GI Flashcards
1
Q
Odynophagia =
Dysphagia =
A
painful swallowing
difficulty swallowing
2
Q
Causes of esophagitis
A
- infections related to immunocomp’d patient: Candida, Herpes, CMV
- GERD
3
Q
How does endoscopy with biopsy for esophagitis patient differentiate the infectious causes?
A
Herpes – Multiple shallow ulcers throughout the esophagus
CMV – Large solitary deep ulcers
Candida – Raised white plaques which can be removed
4
Q
How is esophagitis caused by Candida treated?
A
Fluconazole x 3 weeks
5
Q
Diagnostic test of choice for most esophageal and gastric issues
A
Barium swallow
6
Q
Why is there concern for doing an endoscopy with diverticula?
A
possible perforation
7
Q
What is diverticula within the esophagus called?
A
Zenker’s Diverticula
8
Q
Zenker’s Diverticula treatment
A
Hydration after meals
Thorough chewing
Surgical repair of diverticula
9
Q
Decreased peristalsis of the esophagus along with increased muscle tone of the lower esophagus
A
Achalasia
10
Q
Barium swallow of achalasia
A
bird’s beak (clear tapering at LES)
11
Q
I came in to see my physician assistant because of…
- Regurgitating undigested food hours after a meal
- Bad breath
- Neck pain
- Odynophagia
- Dysphagia
A
Zenker’s Diverticula
12
Q
I came in to see my physician assistant because of…
- Dysphagia with both fluids and solids and will continue to get progressively worse
- Regurgitation of undigested foods
- Non-cardiac chest pain
A
Achalasia
13
Q
Achalasia treatment
A
CCBs – Nifedipine
Try to dilate LES: Nitrates, Botox injections, Pneumatic dilation
Surgical myotomy
14
Q
Patient c/o forced retching vomiting and is now vomiting blood. Also has epigastric pain. Likely dx?
A
Mallory-Weiss tears (longitudinal lacerations of esophagus)
15
Q
Mallory-Weiss tear treatment
A
Usually self limiting
Transfusion if high loss of blood
Endoscopy with epinephrine injection or thermal coagulation
16
Q
Treatment of esophageal strictures
A
Treat for GERD since most likely cause
PPIs - omeprazole
H2 Blockers - Zantac
Surgical correction
17
Q
DDX of hematemesis (vomiting blood)
A
Mallory-Weiss tears, esophageal varices, PUD, cirrhosis…
18
Q
I came in to see my physician assistant because of…
- Substernal chest pain
- Pain typically postprandial
- Dysphagia
- Chronic dry cough and laryngitis
A
GERD
19
Q
I came in to see my physician assistant because of…
Hematemesis (vomiting blood)
Black, tarry or bloody stool
Signs and symptoms of GI bleed (lightheaded etc)
A
Esophageal varices
20
Q
Pathophysiology of esophageal varices
A
dilated veins of esophagus secondary to alcoholism, cirrhosis, and/or portal HTN
21
Q
What is diagnostic and therapeutic for esophageal varices?
A
Endoscopy
- Variceal ligation or banding
- Sclerotherapy
- Balloon tamponade
22
Q
Behavior modifications to relieve GERD?
A
Smaller portion sizes Not laying down after meals Weight reduction Avoid acidic foods Avoid things that relax the lower esophageal sphincter - fatty foods, mint, chocolate, alcohol, smoking
23
Q
Medical treatment for GERD
A
OTC antacids - rolaids, TUMS, Pepto-Bismol, Milk of Magnesia
H2 blockers - rantidine (Zantac), famotidine (Pepcid)
PPIs - omeprazole
24
Q
Possible complications of GERD
A
Increased risk for esophageal strictures
Barrett’s esophagus (pre-malignancy)
Peptic ulcers
25
I came in because of…
- Unexplained weight loss
- Abdominal discomfort
- Dysphagia
- Anorexia
- Enlarged left supraclavicular lymph node (virchow’s node)
Must not miss dx?
Gastric adenocarcinoma
26
Risk factors for gastric adenocarcinoma
Smoking
H. Pylori
Male (3:1)
27
Gastrin secreting tumor of pancreas resulting in GERD symptoms, diarrhea, and unexplained weight loss?
