GI #4 Flashcards
Infectious esophagitis MC occurs in those with _______, but can occur in healthy individuals as well
Immunocompromised states (HIV, post-transplant, malignancy, chemotherapy)
MCC of infectious esophagitis
Candida
Clinical manifestations of infectious esophagitis (triad of symptoms)
- Odynophagia
- Dysphagia
- Retrosternal chest pain
On endoscopy for Candida infectious esophagitis, what is expected to be seen?
-linear yellow-white plaques
First-line treatment for Candida infectious esophagitis
- PO Fluconazole
- 2nd line options: Voriconazole, Caspofungin
On endoscopy for CMV infectious esophagitis, what is expected to be seen?
-Large, superficial shallow ulcers
What is the first-line treatment for CMV infectious esophagitis?
Ganciclovir
What is expected to be seen on endoscopy for HSV esophagitis?
small, deep ulcers
What is the first-line treatment for HSV esophagitis?
Acyclovir
Eosinophilic esophagitis is MC seen in…
Children and associated with atopic disease (asthma, eczema, etc.)
Symptoms of eosinophilic esophagitis
Dysphagia (solids), Odynophagia, Reflux or feeding problems in kids
What is seen on endoscopy for eosinophilic esophagitis?
-Normal or multiple corrugated rings, white exudates
Management for eosinophilic esophagitis
- Remove foods that incite allergic response
- PPIs may be needed in some
- Inhaled topical corticosteroids WITHOUT a spacer to allow penetration
What medications MC cause pill-induced esophagitis?
- NSAIDs
- Bisphosphonates
- BB, CCB
- Iron Pills
- Vitamin C
How do you manage pill-induced esophagitis?
- Take pills with at least 4 ounces of water
- Avoid laying down 30-60 minutes after pill ingestion
What is caustic (corrosive) esophagitis from?
-Ingestion of corrosive substances: alkali (drain cleaner, bleach) or acids
Management of caustic (corrosive) esophagitis
- Supportive
- Pain medications
- IVF
MC type of hiatal hernia
Sliding (Type I): GE junction slides into mediastinum (increases reflux)
MC type of hiatal hernia
Sliding (Type I): GE junction slides into mediastinum (increases reflux)Wh
A paraesophageal hiatal hernia (rolling hernia), occurs when
the fundus of the stomach protrudes through diaphragm with the GE junction remaining in anatomic location
Symptoms of a hiatal hernia
- Postprandial fullness (prolonged persistence of food in stomach)
- May be asymptomatic
- May have intermittent epigastric pain
- Nausea, vomiting
Treatment for sliding hernia
-Management of GERD + PPI + Weight loss
Treatment for paraesophageal hernia
-Surgical repair if complications (volvulus, strangulation, bleeding)
What is an esophageal atresia?
Complete absence or closure of a portion of the esophagus (associated with tracheoesophageal fistula, polyhydramnios)
Symptoms of esophageal atresia
-Presents immediately after birth with excessive oral secretions that lead to choking, drooling, inability to feed, respiratory distress, and coughing
How to diagnose esophageal atresia?
- Inability to pass NG tube further than 10-15 cm (coiling in esophagus)
- Fluoroscopy: water-soluble contrast may help visualize it
How to treat esophageal atresia
-Surgical ligation of fistula
GERD is due to an
Incompetent lower esophageal sphincter
What is the pathophysiology of GERD
-Transient relaxation of LES (incompetency) –> gastric acid reflux –> esophageal mucosal injury
Typical Symptoms of GERD
- Heartburn (Pyrosis): increased with supine position
- Sour taste in mouth
- Cough
- Sore Throat
- Regurgitation
Alarm Symptoms of GERD
- Dysphagia
- Odynophagia
- Weight loss
- Bleeding
4 main complications from GERD may present with alarm symptoms
- Esophagitis
- Stricture
- Barrett’s Esophagus
- Esophageal Adenocarcinoma
Although GERD is a clinical diagnosis based on history if presenting with classic, typical symptoms, what is the GOLD standard if confirmation is needed?
-24-hour ambulatory pH monitoring
What does an esophageal manometry show if the patient has GERD?
Decreased LES pressure
If the patient has persistent symptoms or alarm symptoms, what diagnostic should be done?
Endoscopy
Management for early or Stage 1 GERD
-Lifestyle modifications: elevate head of bed, avoid laying down for 3 hours after eating, smoking cessation, decreased alcohol intake, avoid chocolate/peppermint/caffeine/spicy foods, weight loss
Management for Stage 2 GERD ( < 2 episodes per week)
Antacids and H2 receptor antagonists
Management for Stage 3 GERD ( 2 or more episodes per week)
PPI
If the GERD is medication-refractory, what is the treatment?
Nissen fundoplication
Name some H2 receptor antagonists
- Famotidine (Pepcid)
- Cemetidine (Tagamet)
- Nizatidine
Name some PPI
- Omeprazole
- Pantoprazole
- Rabeprazole
Mechanism of action of PPI
-block gastric acid secretion by irreversibly binding to and inhibiting the hydrogen-potassium ATPase pump that resides on the luminal surface of the parietal cell membrane
What is Barrett’s Esophagus?
-Esophageal squamous epithelium replaced by precancerous metaplastic columnar cells from cardia of stomach (complication of long-standing GERD)
How to diagnose Barrett’s Esophagus
-Upper endoscopy with biopsy
Recommendations for treatment based on findings of upper endoscopy with Barrett’s Esophagus…
- Barrett’s Esophagus only (metaplasia): PPI and rescope every 3-5 years
- Low-grade dysplasia: PPI and rescope every 6-12 months
- High-grade dysplasia: Ablation with endoscopy, radio frequency ablation
What type of esophageal neoplasms is the MC in the US?
Adenocarcinoma
Adenocarcinoma of the esophagus is common in ______ and is MC in what area of the esophagus?
Caucasian males
-Distal esophagus, esophagogastric junction
What type of esophageal neoplasm is the MCC worldwide?
Squamous cell
Squamous cell esophageal cancer is MC in _____ and is most common in what area of the esophagus
- African-Americans
- Mid to upper third of esophagus
Risk factors for Adenocarcinoma of the esophagus
- Barrett’s Esophagus
- Smoking
- High body mass index
Risk factors for Squamous Cell Carcinoma of the Esophagus
- Smoking
- Alcohol
- Poor Nutritional status
- Drinking beverages at high temperatures
- HPV infection
- Achlasia
What are two protective factors for esophageal neoplasms?
-Aspirin or NSAIDs
What are some symptoms of esophageal neoplasms?
- Progressive dysphagia (solid food progressing to fluids)
- Odynophagia
- Weight loss, anorexia
- Iron deficiency anemia (chronic blood loss)
- Hoarseness (recurrent laryngeal nerve)
- Horner’s Syndrome
What is the diagnostic study of choice for Esophageal neoplasms?
-Upper endoscopy with biopsy
What is the preferred method for pretreatment staging for esophageal neoplasms?
Endoscopic US
Treatment for esophageal neoplasms
- Esophageal resection with chemotherapy
- Palliative stenting to improve dysphagia
