Gastrointestinal Step Up Flashcards
what do you do if a patient has a positive FOBT? even if they are asymptomatic?
colonscopy
most sensitive and specific test for colon cancer
colonscopy
what test is complementary to flexible sigmoidoscopy in evaluating CRC?
barium enema
what is CEA useful for?
NOT SCREENING
- used for baseline and recurrence surveillance
what pre-op value of CEA implies worse prognosis in CRC?
> 5 ng/mL
what type of polyps have the highest malignant potential?
villous adenomas (Vs. tubular adenomas)
polyps plus osteomas, dental abnormalities, benign soft tissue tumors, desmoid tumors and/or sebaceous cysts
Gardner’s syndrome
- risk of CRC is 100% by age 40
polyps plus cerebellar medulloblastoma or glioblastoma multiforme
Turcot’s syndrome
multiple hamartomas throughout entire GI tract and pigmented spots around oral mucosa, lips and genitalia
Peutz-Jegher’s syndrome
Lynch syndrome I
site specific CRC - early onset CRC
Amsterdam Criteria I
for dx. Lynch syndrome
- atleast 3 relatives with CRC (one first degree)
- 2+ generations
- one onset before age 50
- FAP has been excluded
Lynch syndrome II
early onset CRC plus other cancers (breast, endometrial ca, skin, stomach, pancreas, brain etc)
MCC of large bowel obstruction in adults
CRC
MC presenting symptom in CRC
abdominal pain
pt suspected of having CRC presents with anemia, weakness, occult blood in stool, melena, and iron deficiency anemia - where is the tumor likely located?
right sided tumors i.e. cecum
- lack of obstructive symptoms
pt suspected of having CRC presents with alternating constipation and diarrhea; he also has hematochezia - where is the tumor likely located?
left sided tumor
MC symptoms of rectal cancer
hematochezia with tenesmus and incomplete feeling of evacuation due to rectal mass
in what case of CRC is radiation therapy indicated?
rectal cancer
follow-up of CRC after resection includes? (4)
- stool guaic test
- annual CT scan of abdo/pelvis and CXR for 5 years
- colonscopy at 1 year and then every 3 years
- CEA levels
MC non-neoplastic polyps
hyperplastic (metaplastic) polyps
- commonly removed even though they are benign
MC type of neoplastic polyp
tubular adenoma
at what size is there greater risk of malignant potential in a colon polyp?
> 2.5 cm
what shape of polyp is most likely to be malignant
sessile (vs. pedunculated)
MC location of diverticulosis
sigmoid colon
test of choice for diagnosing diverticulosis
barium enema
tx. of diverticulosis
high-fiber diet (bran) to increase stool bulk
complications of diverticulosis
painless rectal bleeding
diverticulitis
how do you manage painless rectal bleeding as a complication of diverticulosis
usually stops on its own
colonscopy - to locate site of bleeding
if bleeding persists or recurs - consider segmental colectomy
pt presents with fever, LLQ and leukocytosis; you find inflammation of pericolic fat, bowel wall thickening and pericolic fluid collection - what should you consider?
diverticulitis
complications of diverticulitis
abscess formation - drained surgically
colovesical fistula
obstruction
colonic perforation - peritonitis
Dx. test of choice in diverticulitis
CT scan w/ oral and IV contrast
- avoid barium enema and colonscopy due to risk of perforation
Tx. of uncomplicated diverticulitis
IV antibiotics, bowel rest (NPO) and IV fluids
- if sx persist for 3-4 days, may need to consider surgery
Tx. of complicated diverticulitis
surgery - resection of involved segment
tortuous, dilated veins in the submucosa of the proximal wall of colon
Angiodysplasia of colon
- aka. AV malformation or vascular ectasia
MC sx. of angiodysplasia of colon
lower GI bleeding - usually stops on its own
Dx. of angiodyplasia
colonoscopy - preferred over angiography
Tx. of angiodysplasia of colon
usually not needed
- colonscopy coagulation of lesion if frequent bleeding
- right hemicolectomy if persistent bleeding
what condition is angiodysplasia (oddly) associated with?
aortic stenosis
four “causes” of acute mesenteric ischemia
arterial embolism
arterial thrombosis
non-occlusive mesenteric ischemia
venous thrombosis
pt presents with acute onset, severe abdominal pain; abdominal exam is benign - what test(s) should you order in order to get a diagnosis?
