Gastrointestinal Disorders Flashcards
Medications that can cause direct esophageal mucosal injury
Antibiotics Anti-inflammatory Biphosphonates KCl Iron
Medication-induced esophagitis clinical presentation
Sudden onset, retrosternal pain or heartburn, odynophagia, dysphagia
Pain may be so severe that swallowing saliva is difficult
Onset of the sxs - within a few hours to 1 month after ingestion of the culprit medication
Often have a history of swallowing a pill without water, commonly at bedtime
Clinical diagnosis may be made by history alone
Medication-induces esophagitis diagnosis
EGD with severe symptoms, or persistent for greater than one week.
EGD with biopsy can establish the diagnosis and r/o other etiologies
Medication-induced esophagitis treatment
Discontinue causative medication (if continued try to switch to liquid)
Most will heal within 7-10 days
After healing can resume med with plenty of water
Eosinophilic esophagitis
Chronic, immune-mediated inflammatory disorder or the esophagus
Eosinophilic esophagitis clinical features
Food impaction and dysphagia
> 15 eosinophils on histological exam
Exclusion of other disorder (GERD)
Eosinophilic esophagitis (EoE) risk factors
Hx of asthma, allergic rhinitis, eczema, environmental allergies
Causes of eosinophilic infiltration
*Think about things that would cause inflammatory response.
GERD, EoEparasites, fungi, IBD, Hodgkin’s disease, Scleroderma, drug injury, allergic vasculitis
EoE vs GERD
They often coexist, but are not related
Typically EoE patients will be put on PPI but will not have resolution of symptoms.
EoE clinical presentation
Dysphagia, heartburn, chest pain
Prone to food trapping
Patients typically with hx of atopy (asthma, eczema, food allergy)
EoE diagnosis
Eosinophils of EGD with biopsy
EGD shows cat esophagus (multiple concentric rings) with white plaques or specks
CBC for peripheral eosinophilia
Barium study not required
EoE treatment
- Dietary therapy (Elimination diet)
- Pharmacologic therapy
- Dilation of esophageal structures
Should be referred to an allergist for food allergy testing.
Elimination diet
Elimination of the most common allergenic foods to decrease allergen exposure.
Food is reintroduced one at a time to look for reoccurrence of symptoms.
EoE pharmacotherapy: Fluticasone
Swallowed fluticasone (glucocorticoid) via MDI Initial treatment for 6-8 weeks
EoE pharmacotherapy: Budesonide
Alternative to fluticasone, but is not a first line drug treatment
EoE pharmacotherapy: PPI
Acid suppression can treat coexisting GERD so it may be worth trying for improvement
EoE treatment: Dilation
Some patients (adults) with rings or strictures may require dilation if failed trial of fluticasone.
EoE prognosis
Unclear due to lack of studies
No reports of increased risk of malignancy
Symptoms frequently recur from childhood into adulthood.
GI disorders common signs and symptoms
Dysphagia Nausea and vomiting Diarrhea or constipation Abdominal pain Acute GI bleeding Occult GI bleeding Jaundice Abnormal liver chemistries Ascites Malnutrition
Dysphagia
Difficulty swallowing or sensation of obstruction to the passage of food anywhere from the mouth to the stomach.
Odynophagia
Pain on swallowing
Can coexist with dysphagia
Globus
Constant sensation of a lump of fullness in the throat without difficulty swallowing
Aphagia
Inability to swallow
Can result in food bolus getting impacted in the esophagus; can result from pharyngeal muscle paralysis (due to neurologic issue)
Xerostomia
Dryness of the mouth from decreased salivation
Causes difficulty initiating swallow due to poor lubrication of food bolus.
What are the two types of dysphagia?
Oropharyngeal and esophageal
Oropharyngeal dysphagia
Difficulty with food from mouth to esophagus. Disorders typically affect the function of oropharynx, larynx, and upper esophageal sphincter.
Most commonly a neurological or muscle disorder.
Esophageal dysphagia types
Mechanical (structural): Something blocking the esophagus such as a tumor, stricture, or scar
Motility (propulsive): Food not being move forward properly such as with esophageal contractions or sphincter function.
Key questions to ask when evaluating dysphagia
- Is it actually dysphagia?
- At what level is the obstacle?
- Is dysphagia for solids, liquids, or both?
- Is it intermittent or progressive?
Key questions to ask when evaluating dysphagia
- Is it actually dysphagia?
- At what level is the obstacle?
- Is dysphagia for solids, liquids, or both?
- Is it intermittent or progressive?
- Do you have associated symptoms?
- Do you have any other medical problems?
- Any hx of radiation?
- What medications are you taking now?
- Hx of prior surgery?
Infectious esophagitis risk factors
HIV/AIDS Leukemia/lymphoma Solid organ transplant Uncontrolled diabetes mellitus (DM) Chronic systemic steroid use (Immune compromised patients)
What is the most common cause of fungal esophagitis in HIV patients?
