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Julie W: Module 9 - GI > GI Conditions - Esophagus - Prof. Wall > Flashcards

GI Conditions - Esophagus - Prof. Wall Flashcards

1
Q

Esophagus

GERD

A

Return of stomach contents into esophagus (w/ symptoms)

Most Common D/O of Esophagus

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2
Q

Esophagus

GERD

A

Lower esophageal sphincter is weak or relaxes inappropriately

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3
Q

Esophagus

GERD

+

Hiatal Hernia

A

When the LES & Upper Stomach Portion move up into chest wall through small opening in diaphragm

Causes GERD more often

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4
Q

Esophagus

GERD

+

Epidemiology

A
  • Affects 15-20% of population (report weekly heartburn)

​

  • Caucasians & Pregnancy
  • N. America & Europe
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5
Q

Esophagus

GERD

+

Signs & Symptoms

A
  • Heartburn
  • Odynophagia
  • Dysphagia
  • Regurg
  • Bleching
  • Nausea
  • Anorexia/Weight Loss

​

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6
Q

Esophagus

GERD

+

Atypical Signs & Symptoms

A
  • Sore Thorat
  • Dental Caries
  • Chronic Cough
  • Asthma
  • Hoarseness
  • Recurrent Pneumonia
  • Chest Pain

​

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7
Q

Esophagus

GERD

+

Diagnostics

A
  • Empircally
  • Upper endoscopy w/ bx (esophagogastroduodenoscopy)
  • Barium Esophagogram
  • Ambulatory esophageal pH monitoring

​

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8
Q

Esophagus

GERD

+

Complications

A
  • Esophagitis
  • Atypical symptoms
  • Stricture - GE Junction
  • Barret’s Esophagus!
    • ​Neoplastic changes
    • Risk: 40-100x greater than general population

​

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9
Q

Esophagus

GERD

+

Management

A
  • Repeat Endoscopy every 2 years w/ biopsy
  • Surgical resection - if high grade dysplasia >25%
  • Stay on Proton Pump Inhibitors FOREVER!

​

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10
Q

Esophagus

GERD

+

Treatment Goals

A
  • Provide symptom relief
  • Heal damage
  • Prevent complications

Combo of Pharm & Non-Pharm Tmts

​

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11
Q

Esophagus

GERD

+

Non-Pharm Tmts

A
  • Lifestyle!!!
    • Avoid certain foods & drink
    • Decrease portion size
    • Lose weight
    • Elevate head of bed
    • Avoid eating 2-3 hours before bed

​

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12
Q

Esophagus

GERD

+

Pharm Tmts

A
  • Antacids
    • Mg, Ca, Al
    • *May cause constipation in elderly
  • Sialogogues
    • Gum
  • H2 Receptor Agonists
    • 30 min to work & last 8 hours
  • PPIs
    • ​$$$
    • Once daily dosing

​

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13
Q

Esophagus

GERD

+

Pharm Tmts

A
  • Antacids
    • Mg, Ca, Al
    • *May cause constipation in elderly
  • Sialogogues
    • Gum
  • H2 Receptor Agonists
    • 30 min to work & last 8 hours
  • PPIs
    • ​$$$
    • Once daily dosing

​

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14
Q

Esophagus

GERD

+

PPIs for Severe Disease!!!!

A
  • PPIs
    • ​1-2x daily
    • Therapy course: 8-12wks
      • Most pts relapse & continue with tmt

​

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15
Q

Esophagus

Esophageal Spasm

A
  • Motility D/O
  • Assc. w/
    • Chest Pain
    • Dysphagia

​

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16
Q

Esophagus

Esophageal Spasm

Nutcracker Esophagus

A
  • Hypertensive Peristalsis
  • Increased contraction pressure
    • >180mmHg during Peristalsis

​

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17
Q

Esophagus

Esophageal Spasm

Treatment

A
  • Nitrates
  • CCBs
    • Diltiazem

​

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18
Q

Diagnostics

Esophageal Manometry

A

Evaluates Peristalsis ​

Upper & Lower Esophageal Sphincters

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19
Q

Diagnostics

Esophageal Manometry

Examples

A
  • Achalsia
    • No Relaxation at LES
    • Lack of Peristalsis
  • Nutcrack Esophagus
    • Hyper-contractile especially at LES
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20
Q

