GI #6 Flashcards
What is the diagnostic of choice for esophageal webs?
Barium esophagram (swallow)
Treatment for esophageal web
Endoscopic dilation of the area
-PPI therapy after dilation to reduce recurrence
What is an esophageal web?
Noncircumferential thin membrane in mid-upper esophagus
What is Plummer-Vinson Syndrome?
Triad of dysphagia + cervical esophageal webs + iron deficiency anemia
(May also be associated with atrophic glossitis, angular cheilitis, splenomegaly)
Patients with Plummer-Vinson Syndrome are at increased risk for _____
Esophageal Squamous Cell Carcinoma
An esophageal (Shatzki) Ring is
-Circumferential diaphragm of tissue that protrudes into the esophageal lumen
An esophageal ring is most common in which location?
Lower esophagus (at squamocolumnar junction)
What are some risk factors for esophageal rings?
Hiatal Hernia
Acid reflux
Eosinophilic Esophagitis
Symptoms of esophageal ring
-Episodic dysphagia (especially to solids) because bolus gets stuck in lower esophagus
What diagnostic is the most sensitive for an esophageal ring?
-Barium Esophagram (Swallow)
Treatment for esophageal ring
- Symptomatic: Dilation
- Antireflux surgery if reflux present
Esophageal varices are a complication of
portal vein hypertension
What are the main risk factors in adults vs children for esophageal varices?
Adults: cirrhosis
Children: portal vein thrombosis
Symptoms of an esophageal varice
Upper GI Bleed: hematemesis, melena, hematochezia
Test of choice for esophageal varices
-Upper endoscopy
What is included in the stabilization of the patient in managing an acute variceal bleed?
- Stabilize patient: 2 large bore IV lines, IVF
- -Packed red blood cells if low hematocrit
- -FFP if increased INR and/or PT
What is the initial treatment of choice for an acute variceal bleed?
-Endoscopic intervention: endoscopic variceal ligation is initial treatment of choice
What is the first-line medical management for an acute variceal bleed?
Octreotide: somatostatin analog that causes vasoconstriction of the portal venous flow, decreasing portal pressure and reducing bleeding
Second-line medical management for acute variceal bleed, if Octreotide is not an option
- Vasopressin
- Adverse effects: causes vessel constriction in other areas such as an MI, bowel ischemia, etc.
What are other options, surgical-related, for acute variceal bleeds?
- Balloon tamponade
- Surgical decompression: TIPS if not responsive to medication or advanced
What antibiotics are given to prevent infectious complications in an acute variceal bleed?
Fluoroquinolones (Norfloxacin) or Ceftriaxone
To prevent a rebleed, what medication(s) are used
Nonselective beta blockers (Nadolol or Propanolol)
Explain Celiac Disease (Sprue)
-Autoimmune-mediated inflammation of the small bowel due to reaction with alpha-gliadin in gluten-containing foods (wheat, rye, barley)
What is the pathophysiology of celiac disease?
Loss of villi with subsequent malabsorption
Who is Celiac Disease most common in?
Females, European descent (Irish and Finnish)
Symptoms of Celiac Disease
- Malabsorption: diarrhea, abdominal pain, bloating, steatorrhea
- Growth delays in children
- Dermatitis herpetiformis: pruritic, papulovesicular rash on extensor surfaces, neck, trunk, and scalp
What is the initial test of choice for celiac disease?
-Transglutaminase IgA antibodies (Endomysial IgA antibodies)
However, what is the definitive and confirmatory diagnostic for Celiac Disease?
Small bowel biopsy (shows atrophy of the villi)
Treatment for celiac disease
- Gluten-free diet: avoid wheat, rye, barley
- Limit oat consumption
- Vitamin supplementation (iron, B6, B12, copper, zinc)
Lactose intolerance is the inability to digest lactose due to low levels of
lactase enzyme
Symptoms of lactose intolerance
-Loose stools, abdominal pain, flatulence, borborygmi after ingestion of milk products
What is the test of choice for lactose intolerance?