check lactate level
plain films - R/O other causes of pain
mesenteric angiography - test of choice for acute mesenteric ischemia
what classic finding can be seen on XR/barium enema in ischemic colitis?
thumb-printing (due to thickened edematous mucosal folds)
Tx. of choice for arterial causes of acute mesenteric ischemia
direct intra-arterial infusion of papaverine (vasodilator) into SMA during arteriography
what drugs should be avoided in mesenteric ischemia?
vasopressors
older patient presents with dull abdominal pain classicaly following every meal; there has been significant weight loss (bc the patient now seems to be avoided eating) - what test do you order to confirm your diagnosis?
chronic mesenteric ischemia
- order mesenteric angiography
Tx. of chronic mesenteric ischemia
surgical revascularization
patient presents with signs and symptoms of large bowel obstruction; radiographic imaging confirms this - however, there is no actual mechanical obstruction - dx?
Ogilvie’s syndrome
what is the sign of impending bowel rupture?
colonic distention with diameter > 10 cm
- you need to decompress immediately
patient who was recently tx. with clindamycin develops profuse watery diarrhea and crampy abdominal pain - dx?
pseudomembranous colitis
- usually occurs after course of ampicillin, clindamycin or cephalosporing antibiotics
how do you confirm diagnosis of pseudomembranous colitis?
C.difficle toxin in stool
abdominal XR to r/o complications
DOC for pseudomembranous colitis
oral metronidazole (can also be given IV) - if this does not work, try oral vancomycin
what drug can be used as adjuvant tx. to improve the diarrhea associated with pseudomembranous colitis?
cholestyramine
twisting of loop of intestine around its mesenteric attachment site, most commonly in the sigmoid colon
colonic volvulus
RFs for colonic volvulus
chronic illness age institutionalization CNS disease chronic constipation/antimotility drugs laxative abuse prior abdominal surgery
plain film findings in
- sigmoid volvulus (1)
- cecal volvulus (2)
(1) omega loop sign - indicates dilated sigmoid colon
(2) distention of cecum/small bowel; coffee bean sign indicating large air-fluid level in RLQ
preferred diagnostic test for sigmoid volvulus
sigmoidoscopy - it also usually successfully decompresses and untwists it leading to tx. as well - but these commonly recur, so you should offer your patient an elective sigmoid resection
what is used to measure disease severity in liver cirrhosis and serves as a predictor of morbidity/mortality?
Child's classification - class A is mild disease; class C is severe dz
MCC of cirrhosis
alcoholic liver dz
chronic viral infection - hepC
gold standard test for diagnosis of liver cirrhosis
liver biopsy
how can you lower portal HTN?
transjugular intrahepatic portal-systemic shunts (TIPS)
how do you tx. someone with perforated esophageal varices?
- IV fluids - stabilize BP
- IV octreotide - 3-5 days
- upper GI endoscopy with variceal ligation/banding or sclerotherapy
- IV antibiotics prophylactically
how do you prevent rebleeding in someone with esophageal varices?
tx. with non-selective B-blockers
what tests should be done in suspected ascites?
abdominal USG - can detect as little as 30 ml fluid
paracentesis
indications for paracentesis
new onset ascites
worsening ascites
suspected spontaneous bacterial peritonitis
serum ascites-albumin gradient
if > 1.1 g/dL = portal HTN
if < 1.1 g/dL = must consider other causes of ascites
step-wise tx. of ascites
- Na+ and water restriction
- spironolactone
- furosemide - not > 1L/day
- therapeutic paracentesis
what test should patients with cirrhosis have done?
