeine, chocolate, peppermint
Pt c/o epigastric burning pain radiating up into chest. He also c/o sore throat, bad taste in mouth (metallic), hoarseness, or cough.
GERD
42 y.o man comes to office w/ several weeks of epigastric pain radiating up under his chest which becomes worse after lying flat for an hour. He has a “brackish” test in his mouth and a sore throat. What’s next step?
Lansoprazole (or other PPI)
GERD: diagnosis
- primarily patient history
- if unclear, 24 hr pH monitoring
Indications for endoscopy
- Signs of obstruction (dysphagia or odynophagia)
- Weight loss
- Anemia
- 5 - 10 years of symptoms to exclude Barrett’s esophagus
GERD: Treatment
- Lose weight if obese
- Avoid alcohol, nicotine, caffeine, chocolate, peppermint
- Avoid eating at night before sleep
- Elevate head of bed for 6-8 inchest
Mild GERD: tTreatment
Liquid antacids or H2 blockers
Moderate GERD: Treatment
PPIs
- no difference in efficacy between PPIs
GERD Treatment: refractive to medical therapy
- Nissen fundiplication: wrapping stomach around LES
- Endoinch: using scope to place suture around LES to tighten it
- Local heat or radiation to LES: causes scarring
Barrett’s esophagus
- caused by longstanding GERD changes LES to columnar metaplasia
- usually occurs after 5 years of reflux
- no unique physical findings or lab test
Barrett’s esophagus: diagnosis
- Biopsy
* columnar metaplasia w/ intestinal features has greatest risk of changing to cancer
Barrett’s esophagus: treatment (alone)
PPIs and rescope every 2-3 years
Low grade dysplasia (esophagus): treatment
PPIs and rescope every 6-12 months
High grade dysplasia (esophagus): treatment
Ablation w/ endoscopy
Photodynamic therapy
Radiofreqency ablation
Endoscopic mucosal resection
Gastritis
- inflammation or erosion of gastric lining that is sometimes called gastropathy
- can be caused by:
- Alcohol, NSAIDS, H. pylori, Portal HTN, stress
Pt c/o GI bleeding without pain. Has hx of NSAID use and alcohol abuse. Likely diagnosis?
Gastritis
Rough estimations of blood loss by physical finding
- Coffee-ground emesis: 5-10 mL of bleeding
- Guaiac positive stools: 5-10 mL of bleeding
- Melena: 50-100 mL of bleeding
Gastritis: diagnosis
- upper endoscopy is best way to diagnose gastrisit
- if there is active bleeding, capsule endoscopy is not appropriate
- test for H. pylori since it is associated w/ gastritis
Most accurate test for H.pylori
Endoscopic biopsy
- but is invasive
Serology testing for H.pylori
- inexpensive and can exclude infection
- lacks specificity and positive test doesn’t differentiate between past and current infection
Urea breath testing
- positive only in active infection (noninvasive)
- requires expensive equipment in office setting
H. pylori stool antigen testing
- positive in active infection (noninvasice)
- requires stool sample
Gastritis: Treatment
- PPIs
- H2 blockers, sucralfate, and liquid antacids are not as effective as PPIs
- Sucralfate is inert substance that coats te stomach
Stress ulcer prophylaxis indications
- Mechanical ventilation
- Burns
- Head trauma
- Coagulopathy
Peptic Ulcer Disease
- refers to both duodenal and gastric ulcers
- cannot be distinguished w.out endoscopy
PUD: Etiology
- most commonly caused by H.pylori
- ## NSAIDS are second most common (bleeding > pain)
Less common causes of PUD
- Burns
- Head trauma
- Crohn disease
- Gastric cancer
- Gastrinoma (Zollinger-Ellison syndrome)
PUD: presentation
- ## recurrent episodes of epigastric pain (dull, sore, and dnawing)
Duodenal ulcer vs Gastric ulcer
- often improves with eating (“duodenal ulcer DECREASES with pain”)
- Gastric ulcer is GREATER with pain
PUD: Diagnostic Tests
- Upper endoscopy (most accurate tests)
- Upper GI series can detect ulcers but not cancer and H.pylori
PUD: Treatment
- PPIs but will recur if H.pylori is untreated
Duodenal ulcer: treatment
- must eradicate H.pylori with PPI + clarithromycin and amoxicillin
- can use metronidazole or tetracycline as alternative abc
- Retest stool antigen or breath test to confirm eradication of H.pylori
56 y.o F comes to clinic b/c her symptoms of epigastric pain from endoscopically confirmed duodenal ulcer have not responded to several weeks of PPI, clarithromycin and amoxicillin. Next step in management?
