GI Flashcards
What are the indications for EGD in a patient with GERD?
“Because of the high sensitivity and specificity of symptoms (>90%), most patients do not need endoscopy or any other diagnostic intervention. Patients with refractory GERD or those with new symptoms over age 45 years (50 by some sources) warrant endoscopy.”
What are the red flag symptoms for GERD?
“Red flag symptoms include dysphagia, weight loss, anemia, aspiration, early satiety or vomiting, and cough”
If a GERD patient has already failed H2-blockers and antacids, what is the next treatment?
“Testing is actually less sensitive than symptoms for GERD with the sensitivity of tests varying between 50% and 70%. Many patients have a false-negative EGD. While H2 blockers should still be first-line treatment in patients with GERD, this patient has already failed cimetidine. Starting a proton pump inhibitor (PPI), like omeprazole, is the next step and is preferred as first-line therapy in patients with severe symptoms”
What is the most common finding on EGD for patients with GERD?
“Most patients with GERD will have negative endoscopic findings (termed nonerosive reflux disease[NERD]—really, we didn’t make this one up). Symptoms do not correlate well with the presence or degree of esophageal inflammation or erosion.”
What is the role of fundoplication in GERD?
“While fundoplication will alleviate symptoms in 80–95% of patients, there is progressive loss of effectiveness over time (only 40% are without medication after 10 years). Adverse effects of surgery include persistent dysphagia (requiring additional interventions in 3–7%), gas, bloating, and inability to belch”
What is Barrett’s esophagus and what are 2 risk factors?
“Barrett esophagus is diagnosed histologically when esophageal mucosal metaplasia has occurred and the usual squamous epithelial cells have changed to columnar epithelium. Risk factors for Barrett include long-standing reflux, male gender (6:1 male:female preponderance), middle age, tobacco use, and white race. Barrett esophagus occurs in 10–15% of patients with erosive esophagitis, and it dramatically increases the risk of esophageal adenocarcinoma (30-fold). However, the absolute risk of adenocarcinoma is still small, about 0.12–2% annually”
What is the CREST syndrome?
“CREST is an acronym for a syndrome that includes Calcinosis cutis, Raynaud phenomenon, Esophageal dysmotility, Sclerodactyly, and Telangiectasias. Figure 7–1 shows telangiectasias on the palmar digital pad. Up to 60% of patients with CREST have erosive esophagitis. Dysphagia is common and is due to esophageal stricture and/or dysmotility.”
What is the appropriate management for the esophageal dysmotility that is related to the CREST syndrome?
“Severe reflux and dysphagia are hallmarks of CREST syndrome. The esophagus may be amotile with impaired function of the lower esophageal sphincter. The barrier to acid reflux and the motor clearance of refluxing material are affected, requiring chronic and potent acid suppressive medications, such as PPIs” “Steroids could worsen the GI symptoms by irritating the gastric mucosa”
How does eosinophiliac dysphagia present?
“The classic adult patient presents with dysphagia to solids to the extent that it may cause food impaction. Children often present with feeding problems (age 2), recurrent vomiting (age 8), and chronic abdominal pain (age 12) or food impaction (teenage years). Association with childhood asthma is strong and dietary elimination therapy may be helpful in children.”
What is the treatment for eosinophiac dysphagia?
“Treatment in adults (and often children) involves swallowing inhaled corticosteroids (fluticasone), montelukast, and, in severe cases, systemic steroids. Systemic eosinophilia is rare.”
A person develops regurgitation 4 hours after eating. What is the most likely diagnosis?
“Late regurgitation of undigested food is pathognomonic for Zenker diverticulum. A Zenker diverticulum is an outpouching of esophageal mucosa that is acquired and typically becomes symptomatic in middle age or later in life. The diagnosis is confirmed by lateral view of a barium swallow.”
What is nonulcer dyspepsia?
“Nonulcer dyspepsia is an ill-defined condition characterized by the presence of recurring intermittent symptoms of epigastric discomfort and fullness with other associated symptoms in the absence of mucosal lesions or other structural abnormalities of the GI tract. Nonulcer dyspepsia is also known as “functional dyspepsia,” as there are no identifiable structural or anatomic abnormalities of the GI tract. While about 20% of the general population has nonulcer dyspepsia, only about 20% of these seek medical attention”
Name 3 symptoms of nonulcer dyspepsia.