Esophageal Dysphagia Algorithm

A
  • Solid Foods -
    • Mechanical Obstruction
  • Solid Food & Liquirds -
    • Neuromsk Obstruction
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21
Q

Esophagitis

A

Inflammation of the Esophagus

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22
Q

Esophagitis

+

GERD

A

50% of those w/ GERD develop Esophagitis

Incidence increases with Age

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23
Q

Esophagitis

+

Risk Factors

A
  • GERD
  • Infectious
    • Viral, fungal, bacterial, parasitic
  • Pill/Med-Induced
    • Abx, KCl, Bisphosphonates
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24
Q

Esophagitis

Signs & Symptoms

A
  • Odynophagia
  • Dysphagia
  • Substernal Chest Pain
  • Oral Thrush
  • Herpes Labialis
  • Retinitis (CMV)
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25
**Esophagitis** Herpes Simplex Esophagitis *Signs & Symptoms*
* Nausea * Vomiting * Fever * Chills * +/- Herpetic Vesicles on Nose & Lips * Painful!
26
**Esophagitis** Herpes Simplex Esophagitis *Diagnostics*
* Endoscopy: * Vesicles * Small, discrete superficial ulcerations * Culture will show **HSV**
27
**Esophagitis** Herpes Simplex Esophagitis *Treatment*
* Oral or IV Acyclovir * 7-21 days * IV if complications
28
**Esophagitis** Varicella Zoster Virus
* Kids w/ chickpox or adults w/ zoster * Differentiate from HSV via * Culture or Cells
29
**Esophagitis** Varicella Zoster Virus
* Vesicles & Confluent Ulcers
30
**Esophagitis** Varicella Zoster Virus *Treatment*
* Usually resolve spontaneously * BUT may cause Necrotizing esophagitis * Acyclovir
31
**Esophagitis** Cytomegalovirus
**Only occurs in _Immunocompromised_**
32
**Esophagitis** Cytomegalovirus
* Creeping ulcer in otherwise Normal Mucosa * May become GIANT
33
**Esophagitis** Cytomegalovirus *Patients present with...*
* Odynophagia * Persistent chest pain * Hematemesis * Nausea * Vomiting
34
**Esophagitis** Cytomegalovirus *Treatment*
* IV Ganciclovir
35
**Esophagitis** Candidia
* Normally in throat * Esophagitis form in **_Immunocompromised_**
36
**Esophagitis** Candidia *Complicated by:*
* Bleeding * Perforation * Stricture
37
**Esophagitis** Candidia *Endoscopy shows*
* Small * Yellow-white * Raised * **Plaques**
38
**Esophagitis** Candidia *Treatment*
* Oral or IV Fluconazole
39
**Esophageal Lesions** _Mallory-Weiss Syndrome_
* Intraluminal mucosal tear or distal esophagus or gastric cardia * Arterial Bleeding * Self-limiting (v. varices)
40
**Esophageal Lesions** Mallory-Weiss Syndrome *Caused by:*
* Intra-abdominal Pressure
41
**Esophageal Lesions** Mallory-Weiss Syndrome *Boerhaave Syndrome*
* Esophageal Rupture
42
**Esophageal Lesions** Mallory-Weiss Syndrome *Epidemiology*
* Alcoholics * Hiatal Hernia Can also occur after: * Seizures * Childbirth * Lifting/Straining/Coughing * Blunt Abdominal Trauma * Bulimia
43
**Esophageal Lesions** Mallory-Weiss Syndrome *Signs & Symptoms*
**Painless** * **​**Multiple bouts of vomiting & retching followed by _Hematemesis_ * _​_Arterial bleeding * Abdominal pain
44
**Esophageal Lesions** Mallory-Weiss Syndrome *Diagnosis*
* Endoscopy * CBC, PT, PTT * BUN/Cr * LFTs * Type & Cross match * +/- CXR and EKG
45
**Esophageal Lesions** Mallory-Weiss Syndrome *Stablize!!*
* Airway, Breathing, Circulation * Transfusion * Gastric Lavage to remove blood
46
**Esophageal Lesions** Mallory-Weiss Syndrome *Endoscopically control Bleeding!*
* Coagulation techniques * Blood clotthing agents application
47
**Esophageal Lesions** Mallory-Weiss Syndrome *Treatment*
* Most bleeding resolves spontaneously * Benign & Self-limiting
48