Zollinger Ellison Syndrome (gastrinoma)
28
Patient c/o achy stomach pain, nausea, hematemesis, and anorexia. Urea breath test positive for H. pylori. Likely dx?
Peptic ulcer disease
29
Where can peptic ulcer disease occur? Most likely spot?
mucosal lining of stomach or duodenum
ulcer 4-5x more likely to be found in duodenum
30
Risk factors for Peptic Ulcer Disease
H. Pylori (90% of cases)
NSAIDS
Smoking
31
How is H. Pylori detected?
urea breath test
32
Gold standard for PUD diagnosis
endoscopy with biopsy
33
Peptic Ulcer Disease treatment plan
1st line: triple therapy = PPI + 2 antibiotics x 2 weeks
(omeprazole + clarithromycin + amoxicillin)
Quadruple therapy = PPI + bismuth subsalicylate + 2 antibiotics x 2 weeks
PPIs long term
Surgical repair of ulcer if necessary
34
An 4 wk old infant comes in with projectile vomit and abd distention. Epigastric olive-like mass found on palpation. DX?
Pyloric stenosis
35
Barium swallow test results for Pyloric Stenosis
String sign
| or railroad track sign
36
Treatment of Pyloric Stenosis
Fluids for dehydration
Pyloromyotomy (Ramstedt’s procedure)
37
Average age of Pyloric Stenosis
6 weeks old
38
corkscrew appearance on Barium swallow =
esophageal spasms
39
What is the best test to diagnose peptic ulcer disease?
endoscopy
40
A 65 year old male has had GERD for years. Over the past year he has noticed an increase in difficulty swallowing his food. What is the most likely diagnosis?
Esophageal strictures
| achalasia and esophageal also possible, but strictures more likely with h/o GERD
41
________ is a direct cause of esophageal varices.
Portal HTN
42
________ is an infection of the gallbladder.
Cholecystitis
43
Explain pathophysiology behind the most common cause of Cholecystitis.
90% of cases are associated with gallstones (cholelithiasis)
Cholesterol builds up in gallbladder to form stones that can block cystic duct (choledocholithiasis)
44
Risk factors for Cholecystitis
```
Native American
Females slightly higher rate
Obesity
Diabetes
Pregnancy
Crohn’s disease
```
45
What is Murphy sign? When is it positive?
Inhibited inspiration with pressure over RUQ secondary to pain
Cholecystitis
46
Woman comes in with pain in RUQ that worsens after fatty meals. She is jaundice and has elevated bilirubin. DDX?
Cholecystitis, Cholangitis
47
Cholecystitis treatment
Asymptomatic gallstones require no treatment
Initially antibiotics and NSAIDs are given to stabilize patient and bring down inflammation (2nd gen cephalosporin OR fluoroquinolone + Metronidazole)
Cholecystectomy is the definitive treatment for cholecystitis
48
Labs that indicate gallbladder infection
WBC
Bilirubin
Alk Phos and ATF
* all will be elevated
49
Charcot's triad includes symptoms for what disease? What are sx's?
pain, fever, jaundice = Cholangitis
50
What is Reynold's pentad?
Charcot's triad + hypotension and altered mental status = EMERGENCY!!!
51
DDX of RUQ pain
```
Cholecystitis
Cholangitis
Choledocholithiasis
Hepatitis A, B
...
```
52
Most common cause of Cholangitis?
choledocholithiasis
53
Test of choice for Cholangitis
ERCP (Endoscopic retrograde cholangiopancreatography) because it can both diagnose and treat with stone extraction and sphincterotomy
54
infection of common bile duct is
cholangitis
55
Hepatits A treatment
Supportive care as illness is self limiting with full recovery in about 9 weeks
Vaccine available
56
How is Hepatitis A differentiated from other RUQ pains?
hepatomegaly
| anti-HAV
57
Hepatitis A, B, and C transmission
A: fecal-oral
| B, C: blood, needles, sex, across placenta
58
Incubation period of Hep B
6 wks - 6 months
59
Acute and chronic Hep B treatment
Vaccination available; given to all infants
Acute - usually self limiting with sx's improvement in 2-3 weeks and full recovery in 16 weeks; however some become chronic
Chronic - Antiviral therapy
60
What do HBsAG, Anti-HBs, and Anti-HBc indicate on serum testing for Hep B?