Candidiasis caused by candida albicans
Fungal esophagitis clinical presentation
Dysphagia most common
Patients will often have oral thrush.
Oropharyngeal candidiasis in association with symptoms of esophagitis, such as pain or difficulty swallowing, is predictive of esophageal candidiasis
Odynophagia, fever, nausea, vomiting less common
Severity of these symptoms correlates with the degree of immunologic impairment.
Most common types of viral esophagitis?
HSV and CMV
Viral esophagitis clinical presentation: CMV
Odynophagia and chest pain most common
Dysphagia uncommon
May also have low grade fever, nausea and vomiting
Can have involvement of the colon and retina
Viral esophagitis clinical presentation: HSV
Both dysphagia and odynophagia most common as well as fever and continuous chest pain
Can also have herpes labialis (oral lesions)
Bacterial esophagitis clinical presentation
Odynophagia, dysphagia, substernal chest pain
Painful or difficult swallowing may result in dehydration and weight loss
VS may reveal fever and orthostatic hypotension
This is rare in severely immune compromised patients.
Bacterial esophagitis clinical presentation
Odynophagia, dysphagia, substernal chest pain
Painful or difficult swallowing may result in dehydration and weight loss
VS may reveal fever and orthostatic hypotension
This is rare in severely immune compromised patients.
Infectious esophagitis diagnosis
WBC, CD4 count, EGD w/ biopsy
Typical organisms with CD4 < 200
HSV, VZV
Typical organisms with CD4 100-200
Candida, HSV
Typical organisms with CD4 of 50-100
Candida, CMV, HSV
Typical organisms with CD4 of 50-100
Candida, CMV, HSV
EGD: Candidiasis
Multiple adherent, white or yellow lesions, “cottage cheese” plaques
Brushings or biopsy reveal yeast or budding hyphae
EGD: HSV
Small, superficial ulcers
Cytology shows giant cells and ground-glass nuclei
EGD: CMV
Large, well-demarcated, deep ulcers are visualized on gross examination
Immunohistochemical staining for CMV antigens are diagnostic
EGD: VZV
Multiple vesicles and confluent ulcers
Immunohistochemistry or culture
Esophagitis treatment: Candidiasis
Systemic antifungal agents - oral or intravenous (IV)
Oral fluconazole is treatment of choice
Refractory disease or azole resistant Candida:
Amphotericin B IV or Echinocandins (anidulafungin, caspofungin, micafungin) IV
HIV patients should be on HAART (may not improve without it)
Esophagitis treatment: HSV or VSV
First line therapy - acyclovir IV or orally
Can also use ganciclovir, famciclovir, valacyclovir or foscarnet (Foscavir)
Esophagitis treatment: CMV
Antiviral – IV ganciclovir (can cause neutropenia; use if patient is not pancytopenic)
Alternative - foscarnet IV (can cause renal failure, hypocalcemia, and hypomagnesemia)
~30% of patients relapse
*Typically these patients are more immune compromised and require IV treatment.
Motility disorders
Patients usually have problems swallowing both liquids and solids from the onset
Can be peristalsis problem, sphincter problem, or both
Can involve both striated and smooth muscle of esophagus
Can be primary or secondary (associated with another disorder)
Striated muscle motility disorder
Oropharyngeal dysphagia (problem with transfer of food bolus from mouth to esophagus). Voluntary muscle that initiates swallowing.
Causes – neurologic disease, trauma
Most common is stroke (CVA)
Other causes – myasthenia gravis, Parkinson’s, MS (multiple sclerosis), ALS (amyotrophic lateral sclerosis)
Smooth muscle motility disorder
Involuntary muscle involved in swallowing.
Ex: achalasia (most common), diffuse esophageal spasm (DES), nutcracker esophagus, scleroderma (systemic sclerosis)
Motility disorder clinical presentation
Dysphagia and chest pain in absence of obstruction
Diagnosis is based on imaging or motility testing
Achalasia
Combination of a LES that does not relax and a noncontractile, aperistaltic distal esophagus.
Cause is idiopathic
Achalasia clinical presentation
Pt presents with gradual, progressive dysphagia, chest pain, food regurgitation, and mild weight loss
Chest pain: retrosternal heartburn-like pain, associated with regurgitation and lasting <30 minutes OR episodic, spasm-like chest tightness that may radiate to the back, often at night
Regurgitate may be saliva and undigested food or may be acidic due to fermentation and acidification of undigested food in the esophagus
Achalasia: Chagas disease
Protozoan disease commonly seen in Mexico, central, and south America.
Pseudoachalasia
esophageal cancer, lung cancer, or metastatic disease may present with achalasia due to the effects of direct mechanical compression on the esophagus by a tumor mass or due to malignant invasion of the neural plexus (EGD).