endoscopy to assess for presence of esophageal varices - if present, tx. with B-blocker
precipitants of hepatic encephalopathy
alkalosis hypokalemia sedating drugs - narcotics, sleep pills GI bleeding systemic infection hypovolemia
CF of hepatic encephalopathy
changes in mental function
asterixis
rigidity/hyperreflexia
fetor hepaticus - musty odor of breath
Tx. of hepatic encephalopathy
lactulose
neomycin - kills GI flora that produces ammonia
hepatorenal syndrome
progressive renal failure secondary to renal hypoperfusion resulting from vasoconstriction of renal vessels (afferent arteriole) in the setting of advanced liver disease
CF of hepatorenal syndrome
azotemia oliguria hyponatremia hypotension low U-Na+ (<10) no improvement after 1.5 L saline = diagnostic
diagnosis of hepatoregnal syndrome
decreased GFR In absence of shock, proteinuria or other clear cause of renal failure and a failure to respond to 1.5L normal saline bolus
Tx. hepatorenal syndrome
liver transplantation
medical - midodrine, octreotide
a patient with ascites develops fever, vomiting, rebound abdominal tenderness and changes in mental status - what should you consider?
spontaneous bacterial peritonitis
- MC agent is E.coli
how do you confirm diagnosis of spontaneous bacterial peritonitis?
paracentesis - WBC > 500, PMNs > 250
- do gram stain and culture before picking antibiotic (usually 3rd gen cephalosporin)
how do you monitor progress in spontaneous bacterial peritonitis?
repeat paracentesis in 2-3 days to document a decrease in ascitic fluid PMNS < 250
how do you tx. coagulopathy associated with cirrhosis?
fresh frozen plasma
how do you diagnose Wilson’s disease?
increased LFTs
increased PT/PTT - coagulopathy
decreased serum ceruloplasmin levels
biopsy - increased copper concentration
young patient presents with liver disease and neurological signs, including parkinsonian symptoms and psychosis/personality changes - what should you consider?
Wilson’s disease - copper commonly accumulates in liver and brain
- if dx, should screen first degree relatives as well
Tx. of Wilson’s disease
symptomatic pts - D-penicillamine (chelator)
asymptomatic/pregnant pts - Zinc (prevents uptake of dietary copper)
what can cause secondary hemochromatosis?
multiple blood transfusions
chronic hemolytic anemias
complications of hemochromatosis
cirrhosis cardiomyopathy diabetes mellitus arthritis - 2/3 MCP, hips and knees hypogonadism hypothyroidism hyperpigmentation of the skin
what should you order if a pt presents with mild elevations of ALT and AST levels?
iron studies - if elevated, obtain a liver biopsy to dx. hemachromatosis
lab findings in hemochromatosis
elevated serum iron, ferritin and transferrin saturation; decreased TIBC
- liver biopsy is diagnostic w/ elevated iron stores
Tx. of choice for hemochromatosis
repeated phlebotomies
how do you diagnose hepatic adenoma?
CT scan, USG or hepatic arteriography (most accurate, but invasive)
how do you tx. hepatic adenoma?
stop OCPs - if may regress
surgical resection of tumors > 5cm
how can you diagnose a cavernous hemangioma?
USG or CT scan w/ contrast
- biopsy is c/i due to risk of hemorrhage
Tx. of cavernous hemangioma
most do not require tx; consider resection if pt is symptomatic or there is high risk of rupture
what type of liver tumor is similar to hepatic adenoma on imaging but has no malignant potential and is not assoc. with OCP use?
focal nodular hyperplasia
- usually asx and no tx. needed
what type of liver cancer is associated with hepB/C and cirrhosis, is generally unresectable w/ a short survival time?
non-fibrolamellar (most common)
what type of hepatocellular ca. is resectable with longer survival time, usually seen in young adults?
fibrolamellar type
what should you consider in a patient with liver cirrhosis, a palpable mass and elevated AFP?
hepatocellular carcinoma
what is needed for the definitive diagnosis of hepatocellular ca?
liver biopsy
what tumor marker is elevated in HCC?
AFP
- useful as screening tool and for monitoring response to therapy
paraneoplastic syndromes caused by HCC?
erythrocytosis thrombocytosis hypercalcemia carcinoid syndrome hypertrophic pulmonary osteodystrophy hypoglycemia high cholesterol
Tx. of hepatocellular carcinoma
liver resection or liver transplant
your obese, diabetic patient comes in for routine blood work and results show mildly elevated liver enzymes - dx? tx?
most likely non-alcoholic steatohepatitis
tx. is unclear
a young male comes in because he noticed he turned yellow after fasting for the past 3 days; you do blood work and find isolated elevated UCB - dx?