HBsAG (surface antigen) = disease; either acute or chronic
Anti-HBs (Antibody to surface antigen) = immunity; vaccine or recovery from previous infection
Anti-HBc (Antibody to core antigen) = has infection or h/o infection
61
30% of ____ patients are found to also have Hep C.
HIV
62
How will untreated Hep B and C progress?
chronic hepatitis -> cirrhosis -> hepatoellular carcinoma or liver faliure
63
Hep C treatment
Self limiting and recovery is complete in 3-6 months
Meds if doesn't resolve in 3 months and becomes chronic: Interferon alpha, Pegylated interferon, Ribavirin
64
Labs to help dx Hep C
screen for anti-HCV antibody
65
Which hepatitis most likely to become chronic?
Hep C
66
Patient must have _____ in order to contract Hep D.
Hep B
67
Risk factors for cirrhosis
```
Chronic hepatitis
Chronic alcohol abuse
Drug toxicity
Age > 55
Diabetes
Obesity
```
68
Symptoms associated with decreased liver function?
```
jaundice
hepatomegaly
ascites
peripheral edema
asterixis
caput medusa
spider angioma
```
69
Labs results associated with decreased liver function?
Elevated bilirubin (mostly conjugated)
Increased prothrombin time
Decreased serum albumin
70
Diagnostic imaging for cirrhosis
U/S to determine liver size and hepatic blood flow
| CT/MRI with contrast to find hepatic nodules
71
How to manage/treat cirrhosis?
STOP DRINKING ALCOHOL!!!
Treat symptoms:
- restrict fluids and Na+ for edema and ascites
- daily folate, iron for anemia
- fresh frozen plasma for increased bleeding time
ultimately need liver transplant
72
Most cases of cirrhosis will progress to _______.
hepatocellular carcinoma
73
What lab value can differentiate liver cancer from cirrhosis?
hepatocellular carcinoma will have elevated WBC and cirrhosis will not
74
How can hepatocellular carcinoma be prevented?
Hep B vaccines
Monitor patients with cirrhosis or chronic hepatitis with alpha fetoprotein and U/S
75
Test of choice for dx of pancreatitis
CT
76
What are Cullen and Turner signs? What pathology do they suggest?
Cullen sign – ecchymosis in periumbilical region
Turner sign – ecchymosis in the flanks
Both positive in pancreatitis
77
What is included in liver function panel?
bilirubin, Alk phos, ALT/AST, ATF
78
Patient with acute epigastric pain that is alleviated by sitting or leaning forward. Bruising is seen around umbilicus. Likely dx?
acute pancreatitis
79
What is included in a BMP lab order?
BUN, creatinine, glucose, Na, K, Ca
80
Median survival for cases of pancreatic cancer?
less than 1 year
81
Risk factors for pancreatic cancer
```
Age > 60
FHX
Diet - Low in fruits and veggies, high in red meat and sugar
Smoking
Obesity
```
82
Pancreatitis treatment
```
IV fluids
Monitoring of vitals
Pain medication
NPO
Treat abnormal labs -blood transfusion, calcium, albumin
```
83
What lab value is 3x normal level in pancreatitis?
serum amylase
| lipase
84
What is the Trousseau sign?
tender nodules within veins which are small venous thrombi
Hallmark of hypercoagulable state associated with some cancers (pancreatic)
85
Surgical treatment for Pancreatic Cancer
Whipple procedure
major surgery involving a pancreaticoduodenectomy, a gastro-jejunostomy and a cholecystojejunostomy. A successful procedure results in 5 year survival rate of about 20%
86
Abdominal pain beginning periumbilical and moving toward the RLQ
appendicitis
87
Positive tests for appendicitis on PE
Rebound tenderness
Tenderness over McBurney’s point – located on the right side of the abdomen one third of the way from the anterior superior iliac spine to the umbilicus
Obturator sign – pain with flexion and internal rotation of the right hip
Psoas sign – pain with either passive right hip extension or active right hip flexion
88
What are specific managements of appendectomy pre-op?