Achalasia: Diagnosis
Esophagogastroduodenoscopy (EGD) : R/O other disorders, eg, cancer, i.e. pseudoachalasia
No mucosal abnormalities
Barium swallow (barium esophagography): “Bird beak” appearing distal esophagus with proximal dilatation
Manometry (required for diagnosis)
Shows lack of peristalsis and increased LES tone (poorly relaxing), elevated LES post-swallow residual pressures
These findings are NOT found in GERD
Achalasia: Treatment
Goal is to reduce the pressure gradient represented by the LES.
Preferred treatment is an endoscopic dilation of the LES.
Pharmacologic agents – nitrates, calcium channel blockers; not generally used
Surgical – myotomy (cut the LES muscle so that it stays open)
Botulinum toxin injection via EGD.
Achalasia treatment risks
Patients who have received treatment for achalasia are at increased risk for GERD and its complications – any symptoms are controlled with usual GERD treatments
High risk of developing squamous cell CA due to chronic GERD symptoms. Attempt to control with PPI
2 major varients of esophageal spasm
- Diffuse esophageal spasm
2. Hypertensive peristalsis
Diffuse esophageal spasm
Simultaneous, uncoordinated or spastic peristaltic contractions in the distal esophagus.
Patients present with dysphagia, regurgitation, chest pain.
Diffuse esophageal spasm diagnosis
Best diagnosed with manometry and barium swallow
EGD is typically normal.
Nutcracker esophagus (hypertensive peristalsis)
Peristaltic contractions proceed in a coordinated manner but the amplitude is excessive (>180mmHg) and of long duration (>6 seconds).
Patients typically present with chest pain
Nutcracker esophagus diagnosis
Best diagnosed with high-resolution manometry
Barium swallow and EGD typically normal.
Scleroderma
Autoimmune/connective tissue disorder. Can cause severe pain and dysphagia.
Patients have problems with contractility (atonic esophagus) combined with LES remaining open resulting in chronic acid reflux and scarring.
Scleroderma (& spastic disorder of the esophagus) treatment
Often treated with acid blockers - PPIs, nitrates, calcium channel blockers
Often difficult to treat
What is the test of choice for esophageal dysphagia
Upper endoscopy (EGD) Allows for direct visualization of the oropharynx, esophagus, stomach, and proximal duodenum.
Barium swallow test
Alternate test
Useful if subtle strictures suspected
Pre-EGD to road map a tight/complicated stricture
Reveals structural esophageal abnormalities (e.g., tumors, webs, rings)
Motility disorders (e.g. achalasia, diffuse spasm, scleroderma) have typical findings but manometry required for definitive dx
Esophageal manometry
When no structural or obstructive process found on upper endoscopy or barium swallow (esophagram)
Thin catheter is passed through nose, down esophagus, and past the LES
Pressure measurements taken for the entire length of the esophagus (plus UES and LES) – both at rest and during a swallow
Common etiologies of mechanical disorders
Diverticula Schatzki rings Esophageal webs Strictures from inflammatory changes Esophagitis
Esophageal disorder: Diverticula
Pockets in esophageal wall in which food becomes trapped, making it hard to swallow.
They are classified by their location within the esophagus.
Zenker’s diverticula
Outpouching of the posterior oropharynx just proximal to the upper esophageal sphincter.
Esophageal Rings
Pathogenesis is not entirely known. Both can occur from chronic damage from GERD and congenital or developmental origin.
Esophageal strictures
Any type of chronic inflammation that can can lead to narrowing or tightening of the esophagus.
Peptic strictures
Typically related to prolonged reflux esophagitis.
Usually occurs in the distal esophagus just proximal to the squamocolumnar junction.
Peptic stricture treatment
Aggressive acid control with high dose PPI.
Dilation is often required and is done via endoscopy. Less common surgery
Schatzki rings or “steakhouse syndrome”
Another type of stricture that often occurs in the distal esophagus. Due to GERD, pill esophagitis, and most commonly hiatal hernias.
Can be associated with intermittent solid food dysphagia
Schatzki ring treatment
For mild disease patient should chew food carefully.
Endoscopic dilation for more severe and possibly even surgery.
Treat with PPI if reflux symptoms are prominent.
Plummer-Vinson Syndrome
Syndrome characterized by a triad of anemia, upper esophageal webs, and dysphagia. Most commonly seen in middle-aged women.
This is rare but does put the patient at risk for developing squamous cell CA.
Esophageal strictures diagnostics
Labs are generally not helpful (unless CBC for plummer-vinson)
EGD for visualization as well as dilation therapy.
Barium swallow can be useful .
Risk factors for medication-induced esophagitis
Supine patients
Swallowing pills with insufficient wter
Taking prior to bed
Increased esophageal transit time due to anatomic abnormalities.