Gilbert’s disease
- decreased activity of hepatin uridine diphosphate glucoronyl transferase
a patient comes in with melena, hematemesis, jaundice and RUQ pain; upper GI endoscopy shows blood draining out of ampulla of Vater
hemobilia
- blood draining into duodenum via CBD
what is the diagnostic test for hemobilia
arteriogram
consequences of liver cysts associated with polycystic kidney disease?
rarely lead to hepatic fibrosis or failure; usually asymptomatic and dont usually need treatment
a patient presents with a diagnosed large cyst on right lobe of liver; he currently has RUQ pain - what are you worried about? how would you treat this?
- hydatid liver cyst caused by Echinococcus; dont want it to rupture bc can result in anaphylactic shock
- tx. is surgical resection and mebendazole
MC location for liver abscesses
right liver lobe
how do you diagnose a liver abscess?
ultrasound or CT scan
usually also have elevated LFTs
how do you tx. a liver abscess?
IV antibiotics
percutaneous drainage of abcess (sometimes surgical drainage is necessary)
a homosexual man presents with fever, RUQ pain, NV, hepatomegaly and bloody diarrhea - what should you consider?
amebic liver abscess (entameoba histolytica)
how can you diagnose amebic liver abscess?
serology - IgG enzyme immunoassay
Tx. of amebic liver abscess?
IV metronidazole
- may require therapeutic aspiration if large or not going away with medical therapy
occlusion of hepatic venous outflow leading to hepatic congestion and microvascular ischemia
Budd Chiari syndrome
causes of Budd Chiari syndrome
hypercoagulable states myeloproliferative disorders pregnancy chronic inflammatory diseases infection various cancers/trauma
how do you diagnose Budd Chiari syndrome?
hepatic venography
serum ascites albumin gradient > 1.1 g/dL
how do you tx. Budd Chiari syndrome?
balloon angioplasty with stent in IVC
portocaval shunts
at what level of bilirubin does jaundice become evident?
total bilirubin > 2 mg/dL
which form of bilirubin is tightly bound to albumin (water insoluble) and cannot be excreted in urine; also if unbound from albumin, can cross BBB and become toxic?
unconjugated bilirubin - indirect
dark urine and pale stools mean…
conjugated bilirubinemia
a patient comes in with jaundice, lighter stools and dark urine; he also complains of pruritus - lab tests reveal elevated ALP and serum cholesterol; you notice he has skin xanthomas - what should you consider?
cholestasis - blockage of bile flow with resultant increase in CB levels
- he is at risk for malabsorption of fat and fat soluble vitamins
in what scenarios are AST and ALT mildly elevated (hundreds)?
alcoholic hepatitis
chronic viral hepatitis
in what scenarios are AST and ALT moderately elevated (high hundred to thousands)
acute viral hepatitis
in what scenarios are ALT and AST extremely elevated (> 10 000)?
ischemia, shock liver
acetaminophen toxicity
severe viral hepatitis
if you find an elevated ALP in a patient, what is the next test you should order?
GGT - to see if ALP is hepatic in origin (GGT will also be elevated)
cholestatic LFTs
ALP and GGT
- if these are positive, obtain abdominal or RUQ ultrasound
biliary colic
cardinal sx of gallstones; temporary obstruction of cystic duct by gallstone
boa’s sign
referred subscapular pain of biliary colic
test of choice to dx. cholelithiasis (gallstones)
RUQ ultrasound
Tx. of gallstones
asymptomatic - do nothing
symptomatic - laparascopic cholecystectomy
what do you do if a pt refuses laparascopic cholecystectomy?
rx. ursodeoxycholic acid - but this is expensive and has a high risk of recurrence; used in pts who are not good surgical candidates
signs of acute cholecystitis
RUQ pain
Murphy’s sign - pathognomic
hypoactive bowel sounds
low grade fever/leukocytosis
USG findings show thickened gallbladder wall, pericholecystic fluid, distended gallbladder and presence of stones - what is the dx?
acute cholecystitis
what study do you perform to assess complications of acute cholecystitis?
CT scan
what test do you do if the USG findings in suspected acute cholecystitis are inconclusive?