Hydrogen breath test
Treatment for lactose intolerance
- Lactose-free diet or use of enzymes
- Lactaid: prehydrolyzed milk
What are some risk factors for peanut and tree nut allergies
- Genetics
- Timing of exposure: delayed introduction of nuts until > 3 years = increased risk
Name 10 symptoms of a peanut/tree nut allergic reaction
- Pruritus
- Wheezing
- Arrythymias
- Nausea, Vomiting
- Dizziness, Sense of Doom
- Conjunctival Injection
- Cough
- Rhinorrhea
- Sneezing
- Diarrhea
Treatment for an acute allergic reaction
- Antihistamines if mild
- Epinephrine if severe
Dumping syndrome, which is ______, is often a complication of _____
- Symptoms due to rapid gastric emptying when large amounts of carbs are ingested
- Bariatric surgery
Symptoms of dumping syndrome
- Bloating, flatus, diarrhea, nausea (often within 15 minutes)
- Then later, syncope, hypoglycemia
What diagnostics can be used to confirm rapid gastric emptying with dumping syndrome?
-Barium fluoroscopy and radionuclide scintigraphy
How do you manage a patient with dumping syndrome?
- Decreased carbohydrate intake
- Eat more frequently with smaller meals
- Protein rich foods
- Separate liquids from solid intake by 30 minutes
What are the most common etiologies of a peptic ulcer?
- H. Pylori (MCC of gastritis)
- NSAIDs and Aspirin (2nd MCC)
- Zollinger-Ellison Syndrome (gastrin-producing tumor)
- ETOH, Smoking, Stress
- Males, elderly, steroids
MCC of upper GI bleed
PUD
What is the major difference in symptoms of a duodenal ulcer vs a gastric ulcer?
- Duodenal: dyspepsia classically relieved with food, antacids. Worse before meals or 2-5 hours after meals.
- Gastric: symptoms classically worsened with food (especially 1-2 hours after), weight loss
Other symptoms of a peptic ulcer?
- Dyspepsia (burning, gnawing, epigastric pain)
- Nausea, Vomiting
If the ulcer is perforated, what would you expect the symptoms to be?
- Sudden onset of severe abdominal pain (may radiate to shoulder)
- Peritonitis (rebound tenderness, guarding, rigidity)
What is the diagnostic of choice for PUD?
-Upper endoscopy with biopsy
All gastric ulcers need _________ to document healing even if asymptomatic
repeat upper endoscopy
What diagnostics can be done to confirm an H. Pylori infection
- Endoscopy with biopsy: GOLD STANDARD
- Urea Breath Test: Noninvasive
- H. Pylori Stool Antigen: Confirm eradication after therapy
- Serologic Antibodies: Confirm, not for eradication
If the sample is H. Pylori positive, what treatment options can you suggest?
- Quadruple therapy: Bismuth + Tetracycline + Metronidazole + PPI x 14 days
- Triple Therapy: Clarithromycin + Amoxicillin + PPI for 10-14 days (Metro if cannot take Amoxicillin)
- Concomitant Therapy: CAMP for 10-14 days
If H. Pylori negative, what treatment should you recommend?
PPI, H2 blocker, Misoprostol, antacids, Bismuth, Sucralfate
If refractory to medication, what treatment should be pursued for PUD
- Parietal cell vagotomy
- Bilroth II (associated with Dumping Syndrome)
Name some facts about duodenal ulcers
- Almost always benign
- MC in younger patients (30-55)
- Better with meals
- Increased damaging factors (acid, H. Pylori)
- MC in duodenal bulb
Name some facts about gastric ulcers
- 4% malignant
- MC in older patients (55-70)
- Worse with meals
- Decreased mucosal protective factors (NSAIDs, bicarb)
- MC in antrum of stomach
Name some PPI Medications
Omeprazole
Pantoprazole
Rabeprazole
MOA of PPI medications
-Block H+/K+ ATP-ase (proton-pump) of parietal cell, reducing acid secretion
What are some common side effects of PPI’s
- B12 deficiency
- Diarrhea
- Headache
- Hypocalcemia, Hypomagnesemia
What is the most effective drug class to treat PUD?
PPI