**Esophageal Lesions** Mallory-Weiss Syndrome *Admit*
* Continuous or massive hemorrhage * Hemodynamic Instability/Hypovolemic * Age extremes * Underlying medical condition
49
**Esophageal Lesions** Mallory-Weiss Syndrome *Discharge*
* History of minimal bleeding that has stopped * Hemodyamically stable/Stable H+H * Heme negative stool
50
**Esophageal Lesions** Esophageal Ring
* **Schatzki's Ring:** * **​**Ring of tissue located at junction of esophagus & stomach * Congenital * May be result of Chronic GERD * Affects 4 our of 10,000
51
**Esophageal Lesions** Esophageal Ring *Symptoms*
* Dysphagia * Esp. w/ poorly chewed food boluses * Liquids are generally *okay!* * May help dislodge bolus
52
**Esophageal Lesions** Esophageal Web
Similar to Esophageal Ring, but in Mid- to Upper- Esophagus **One or more thin membranes of squamous mucosa that can cause intermittent dysphagia to solid food**
53
**Esophageal Lesions** Esophageal Web
**"Smooth, circumferential ring of squamous mucosa, often responsible for causing difficulty swallowing, which can be located anywhere along the esophagus. May be asymptomatic"​**
54
**Esophageal Lesions** Esophageal Web *Etiology*
Unknown
55
**Esophageal Lesions** Esophageal Web *Plummer-Vinson Syndrome*
* Webs w/ Iron Deficiency Anemia & Glossitis * Treat with Iron!
56
**Esophageal Lesions** Esophageal Web & Rings *Diagnosis for both:*
* Barium Esophagram * EGD *\*Endoscopy is less sensitive than barium esophagram* \*Esophagram is like an x-ray using contrast dye
57
**Esophageal Lesions** Esophageal Web & Rings *Treatment*
* Mechanical Dilation w/ Balloon
58
**Esophageal Varices**
*Dilated submucosal veins that develop in patients with _Portal Hypertension_*
59
**Esophageal Varices** **Most common cause...**
## Footnote **Cirrhosis!!**
60
**Esophageal Varices** **Other causes**
* Portal Vein Thrombosis * Budd Chiari Syndrome * Infiltrative Liver Disease
61
**Esophageal Varices** Pathophys
* Blood flow is increases through microscopic blood vessels w/in esophageal awall * Blood flow increases * Dilation can be profound * Dialate, dialate, dilate then... * RUPTURE!
62
**Esophageal Varices** Mortality Rates
* First time varices rupture = ~40-70%
63
**Esophageal Varices** Most common site of Rupture
* Distal Esophagus * Varcies at GE Junction most likely to rupture (most superficial)
64
**Esophageal Varices** Signs & Symptoms
* Hematemesis * \>50% stop bleeding spontaneously * Melena * Weakeness/Fatigue * Tachycardia * Hypotension * Abdominal Pain * Syncope * Jaundice
65
**Esophageal Varices** Labs
* CBC * PT/PTT * Electrolytes * BUN/Cr * Type & Cross
66
**Esophageal Varices** Treatment *Immediate*
* Control bleeding (if doesn't stop on own) * Emergent Endoscopy * Variceal Ligation (rubber band) * Sclerotherapy * Balloon Tamponade
67
**Esophageal Varices** Treatment *Long-Term Treatment*
* Antibiotics (prevents Peritonitis) * Decrease portal hypertension * Beta-blockers (propanolol) * Nitrates * Shunts * TIPS * Liver Transplant * **Stop Drinking!!**
68
**Achalasia** Greek for: "Does not relax"
Loss of Peristalsis in distal esophagus & failure of LES to relax Symptoms mostly occur b/c LES is NOT relaxing
69
**Achalasia**
Results in Functional Obstruction of esophagus that Persists until the pressure of the retained material causes it to move through the LES Food backs up & ferments in the esophagus.... *Distention & Dilation*
70
**Achalasia** Causes
* Damage to nerves of esophagus * Infection * (Chagas) * Hereditary Factors
71
**Achalasia** Incidence
* Frequency increase with older age * Incidence: * 2 out of 10,000 people
72