HIDA scan - gallbladder is not visualized 4 hours after injection
Tx. for acute cholecystitis
admit to hospital - supportive measures include IV fluids, antibiotics, analgesics, NPO
what is the most appropriate next step once a patient is recovered from acute cholecystitis (or stable)
laparascopic cholecystecomy - best w/in 24-48 hours
Tx of choice for acalculous cholecystitis?
emergent cholecystectomy
- if pt is to ill for surgery, do percutaneous drainage with cholecystomy
pt presents with RUQ/epigastric pain and jaundice; labs show elevated total and direct bilirubin and ALP - dx? and test? and tx?
choledolithiasis
- do USG first followed by ERCP (gold standard)
- tx. ERCP stone removal and sphincterectomy and stent
pt presents with RUQ pain, jaundice and fever; soon after evaluation she develops signs of septic shock and altered mental state - what is the dx? and initial study?
cholangitis - medical emergency
- initial study is RUQ ultrasound (directs next step)
how do you approach patient with cholangitis?
blood cultures
IV fluids
IV antibiotics - based on culture results
decompress CBD when pt is stable
tests to do in cholangitis after RUQ ultrasound?
cholangiography:
PTC - if bile ducts are dilated
ERCP - if bile ducts are normal
- can only do these once patient has been afebrile for 48 hours and patient is stable; used to diagnose and decompress the CBD
most feared complication of cholangitis?
hepatic abscess
what do you do with a finding of porcelain gallbladder?
prophylactic cholecystectomy
- 50% will develop cancer
pt presents to you with jaundice and pruritus of the skin; she also feels more tired lately and has been losing weight; she is scared this is related to her ulcerative colitis - what are you thinking of?
primary sclerosing cholangitis
- do ERCP and PTC to diagnose
biopsy findings in ERCP and PTC
multiple bead-like strictures and dilations of both intra and extrahepatic bile ducts
tx. of primary sclerosing cholangitis
liver transplant
ERCP w/ stenting to relieve symptoms of strictures; cholestryamine to help with pruritus
pt with UC comes in complaining of severe pruritus at night; she has some RUQ discomfort and fatigue, you do tests and note she has high cholesterol and xanthelasmas - dx? what tests should you order?
consider primary biliary cirrhosis
order antimitochondrial ab’s and liver biopsy to confirm diagnosis
lab findings in primary biliary cirrhosis
cholestatic LFTs
positive AMAs
elevated cholesterol, HDL
elevated IgM
what drug has been shown to slow progression of primary biliary cirrhosis?
ursodeoxycholic acid
- but liver transplant is only curative tx
Klatskin tumor
cholangiocarcinoma - in proximal 1/3 of CBD involving junction of right and left ducts; MC but worst prognosis bc it is unresectable
RFs for cholangiocarcinoma
primary sclerosing cholangitis
UC
choledochal cysts
clonorchis sinensis (Hong Kong)
a woman presents with epigastric pain, jaundice and fever; a RUQ mass is felt on physical exam - what tests should you order? what is your suspected diagnosis?
dx - choledochal cyst
tests - USG first, ERCP is definitive test
choledochal cyst
cystic dilation of biliary tree in either extrahepatic or intrahepatic ducts
Tx. of choledochal cysts
surgery - complete resection of cyst with biliary-enteric anastomosis to restore continuity of biliary system with bowels
pt comes in with her 5th episode of biliary colic, you do another USG and again find no gallstones - what study should you consider next? diagnosis?
possible biliary dyskinesia (motor dysfunction of sphincter of oddi)
- order HIDA scan (w/ CCK IV to determine ejection fraction of gallbladder
tx. of biliary dyskinesia
laparscopic cholecystectomy or endoscopic sphincterectomy
Rovsing’s sign
appendicitis
- deep palpation in LLQ causes pain in RLQ
Psoas sign
appendicitis
- RLQ pain when right thigh is extended as patient lies on left side
obturator sign
appendicitis
- RLQ pain when flexed right thigh is internally rotated when patient is supine
dx. of appendicitis
clinical diagnosis!!