- Re-confirm presence of H.pylori
- can use urea testing, stool antigen testing, repeat endoscopy or repeat biopsy
- can switch to alternate abx such as tetracycline or metronidazole
Treatment failure of PUD stems from:
- nonadherence to meds
- alcohol
- tobacco
- NSAIDS
Diabetic Gastroparesis
- long standing diabetes leads to gastric dysmotility
- distention of stomach and intestines is most important stimulant to motility
- autonomic neuropathy leading to dysmotility bc unable to detect stretch
Diabetic pt w/ chronic abdominal discomfort, “bloating” and constipation. Anorexia, nausea, vomiting, and early satiety. Likely diagnosis?
Gastroparesis
64 y.o patient w/ diabetes for 20 years comes to office w/ several months of abdominal fullness, intermittent nausea, constipation, and sense of “bloating”. On physical exam, “splash” is heard over stomach on auscultation of stomach when moving patient. Appropriate next step?
Erythromycin (or metoclopromide) to increase gastric motlity
69 y/o F comes to ED w/ multiple red/black stools over last day/ Her medical hx is significant for aortic stenosis. Her pulse is 115 bpm and her BP is 94/62 mm Hg. The physical exam is otherwise normal. What is the most appropriate next step?
Bolus of normal saline
- fluid resuscitation is more important than finding etiology of GI bleeding
- don’t check for orthostatic if systolic BP
Most common cause of upper GI bleeding
Ulcer disease, but can also be caused by:
- gastritis
- esophagitis
- duodenitis
- cancer
- varices
Most common cause of lower GI bleeding
Diverticulosis
Other common causes of lower GI bleeding (aside from diverticulosis)
- Angiodysplasia (AV malformations)
- Polyps or cancer
- Inflammatory bowel disease
- Hemmorrhoids
- Upper GI bleeding w/ rapid transit form high volume
GI bleeding: presentation
- Orthostasis (> 10 pt rise in pulse when going from lying down to standing up)
- Systolic BP (< 20 pts or more when sitting up)
Variceal bleeding: presentation
- Signs of liver disease
- Vomiting blood +/- black stool
- Spider angiomata and caput medusa
- Splenomegaly
- Palmar erythema
- Asterixis
GI bleeding: Treatment
If bleeding is severe, replacing fluids more important than finding etiology of
- check hematocrit, platelet count, and coagulation tests such as PT and INR
Nasogastric Tube
- can identify upper GI bleeding and need for upper endoscopy
- if stool is black in person w/ cirrhosis, NG tube can identify upper GI bleeding which indicates variceal bleeding
Indication of nuclear bleeding scan
- when endoscopy is unremarkale in massive acute hemorrhage
Indication for angiography
- specific site or vessel needs to be ID’d before suerger
- embolization of the vessel, use in massive, nonresponsive bleeding
Capsule endoscopy indication
small bowel bleeding
- when upper and lower endoscopy doesn’t show etiology
GI Bleeding: Treatment
- Fluid resuscitation w/ high volume blood loss
- Packed RBCs if hematocrit is below 30
- Fresh frozen plasma if PT or INR is elevated
- Platelets if count < 50K
- Octeotride for variceal bleeding
- Endoscopy to identify diagnosis
- IV PPI for upper GI bleeding
Esophageal and Gastric Varices: Treatment
- OCTREOTIDE (somatostatin) decreases portal pressure
- BANDING performed by endoscopy
- TIPS used to decrease portal pressure uncontrolled by octreotide
- PROPRANOLOL to prevent recurrent episodes of bleeding. Doesn’t help present bleeding
- ABX to prevent SBP w/ ascites
