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Clin Med > GI: esophagus > Flashcards

GI: esophagus Flashcards

1
Q

Esophageal Atresia

  • RF
  • CM
  • diagnosis/how to confirm
  • atenatal diagnosis?
  • TX
  • later life complications
A

RF: maternal exposure to methimazole, exogenous sex hormones, infectious dz, ETOH, smoking, DM, adv age, maternal employment in agriculture

CM:
at the first few feedings baby will have choking or vomiting

Diagnose:
an attempt to pass catheter into the stomach does not work
*CONFIRMED: AP xray with catheter in place

Atenatal diagnosis:
-polyhydraminos–high amt of amniotic fluid because baby cannot swallow amniotic fluid

TX:
-surgical repair

Later life complications:

  • dysphagia
  • strictures
  • peristalsis
  • reflux
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2
Q

Infantile Hypertrophic Pyloric Stenosis

  • RF
  • CM
  • when does it start
  • PE
  • confirm diagnosis?
  • definitive tx
A

RF:
-incr freq in first born M

CM:

  • postprandial vomiting
  • forceful, NONBILIOUS vomiting immediately after meals
  • starts around 2-3 weeks post birth

PE:

  • weight loss
  • electrolyte imbalances
  • dehydration
  • irritable infant bc they are hungry but have esophageal discomfort
  • palpable olive shaped mass in RUQ (enlarged/thickened pylorus)

diagnosis:
* confirmed with US with target sign

TX:
-surgical pyloromyotomy

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3
Q

palpable olive shaped mass in RUQ

A

hypertrophic pylorus

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4
Q

target sign on US

A

infantile hypertrophic pyloric stenosis

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5
Q

Infantile GERD

  • CM
  • complications
  • diagnosed
  • TX (1st, 2dn, 3rd)
A

CM:

  • excessive vom
  • food refusal
  • unexplained crying
  • choking
  • gagging

Complications

  • esophagitis
  • hemorrhage
  • stricture
  • Barrett Esophagus (RARE)

Diagnosed
*clinically

TX:
*1st: mom + baby dietary changes
2nd: H2 blockers and antacids
3rd or mod-severe: PPI

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6
Q

Dysphagia

  • CM
  • mangement
A

CM

  • stabbing pain at the level of obstruction
  • discomfort after swallowing
  • regurg
  • unpleasant taste sensation
  • vomiting
  • aspiration
  • wt loss

Managed:

  • eat small meals
  • drink fluid with meals
  • eat slowly
  • sleep with head upright to prevent regurg and aspiration
  • tx underlying etiology
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7
Q

PT has dysphagia with solids AND liquids–most likely due to?

A

motor disorder

  • achalasia
  • scleroderma
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8
Q

PT has dysphagia with only solids— most likely due to?

A

mechanical obstruction

  • rings
  • stricture
  • CA
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9
Q

recent or rapid onset of dysphagia points to?

A

infections

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10
Q

persistent or intermittent dysphagia points to?

A

esophageal motility disorder

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11
Q

Progressive dysphagia points to?

progressive to just solids?
progressive to foods + liquid?

A

solids alone: stricture or esophageal CA

solids + liquids: scleroderma or achalasia

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12
Q

GERD

  • CMs
  • what are alarm symptoms?
  • Diagnosis–1st line TOC
  • treatment: 1st, 2nd, 3rd, refractory
  • complictions from dz
A 
CM: 
*retrosternal and postprandial pain-->heartburn*** HALLMARK
*pain worse when laying flat 
*sometimes relieved by antacids 
\+regurgitation 
\+sour taste in mouth 
\+Cough/ dysphagia 
\+sore throat 
\+/- laryngitis 
\+asthma attacks

ALARM S/S:

  • dysphagia
  • odynophagia
  • Wt loss
  • bleeding

DIAGNOSIS:

  • TOC: endoscopy with biopsy (but not necessary in uncomplicated cases)
  • TX first with meds… and if refractory to meds…then order the endoscopy*
  • GOLD STANDARD to diagnose: 24 hr pH monitoring

TREATMENT:
1st: *life style mods: elevate head of bed 6-8 inches, avoid lying flat for 3 hrs after eating, avoid fatty or spicy foods, chocolate, decrease ETOH

2nd: intermittent or mild–(<2 episodes/week).. PRN antacids and H2 receptor antagonists
3rd: PPI in moderate to severe (>2 episodes/week)
refractory: surgical with Nissen Fundoplication

Complications:

  1. Esophagitis
  2. stricture
  3. Barretts esophagus
  4. Esophageal adenocarcinoma
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13
Q

gastroparesis
CMs
TX

A

nausea
vomiting
abdominal pain
postprandial fullness or bloating

TX

  • motility agents
  • gastric “pacemaker”
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14
Q 
Mallory Weiss Syndrome 
RF 
CM
Diagnosis--TOC 
TX
A

RF: ETOH binges, retching, hiatal hernias

CM:

  • Upper GIB after retching or vomiting–hematemesis, melena, hematochezia,
  • syncope
  • can develop abdominal pain, back pain or hydrophobia