- can do a CT scan or USG if uncertain or atypical presentation
what nutritional deficiency is someone with a carcinoid tumor at risk for?
niacin deficiency - pellagra
- use up all tryptophan to make serotonin
tx. of carcinoid tumor
surgery
- if unable to resect: octreotide
drugs that can cause pancreatitis
diuretics - thiazides, loops
IBD - sulfasalazine, 5ASA
immunosuppressants - azathioprine, asparaginase
epileptic drugs - valproate
AIDs - didanosine, pentamidine
antibiotics - metronidazole, tetracycline
main RFs for pancreatitis
alcohol
gallstones
post-ERCP - 10% of pts
blunt abdominal trauma - children
classic pain seen in acute pancreatitis
epigastric pain that radiates to the back; worse when supine and after meals
Ranson’s admission criteria for acute pancreatitis
GA-LAW
- glucose > 200 mg/dL
- age > 55 yo
- LDH > 350
- AST > 250
- WBC > 16000
Ranson’s initial 48 hr criteria for acute pancreatitis
C-HOBBs
- calcium < 8 mg/dL
- Hct decreased by > 10%
- PaO2 < 60
- BUN increase > 8 mg/dl
- base deficit > 4 mg/dL
- fluid sequestration > 6L
diagnostic test for acute pancreatitis
CT abdomen
indications for ERCP in acute pancreatitis
severe gallstone pancreatitis w/ biliary obstruction OR to identify causes of recurrent pancreatitis
how do you tell sterile from infected pancreatic necrosis?
CT guided percutaneous aspiration w/ gram stain and culture of aspirate
- infected needs surgical debridement and antibiotics
diagnostic test and tx. of pancreatic pseudocyst?
CT scan
- treat cysts > 5 cm with drainage (percutaneously or surgically)
complications of acute pancreatitis
hemorrhagic pancreatitis ARDS pancreatic ascites/pleural effusion ascending cholangitis pancreatic abscess
Tx, of mild pancreatitis
NPO - bowel rest
IV fluids
pain control - fentanyl or meperidine
NG tube if vomiting or ileus present
tx. of severe pancreatitis
pts with 3+ Ranson’s criteria should be admitted to ICU
- enteral nutrition with nasojejunal tube w/in 72 hours
- imipenem if > 30% necrosis present
pt comes in with chronic epigastric pain, steatorrhea and diabetes mellitus - you do XR and find calcifications - dx?
chronic pancreatitis
initial study of choice for chronic pancreatitis
CT scan
- ERCP is gold standard but is not done routinely
what is the stool elastase test for?
to diagnose malabsorption secondary to pancreatic exocrine insufficiency
what drugs should be given with pancreatic enzyme supplements?
H2 blockers
- prevent degradation of enzymes in stomach acid
surgery procedure most commonly done for relief of incapacitating pain due to chronic pancreatitis?
pancreaticojejunostomy
pancreatic cancer of head - symptoms?
weight loss
steatorrhea
obstructive jaundice
pancreatic cancer of body/tail - symptoms?
pain
weight loss
CF of pancreatic cancer
abdominal pain - vague, dull ache jaundice - increased CB and ALP weight loss/anorexia recent glucose intolerance migratory thrombophlebitis palpable gallbladder
preferred test for assessment and diagnosis of pancreatic cancer
CT scan
most sensitive test for dx. pancreatic cancer
ERCP
patient presents with small upper GI bleed from duodenum; in his history he has previously had aortic graft surgery - what should you do?
perform endoscopy or surgery immediately - you are afraid of lethal aortoenteric fistula
Diuelafoy’s vascular malformation
submucosal dilated arterial lesions that can cause massive upper GI bleeding
other than blood, what can cause dark stools?
charcoal bismuth iron spinach licorice
initial test in hematemesis
upper GI endoscopy
initial test in hematochezia
rule of anorectal cause
order colonoscopy
initial test in melena
upper GI endoscopy
- if nothing found, order colonscopy
initial test in occult blood
colonoscopy
elevated PT may be indicative of.. (4)
liver dysfunction
vit K deficiency
consumption coagulopathy
warfarin therapy
what lab finding may be elevated in Upper GI bleeding?
BUN-Cr ratio - the higher the ratio, the more likely the bleeding is from an upper GI source
most accurate test for Upper GI bleeding
upper endoscopy
what is top priority in pt with GI bleed?
fluid resuscitation if hemodynamically unstable
what is usually the initial procedure in GI bleed?
nasogastric tube - empties stomach, prevents aspiration and assesses fluid
what is the general rule for replacement fluids in pt who has lost a lot of blood due to GI bleed?