Keep patient NPO
| IV antibiotics
89
Pathophysiology of Celiac disease
Autoimmune disease which is an inflammatory reaction to the protein gluten
Damages villi of small intestine causing poor absorption of nutrients
90
Treatment of Celiac Disease
gluten free diet (avoid wheat) and intestinal villi should heal within weeks
91
What is clinical definition of constipation?
less than 2 bowel movements per week
92
Constipation treatment
```
Fiber supplements
Mineral oil
Osmotic or stimulant laxatives
Digital disimpaction
Enema
```
93
Diverticulosis vs Diverticulitis
Diverticulosis is out-pouching of diverticula due to weakened intestinal walls
Diverticulitis if diverticula become inflamed
94
What tests are contraindicated in acute diverticulitis due to risk of perforation?
endoscopy and colonoscopy
95
Typical location of diverticulitis pain
descending colon in LLQ
96
Treatment of mild/moderate and severe diverticulitis
Mild/mod treated conservatively:
Clear liquid diet
Oral antibiotics (metronidazole, cipro, Augmentin)
Severe:
NPO
IV fluids and abx
Surgery - Removal of diseased colon with temporary colostomy
97
DDX LLQ pain
diverticulitis
diverticulosis
Crohn's Disease
Ulcerative Colitis
98
Labs to look for malnutrition
B12, folate, iron, albumin
99
Disease with cobblestone appearance and skip lesions on colonscopy?
Crohn's Disease
100
Common effects of Crohn's Disease on GI tract
strictures, fistulas, abscesses
| B12 deficiency anemia in small intestines
101
Management of Crohn's Disease
```
Smoking cessation
Encourage fluids
Treat malnutrition
Anti-diarrheals
ABX prn
Prednisone for inflammation
Surgery if abscess, stricture, or fistula
```
102
Patient with bloody diarrhea and abd pain localized to LLQ. Blood is found on DRE but stool cultures are negative. Likely dx?
Ulcerative colitis
103
Difference in sx's and location of Crohn's and Ulcerative colitis
Crohn's: non-bloody diarrhea, can occur anywhere along GI tract (usually intestines)
UC: bloody diarrhea, restricted to colon
104
Ulcerative colitis treatment
NPO only in severe colitis
Topical or oral aminosalicylate agents – 5 ASA (mesalamine)
Topical or oral corticosteroids
Surgical removal of the colon
105
Massive dilation of the colon in acute colitis that makes patient extremely sick.
Toxic megacolon
106
Child laying on exam table holding his knees to chest. Palpable sausage-shaped abdominal mass
Intussusception
107
Pathophysiology of intussusception vs volvulus
intussusception: portion of bowel telescopes into another portion of bowel
volvulus: twisting of bowel on itself
* both cause bowel ischemia
108
Typical age range of intussusception
3 mon to 6 yrs
109
Dx and Tx of intussusception
air contrast enema
110
Patient comes in with diffuse acute abd pain and distention. There are signs of shock and patient has started vomiting. XR shows air fluid levels. Likely dx and tx?
Volvulus
MEDICAL EMERGENCY!
Need surgery
111
Risk factors for ischemia bowel disease
```
> 60 yo
History of a-fib
Vasculitis
Hypercoagulable states
Uses of vasoconstrictors - vasopressins, cocaine, etc.
```
112
currant jelly stool =
intussusception; secondary to bowel ischemia (later finding)
113
Likely dx of patient with severe abdominal pain that is out of proportion to your exam. Has sx's of bloody diarrhea, fever, and shock.
Ischemic bowel disease
114
Treatment of ischemic colitis and mesenteric ischemia
Ischemic colitis
- Supportive care including NPO and IV fluids
Mesenteric Ischemia
- Surgical removal of ischemic bowel
- Patients have 50% survival rate if dx'd within 24 hrs
115
#1 cause of small bowel obstruction
adhesions following abdominal surgery
116
#1 cause of large bowel obstruction
carcinoma
117
Early and late PE findings of bowel obstruction
Early obstruction
- Peristaltic waves
- High pitched bowel sounds
Late obstruction
- Peristaltic waves stop
- Bowel sounds quiet down and stop
118
Abdominal XR findings of bowel obstruction
Dilated loops of bowel
Air fluid levels – step ladder appearance
Free air
119
Condition defined by...
- Abd pain relieved with defecation
- Change in freq, form, or appearance of stool
- Sx's for +6 months
- Normal PE
Irritable bowel syndrome
120
Possible treatments of Irritable Bowel?
```
Modified diet - fiber, probiotics, avoiding aggravators
Increase exercise
Anti-spasmodics
Laxatives
SSRIs or TCAs
```
121
Recommendations for colorectal cancer screening - tests and how often?