**Achalasia** Signs & Symptoms
* **Dysphagia** = MOST COMMON SYMPTOM**​** * Chest Pain * Regurgitation * Difficulty Belching * Weight Loss
73
**Achalasia** Diagnosis
* Chest XR * Barium Swallow * "Bird's Beak"/"Parrot's Beak" appearance * Manometry * pressure gradient * Endoscopy
74
**Achalasia** Treatment
* Nitrates/CCBs * Botulinum toxin * Pneumatic Dilation * Balloon is inflated in LES, reducing pressure * 60-90% effective; last 10 years * Myotomy * Muscular ring around LES cute * 95% success rate
75
**Hiatal Hernia & GERD Treatment** *Nissen Fundoplication*
* Surgical procedure * can be laproscopic * Gastric fundus is wrapped around lower end of esophagus * Complications: * Gas Bloat Syndrome * Dysphagia * Dumping Syndrome
76
**Have an Elderly Patient who just keeps getting Pneumonia?** *Pearl*
* Order a _Modified Barium Swallow_
77
**ESOPHAGEAL CANCER**
* Most are: * Squamous cell\*, or * Adenocarcinoma\*\* * SCC\* is decreasing in US, Adeno\*\* is Rising ALOT!!!
78
**ESOPHAGEAL CANCER** Prognosis
* Poor * 5-year survivial: 10-13% * *Patients diagnosed w/ early stage may be cured*
79
**Esophageal Cancer** *Squamous Cell*
* Middle esophagus * More common in _MALES_ * More common in _BLACKS_ * Common causes: Smoking & Alcohol
80
**Esophageal Cancer** Squamous Cell *Causes*
* 90% attributable to smoking, alchohol and lack healthy diet * Underlying esophageal disease * Achalasia (16x increase) * Lye exposure * Partial gastrectomy * Upper aerodigestive tract cancer
81
**Esophageal Cancer** *Adenocarcinoma*
* Distal esophagus * **Barret's esophagus** * More common in _MALES_ * More common in _WHITE PEOPLE_
82
**Esophageal Cancer** Adenocarcinoma *Increasing in Frequency & GERD!*
* Past 3 decades adenocarcinoma increasing in Frequency!! * GERD!!!!!! * **Most, if not all, esophageal adenocarcinoma is from Barret's metaplasia!** * Risk greatest in those w/ long-standing 20+ years w/ severe symptoms
83
**Esophageal Cancer** Adenocarcinoma *Other Causes*
* Smoking... increases risk * Even after cessation... remains high! * Obesity! * 2.78x greater chance of Adeno if BMI \>30 * *H. pylori* infection * Controversial, but may cause inflammation & metaplasia
84
**Esophageal Cancer** Adenocarcinoma versus Squamous Cell
* AC = disease of Caucasians & Males * Alcohol = * Important factor in SCC, not so much in Adeno * Obesity * Factor in Adeno, not SCC
85
**Esophageal Cancer** Adenocarcinoma + Squamous Cell *Symptoms*
* Have similar clinical presentations * Progressive solid food dysphagia * weight loss * Early symptoms = subtle & non-specific
86
**Esophageal Cancer** Adenocarcinoma + Squamous Cell *More Severe/Later Stage Symptoms*
* Dysphagia occurs once esophageal lumen diameter is * Retro-sternal discomfort, or burning sensation * *Most early cancers detected by chance, or during screening for Barrett's*
87
**Esophageal Cancer** Adenocarcinoma + Squamous Cell *Late Stage Symptoms*
* Chronic gastrointestinal blood loss * May result in Fe Deficiency Anemia * Upper GI bleed = rare * Result of tumor erosion * Tracheobroncial fistulas = late complication * Direct invasion through esophageal wall into main stem bronchus * Intractable coughing & frequent pneumonia
88
**Esophageal Cancer** Adenocarcinoma + Squamous Cell *Life Expectancy*
* \<4 weeks following development
89
**Esophageal Cancer** Adenocarcinoma + Squamous Cell *Diagnosis*
* Barium Studies * Endoscopy
90
**Esophageal Cancer** Adenocarcinoma + Squamous Cell *Pre-Op Staging Evaluation*
* CT Scan of chest & upper abdomen * Endoscopic US * PET scan * Bronchoscopy

Julie W: Module 9 - GI (8 decks)

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