3 ml crystalloid fluids for every 1 ml of blood lost
what test definitively locates the point of bleeding - usually used in lower GI bleeds?
arteriography
- should be performed during active bleeding and may be potentially therapeutic
Tx. for upper GI bleeding
EGD with coagulation of bleeding vessel
- repeat endoscopic therapy or surgical intervention if the bleeding continues
indications for surgery in GI bleeding (5)
- hemodynamically unstable patients despite all interventions
- severe initial bleed or recurrence
- longer than 24 hours
- visible vessel at base of ulcer
- ongoing transfusion - 5 units w/in 4-6 hrs
main RFs for squamous cc. of esophagus
alcohol tobacco use diet, HPV, achalasia, Plummer-VInson caustic injury nasopharyngeal carcinoma
main RFs for adenocarcinoma of esophagus
GERD and Barret’s esophagus
what test can confirm diagnosis of esophageal ca?
upper endoscopy with biopsy and brush cytology
- if negative, do a CT scan
what test is usually the first to be done if a patient presents with dysphagia?
barium swallow
what test is done to stage esophageal cancer?
transesophageal ultrasound
Tx of esophageal cancer
surgery for stages 0,1,2a - localized to esophagus; chemo + radiation before surgery may prolong survival
incomplete relaxation of LES and aperistalsis of esophagus are seen in?
achalasia
type of dysphagia common in achalasia
dysphagia for both solids and liquids (vs. esophageal ca. it is initially for solids, then liquids)
clinical features characteristic of achalasia
dysphagia - drink lots of water while eating, move around, twist etc. to push it down
regurgitation of food
complications of aspiration
confirmatory test for achalasia
manometry
- shows failure of LES relaxation (increased pressure) and aperistalsis of esophageal body
what should patients with achalasia be monitored for and how?
squamous cell ca. of esophagus
- do surveillance esophagoscopy to detect tumor at early stage
initial Tx. for achalasia
medical
- try antimuscarinic agenst, sublingual nitro, long acting nitrates or CCBs
- improve swallowing in early stages
definitive “palliative” tx. for achalasia
pneumatic dilation
- botox injections may be effective but need to be repeated every 2 years
in pts who do not respond to dilation therapy for achalasia, what can you do?
surgery - heller myotomy
patient presents with chest pain mimicking angina that radiates to the jaw; he also complains of dysphagia - diagnosis and test?
possibly diffuse esophageal spasm
- should R/O cardiac causes of pain
- upper GI barium swallow
manometry findings in diffuse esophageal spasm?
diagnostic - simultaneous, multiphasic, high amplitude, repetitive contractions; normal relaxation of LES
Tx. of diffuse esophageal spasm
antispasmolytics - nitrates and CCBs
TCAs - may provide sx relief
which type of esophageal hiatal hernias are benign and associated with GERD?
sliding hernia
which type of esophageal hernias can become strangulated, enlarge over time so that whole stomach is in thorax and need to be tx. surgically?
paraesophageal hiatal hernia
complications of sliding hiatal hernias
GERD
aspiration
esophagitis
complications of paraesophageal hernias
strangulation
obstruction
hemorrhage
Tx. of sliding hiatal hernia
medical - anatacids, small meals, elevation of head when sleeping
surgery - Nissen’s fundoplication
Tx. of paraesophageal hernia
elective surgery to prevent complications
alcoholic pt presents with hematemesis; last night he binge drank and has been vomiting ever since - likely dx?
Mallory-Weiss syndrome
- ruptured submucosal aa of distal esophagus and proximal stomach
first step in Mallory-Weiss syndrome?
upper endoscopy - diagnostic
Tx. of Mallory-Weiss syndrome
90% heal on their own
can try vasopressin, endocscopic injection or electrocautery
if still continues, surgery (oversew the tear) or angiographic embolization
pt presents with dysphagia, glossitis and iron deficiency anemia?
Plummer-Vinson syndrome - upper esophageal webs
what are patients with Plummer-Vinson syndrome at risk for?
SCC of oral cavity, hypopharynx and esophagus
Tx. of Plummer-Vinson syndrome
esophageal dilation
what does ingesting alkali do to you esophagus?
liquefactive necrosis with full thickness necrosis; may be complicated with stricture formation and esophageal cancer
tx. of necrosis from alklai ingestion
esophagectomy
- avoid vomiting, oral intake and gastric lavage
- steroids and antibiotics
- bougienage for strictures
pt presents with dysphagia, regurgitation, bad breath and chronic cough - what can you suspect?