Colonoscopy: every 10 years starting at age 50 (more often if h/o polyps)
Fecal occult blood test: annually starting at age 50
122
95% of adenocarcinoma of the colon come from _____ found on colonoscopy.
polyps
123
When is colon polypectomy indicated?
polyps > 2-3 cm
124
Air fluid levels or step ladder appearance on abdominal XR =
perforated bowel
125
Who is at higher risk for colorectal cancer?
H/O of colon polyps, Crohn's disease, or ulcerative colitis
Increasing age
FHX
African Americans
126
Symptoms if neoplasm in rectum
tenesmus
| hematochezia = bright red blood in stool
127
List all 5 of Ranson's Criteria
```
Age > 55 years old
WBC > 16,000
Glucose > 200
Lactate dehydrogenase (LDH) > 350
Aspartate aminotransferase (AST) > 250
```
used to assess severity of pancreatitis upon admission
mneumonic: "GA LAW"
128
What are the first 3 steps in managing pancreatitis?
NPO, IV fluids, pain medication
** Abx currently not recommended. A surgical consult is unnecessary for pancreatitis.
129
A 45 yo male presents with a low grade fever and abdominal pain. He has had non bloody diarrhea x 2 weeks. You decide to have the patient undergo a colonoscopy. On the report it mentions a cobblestone appearance. What is the most likely diagnosis?
Crohn's Disease
130
What are some tests to eval Celiac Disease? What is the definitive test?
Serum antibodies
Gluten challenge
Anti tTG assay
Endoscopic biopsy (definitive)
131
Patient has extreme rectal pain especially during bowel movements. Ulcers are visualized on posterior midline of rectum. DX?
anal fissure
132
Anal fissure treatment
```
Increase fiber
Stool softeners
Sitz baths
Topical nitroglycerin
Botox injection into the anasl sphincter
Sphincterotomy
```
133
An abscess can form if anal gland gets blocked. A ______ is the tract that forms from abscessed gland to skin.
fistula
134
Patient has severe rectal pain with opening of skin near anus. There is purulent discharge and area is tender, red, and swollen. Dx and tx?
anal fistula
tx: surgical drainage and/or repair
135
How is fecal impaction treated and prevented?
Laxatives, water or oil enema
Manual disimpaction
Prevention: reduce occurrence of constipation
136
Ways to prevent constipation
```
increase fiber
increase fluids
daily exercise
regular bowel habits
avoid opiates
```
137
What differentiates internal from external hemorrhoids?
- dentate line divides them
- internal are painless and external are painful
- both have bright red blood per stool
138
What diagnostic imaging is used to assess hemorrhoids?
anoscopy
139
How are hemorrhoids treated and when can they be manually reduced?
Grade I-III (may be manually reduced)
- Sclerotherapy
- Rubber band ligation
- Electrocoagulation
Grade IV or thrombosed (can't be reduced)
- Surgical excision
Symptomatic - Sitz bath, increased fluids and fiber
140
movement of an organ through the wall which normally contains it is called a ________.
hernia
141
Strangulated hernia
a hernia whose blood supply has been cut off; ischemic bowel
142
Most common type of hernia
inguinal hernia
143
indirect vs direct inguinal hernias
Indirect: hernia sac enters inguinal ring through a congential defect
Direct: protrude through weakening in fascia of Hesselbach’s triangle
144
Boundaries of Hesselbach's triangle
rectus abdominalis, inguinal ligament, and inferior epigastric artery
145
2 types of groin hernia? Which is more complicated?
Inguinal - more common
| Femoral - rare but more likely to strangulate
146
Diagnostic imaging for hernias
U/S with doppler
| CT (study of choice)
147
How are hernias managed?
Unincarcerated
- monitor
- reduce if possible
Incarcerated
- NPO
- Narcotics
- Reduce if possible
- Surgical repair
Strangulated
- Surgical emergency!
148
Clinical definition of diarrhea
3 or more watery bowel movements per day OR increase in freq
149
Non-infectious pathologies that cause diarrhea
Inflammatory bowel disease
Irritable bowel disease
Celiac disease
Lactose intolerance
150
Which part of nervous system allows for LES to relax and let food into stomach?
parasympathetic
** nerve branches damaged in achalasia
151
What chemicals stimulates acid release in stomach?