“Nonulcer dyspepsia is characterized by all the other symptoms and also includes such symptoms as abdominal distention, borborygmi (i.e., grandpa’s tummy gurgling heard across the room at Thanksgiving), epigastric or substernal pain, anorexia, nausea, vomiting, and abdominal tenderness.”
What is the preferred test for H. pylori?
“13C urea breath test or stool antigen test”
A patient begins to have diarrhea shortly after beginning a regimen involving a PPI and an H2 blocker to treat nonulcer dyspepsia. Which of the two drugs is most likely the culprit and why?
“Diarrhea is a common adverse effect of PPIs that occurs in at least 5–7% of patients. Discontinuation leads to a rapid resolution in the majority of cases. While reduced stomach acidity from PPIs or H2 blockers may result in bacterial colonization of the proximal GI tract, the early onset and severity of symptoms described argue against bacterial overgrowth as the etiology of this patient’s symptoms. While PPIs can elevate gastrin levels, the hypergastrinemia seen is not comparable to levels seen in Zollinger-Ellison syndrome, which can also cause diarrhea. Stool studies and empiric therapy with antidiarrheals may be considered if discontinuing the PPI does not improve symptoms”
Which drugs are commonly used to treat nonulcer dyspepsia?
“There are no drugs that have great evidence to support their use in nonulcer dyspepsia. PPIs and H2 blockers are often used. Prokinetic agents may be helpful, and in the United States this means metoclopramide or erythromycin. Cisapride has been removed from the market secondary to cardiac arrhythmias (QT prolongation with torsades de pointes). Metoclopramide, of course, is associated with tardive dyskinesia and extrapyramidal reactions. Erythromycin causes GI side effects and prolonged QT”
In the treatment of nonulcer dyspepsia, are drugs more effective than placebo?
“Up to 60% of patients in placebo-controlled trials respond to placebo, making it difficult to prove efficacy of medications. As the above number suggests, spontaneous resolution of symptoms is common, while many patients will have a chronic, intermittent course characterized by symptom-free periods. Most patients will not develop serious pathology”
What are the lifestyle modifications that may be helpful for nonulcer dyspepsia?
“avoid tobacco, caffeine products, and alcohol) and limit or avoid aggravating medications (NSAIDs). Patients should chew their foods slowly and eat more frequent, small meals. Finally, if there is underlying psychiatric morbidity, relaxation training or treatment of specific diseases can be helpful”
What are some of the side effects of PPI’s?
“PPIs are not benign drugs and have been associated with (1) increased risk of hip fracture in the elderly, (2) increased risk of pneumonia, (3) increased risk of Clostridium difficile colitis, and (4) diarrhea as noted above. Stop them as soon as possible”
A normal hemoglobin excludes the existence of a significant G.I. bleed. True or false?
“a normal hemoglobin does not exclude a significant acute bleed, as hemodilution (in the absence of IV fluids) requires several hours”
Orthostatic changes are an absolute indication of hypovolemia. True or false?
“Orthostatic vital signs are not that useful in determining a patient’s volume status. Many hypovolemic patients are not orthostatic and many patients who are euvolemic have orthostatic changes (e.g., patients on antihypertensives and the elderly). So, use orthostatic vital signs to confirm your clinical suspicion, but do not use them as an absolute guide to the patient’s volume status (JAMA 1999;281:1022–1029”
What is the risk of developing a clinically significant G.I. bleed on NSAIDs?
“The risk of a clinically significant NSAID-related GI event, including GI bleeding, perforation, or obstruction, is about 1–4% per year.”
Patients who have suffered a G.I. bleed from an ulcer due to an and said she’d be continued and aunt acids in definitely. True or false?
“Patients with uncomplicated and small (<1 cm) duodenal or gastric ulcers who have received adequate treatment of H. pylori or NSAID-induced ulcer do not need long-term therapy directed at ulcer healing as long as they are asymptomatic following therapy. Antisecretory drugs can be discontinued after 4–6 weeks in these patients”
After in endoscopic examination identifies an ulcer, it is necessary to do a follow-up endoscopic evaluation to confirm it’s healing. True or false
“While nonhealing ulcers may be due to a neoplasm, the vast majority of duodenal ulcers are benign. Therefore, neither endoscopic nor radiologic documentation of healing is necessary”