Esophageal diverticulum
pt presents with oropharyngeal dysphagia and a neck mass that varies in size depending on fluid/food intake
Zenker’s diverticulum
- MC type; in upper third of esophagus
cause of Zenkers
failure of cricopharyngeal mm to relax during swallowing leading to increased intraluminal pressure and outpouching of mucosa through weakened muscle
traction diverticula
midpoint of esophagus; caused by contiguous mediastinal inflammation and adenopathy that causes retraction of esophagus; no tx. required
epiphrenic diverticula
lower third of esophagus due to spastic esophageal dysmotility or achalasia
diagnostic test for diverticula in esophagus
barium swallow
intermittent dysphagia for solids only
lower esophageal ring
progressive dysphagia for solids only
can be either peptic stricture or cancer
intermittent dysphagia for solids and liquids with chest pain
diffuse esophageal spasm
Hamman’s sign
mediastinal crunch - heart beating against air filled tissues in esophageal rupture
diagnostic study for ruptured esophagus
contrast esophagram with soluble Gastrograffin swallow
tx for esophageal rupture
surgery within 24 hours greatly improves survival
most accurate/preferred test for diagnosing ulcers
endoscopy
gold standard for dx. H.pylori
endoscopic biopsy
when is the urea-breath test ok to you for dx of h.pylori?
documents active infection
assesses results of antibiotic therapy
what are the three tests that can test for h.pylori?
biopsy
urea-breath test - most convenient
serology - ab’s can remain elevated longer after eradication
triple therapy for h.pylori
PPI, amoxicillin and clarithromycin
- 10 days to 2 weeks
what drug can be used to reduce risk for ulcer formation associated with NSAID therapy
misoprostol
what kind of therapy is pretty much essential in pts with duodenal ulcers?
triple therapy for h.pylori
how long should a pt with PUD take anti-secretory drugs for?
4-6 weeks if uncomplicated ulcers and patient is asymptomatic; if pt is at risk for recurrence, consider maintenance therapy
how do you diagnose gastric outlet obstruction?
saline load test - empty stomach with NG tube, infuse 750 ml of saline, wait 30 min and aspirate; positive if > 400 ml aspirated
MCC of gastric outlet obstruction
duodenal ulcers type III (prepyloric) gastric ulcers
how do you diagnose perforation of ulcer?
upright CXR shows free air under diaphragm
CT scan is the most sensitive test for perforation
best test for evaluating pt with epigastric pain
upper endoscopy
pt presents with severe hemorrhagic gastric lesions after exposure of gastric mucosa to injurious agents such as NSAIDS and alcohol
acute erosive gastritis
what test is used to dx gastric cancer and what test is used for staging?
dx - endoscopy w/ multiple biopsies
stage - CT scan
5 sites of mets from gastric cancer
Krukenberg - ovary Virchow's node - supraclavicular Irish's node - left axillary node Blumer's shelf - pelvic cul de sac (rectum) Sister Mary Joseph - periumbilical node
how can you clinically tell apart a proximal vs. distal small bowel obstruction?
proximal has lots of vomiting and severe pain whereas distal obstruction has significant abdominal distention
acid-base disorder in small bowel obstruction
hypochloremic, hypokalemia, metabolic alkalosis
what are the indications for surgery in bowel obstruction?
complete obstruction
partial obstruction that is persistent or assoc. with constant pain
strangulation if suspected
abdominal films show a uniform distribution of gas in the small bowel, colon and rectum
paralytic ileus
failure to pass contrast medium beyond a fixed point
paralytic ileus
Tx of paralytic ileus
usually resolves with time or when the cause is addressed medically
- surgery is not usually needed
Tx. algorithm for Crohn’s disease
- 5-ASA - esp. useful if colon involved
- metronidazole - if 5ASA doesnt work
- steroids - acute exacerbations/ if metro doesnt work
- immunosuppressants (azathioprine) - with steroids
- surgery - for complications
Drugs that cause esophagitis
Antibiotics: Tetracyclines
Anti-inflammatory : Aspirin and NSAIDs
Bisphosphonates: Alendronate
Other: KCl, quinidine, Iron