Histamine
Gastrin
Acetylcholine (parasympathetic)
152
H+ release into stomach is inhibited by what?
Somatostatin
Prostaglandins
Secretin
153
Why do NSAIDs cause decreased mucosal protection in the stomach? Which NSAIDs are least damaging?
inhibit prostaglandins which increase mucus secretion
COX-2 inhibitors have fewer GI side effects (Celebrex)
154
Function of the following cells in the stomach: G cells, parietal cells, mucus cells
G cells -> gastrin
parietal cells -> H+ and intrinsic factor
mucus cells -> mucus
155
When and where is secretin secreted? What is its function?
produced by small intestines when food arrives from stomach
stimulates pancreas to secrete bicarbonate to neutralize duodenal contents
inhibits gastrin secretion and thus stomach acid
156
MOA of H2 blockers in peptic ulcer treatment
block histamines that help stimulate parietal cell secretion of H+
157
When food exits stomach, the duodenum, pancreas, and gall bladder release what?
duodenum - CCK and secretin
pancreas - bicarbonate and digestive enzymes
gall bladder - bile
158
Typical virus that causes diarrhea
Rotavirus
159
Define Inflammatory Bowel Disesae (IBD)
chronic inflammation of all or part of GI tract
| Crohn's Disease and Ulcerative Colitis
160
Significance of "coffee grounds" vomit
indicates bleeding after the gastro-esophageal junction
blood has been digested
gastric or duodenal ulcer
161
What is hematochezia?
bright red blood in stool
162
DDX of hematochezia
hemorrhoid
colon cancer
diverticula
163
Where do all the absorbed nutrients from the gut go? via what?
nutrients in gut's venous system go to the liver via the hepatic portal vein
164
_______ occurs due to an increase in conjugated or unconjugated bilirubin.
jaundice
165
Elevation in specifically conjugated bilirubin indicates what?
liver is not secreting bile OR bile cannot be released due to biliary tree obstruction
166
Signs of elevated bilirubin
jaundice (yellowing of skin and sclera)
clay-colored stools
tea-colored urine
itchy skin (bile salt deposits)
167
Elevated AST and ALT =
liver injury
168
Labs that measure liver function? What function specifically?
bilirubin - conjugation
albumin - protein synthesis
PT - clotting factor synthesis
169
Elevated _____ associated with acute liver disease, while a decrease in _____ is generally chronic liver disease.
PT
| albumin
170
Elevated Alkaline Phosphate =
biliary obstruction
171
Serology result that indicates patient has new infection of Hep B? chronic infection?
IgM anti-HBcAg = new infection
| IgG anti-HBcAg = old infection
172
Which hepatitis does not become chronic?
A and E
173
What does positive HBeAg indicate?
highly infectious Hep B
174
Autosomal recessive disease that causes bronze skin, cirrhosis, diabetes, and restrictive cardiomyopathy
Hemochromatosis - high iron in blood
175
Autosomal recessive disease that causes cirrhosis, Kayser-Fleischer rings in eyes, and increased urinary copper.
Wilson's Disease
176
Alcoholic comes to the ER vomiting blood. Classic scenario of what condition?
esophageal or gastric varices
177
pathophysiology of hepatic encephalopathy
liver failure -> decreased detoxification reactions -> toxic chemicals get to brain -> delirium
178
Trace pathway of biliary tree from liver to gall bladder and duodenum
R and L hepatic ducts -> common hepatic duct -> common bile duct -> ampulla of Vater (converges with pancreatic duct) -> duodenum
common hepatic duct -> cystic duct -> gall bladder
179
_____ stimulates contraction of gall bladder and release of bile.
CCK from duodenum
180
_______ is inflammation and obliteration of extrahepatic biliary system in neonates. Have jaundice which leads to severe cirrhosis.
Biliary atresia
181
Two most common causes of pancreatitis
alcoholism and gallstone that obstructs pancreatic duct
182
"Female, fat, forty, and fertile" describes at-risk patient for what pathology?
cholesterol gallstones
183
PE findings of peritonitis
rebound abd pain
guarding
* PID, appendicitis, ruptured bowel???
184
Some conditions that predispose a patient to development of GERD
hiatal hernia, pregnancy, scleroderma, incompetent esophageal sphincter, obesity
