Gastrointestinal

Question 1

Differential diagnosis for abdominal pain

Answer 1

Esophageal: GERD, perf, eosinophilic, spasm
Gastric: PUD, acute gastritis, chronic gastritis
Biliary: stones, acute cholecystitis, cholangitis, choledocholithiasis
Hepatic: Hepatitis, abscess, carcinoma
Pancreatic: acute, chronic, cancer
Bowel: obstruction, IBD, IBS, diverticulitis, appendicitis, volvulus, intussusception, celiac, constipation
Peritonitis: bacterial, comp of dialysis
Cardiac:
Pulmonary
Vascular: dissection, aneurysm, mesenteric ischemia
Urinary/Renal:
Splenic
Gynecologic
Abdominal wall
Neurologic
Metabolic
Hematologic

Question 2

Candida esophagitis

Answer 2

Eti: yeast species
S/sx: dysphagia, odynophagia, retrosternal pain, oral thrush
Risk: immunocompromised
Dx: clinical
Tx: fluconzaole
Comp: stricture-hemorrhage-fistula

Question 3

Herpes simplex esophagitis

Answer 3

Eti: HSV, rare in immunocompetent
S/sx: odynophagia, dysphagia, fever, retrosternal pain
Risk: HIV, malig, steroids, chemo
Dx: endoscopy with brush cytology most sensitive, PCR most specific
Tx: immunocompetent: self resolve, acyclovir etc.
Comp: Gi bleed, perf, fistula, Mallory-Weiss tear

Question 4

Eosinophilic esophagitis

Answer 4

Eti: Chronic immune/antigen- mediated
Risk: Males, caucasian, FH
S/sx: dysphagia, epigastric pain, heartburn, food impaction
Dx: endoscopy biopsy of proximal and distal esophagus
Tx: elimination diet, dietitian, …

Question 5

GERD

Answer 5

Eti: esophagogastric junction incompetence due to LES relaxation, LES hypotension, anatomic distortion
S/sx: heartburn, regurg, also dysphagia
Other sx: chest pain, often substernal radiating to the back, neck, jaw or arms. Globus, odynophagia, chronic cough
Tx: food avoidance

Question 6

Dyspepsia

Answer 6

Indigestion
Eti: Unknown
S/sx: abdominal pain, discomfort, burning, postprandial fullness, early satiety, N/V, belching, bloating
Alarming sx: recurrent vomiting, wt loss, GI blood loss, abdominal mass, age greater than 55, FH of GI cancer
Dx: ROME III criteria
Tx; consider GERD, discontinue NSAIDs, consider ETOH and caffeine, H-pylori, PPI, endoscopy

Question 7

ROME III criteria for dyspepsia

Answer 7

Most have one or more of the following in the past 3 months, with symptoms onset at least 6 months prior to diagnosis:
- postprandial fullness
- early satiety
- epigastric burning
Plus no evidence of structural disease that is likely to explain the disease

Question 8

esophageal stricture

Answer 8

Eti: caustic ingestion, malignancy, radiation, infectious esophagitis, AIDS…
S/sx: heartburn, dyspepsia, dysphagia, food impaction, wt loss, chest pain
Dx: barium esophagography, CT (malignancy)
Tx: endoscopic dilation, steroid injection, diet, PPI, treat other causes

Question 9

gastritis

Answer 9

Eti: imbalance between increased aggressive an decreased protecttive mechanisms of gastric mucosa (swelling of stomach lining)
- H-pylori, NSAIDs, ETOH, meds etc.
S/sx: can be Asx, epigastric pain, N/V, anorexia, bleeding of upper GI
Dx: endoscopy, H pylori testing, FIT test
Tx: H pylori treatment, PPI or H2 blockers

Question 10

hiatal hernia

Answer 10

Eti: protrusion of upper part of stomach into the chest cavity due to diaphragm tear or weakness
S/sx: Most Asx, symptoms of GERD
Risk: age, pregnancy, obesity, abdominal ascities
Dx: barium GI series, endocsopy
Tx: treat GERD sx, some require surgery

Question 11

peptic ulcer disease

Answer 11

Eti: H pylori, NSAIDs (esp ASA), Zollinger Ellision syndrom, ETOH, smoking, stress
Risk: male and above
S/sx: dyspepsia, worse at night, relief with food and antacids, GI bleeding
Dx: H pylori, endoscopy, urea breath test, stool test, serologic test only good to determine infection
Tx: H pylori treatment; refractory - vagotomy