Diagnosis:
TOC: Upper endoscopy will show the tears (superficial longitudinal mucosal erosions)

TX:

  1. not actively bleeding: supportive TX (PPIs, anti-emetics). Most resolve on their own
  2. Severe bleeding
    * thermal coagulation
    * hemoclips
    * endoscopic band ligation (w or w.o epinephrine)
    * balloon tamponade
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15
Q

Boerhaave Syndrome

  • etiologies (MC?)
  • mortality rate
  • CM
  • PE findings
  • Diagnosis–TOC
  • management: stable vs unstable
A

Etiologies:

  • iatrogenic perf of esophagus during endoscopy (MC)
  • repeated forceful retching or vom (ETOH, bulimia)

40% mortality rate

CM:

  • Severe retrosternal CP–worse with deep breathing & swallowing
  • vom
  • hematemesis

PE:

  • crepitus on chest palpation (subcutaneous emphysema)
  • crunching sound on auscultation–Hamman’s Sign (pneumomediasteinum)**

Diagnosis:

  1. TOC–Esophagram with GASTROGRAFIN (not barium–bc it is caustic and will cause problems where it leaks out of esophagus)
  2. CXR or CT scan: left sided hydropneumothorax (MC), pneumomediastimum (air in mediastinum)

TX:

  1. Small and stable: IV fluids, NPO, BS ABX, H2 rec Blockers
  2. Large or severe: surgical repair
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16
Q

what is Hamman’s sign

indicative of?

A

crunching sound on ausculation when PT is in Left lateral decubitus position–pneumomediasteinum
Boerhaave Syndrome **

17
Q

Medication/pill induced esophagitis

*CM

A

CM:

  • odynophagia
  • dysphagia

Diagnosis:
*Endoscopy: singular, small, well defined ulcers of varying depths

TX:

  • take pills with at least 4 ounce of water
  • avoid laying down for 30-60 mins after taking pill
18
Q

Infectious Esophagitis

  • etiologies
  • CM
  • diagnosis and specific findings for each etiology
A

etiologies:
* candida–MC
* CMV
* HSV

CM:

  • Odynophagia (hallmark)
  • retrosternal CP
  • dysphagia
Diagnosis: 
TOC--endoscopy 
1.Candida--linear, yellow-white plaques 
2. CMV--large superficial shallow ulcers 
3. HSV--small (many) deep ulcers

TX:

  • *tx underlying cause**
    1. Candida–PO fluconazole
    2. CMV–Ganciclovir
    3. HSV–Acyclovir
19
Q

Eosinophilic esophagitis

*Mc in who

A

MC in kids with atopic Dz (asthma, eczema)

CM:

  • dysphagia to solids
  • odynophagia
  • reflux/feeding difficulties in kids

Diagnosis:
TOC–endoscopy: normal or will show Corrugated rings with white exudates
*biopsy: abundance of eosinophils

TX

  • Remove foods that cause allg response
  • PPIs PRN
  • inhaled topical cortcosteroids WITHOUT spacer so it can penetrate
20
Q

endoscopy of throat shows Corrugated rings with white exudates

A

Eosinophilic esophagitis

21
Q 
caustic esophagitis 
CM 
diagnosis 
complications 
tx
A

CM:

  • odynophagia
  • dysphagia
  • hematemesis
  • dyspnea

Diagnosis:

  • ednoscopy–will see the extent of damage–look for complications
    1. esophageal perforation
    2. stricture
    3. esoph fistula

tx

  • supportive–pain meds, fluids
  • very very severe– with necrotic tissue +edema present on endoscopy–ICU*****
22
Q

Barretts esophagus

*diagnosis + follow-up tx for each of the different findings o

A

Diagnosis: UPPER ENDOSCOPY w. BIOPSY

Follow up TXs:
1. Barretts esophagus only (metaplasia): PPIs + rescope every 3-5 yrs

  1. Low-grade dysplasia: PPIs and rescope every 6-12 MO
  2. High grade dysplasia: ablation with endoscopy or mucosal resection
23
Q 
Achalasia 
CM 
etiologies (3) 
diagnosis--most accurate test? 
tx--definitive?
A

CM

  • dyphagia to both solids and liquids
  • regurgiation
  • CP
  • weight loss
  • cough
  • dehydration

etiologies:
* MCC idiopathic
* 2nd MC: proximal stomach CA
* worldwide cause–CHAGAS dz (tropical dz–kissing bugs)

Diagnosis:
1. barium esophagram will show BIRDS BEAK of the LES (LES narrowing) with proximal esophageal dilation + loss of peristalsis

  1. Manometry–MOST ACCURATE TEST– shows increased LES pressure and lack of peristalsis
  2. Endoscopy–usually performed prior to initiating TX to r/o esophageal squamous cell carcinoma (bc achalasia is a RF)

TX:

  1. decrease the LES pressure–botulinum toxin injections, nitrates, surgery is most effective
  2. Pneumatic dilation of LES
  3. Esophagomyomectomy (definitive)
  4. adaptive measures–chewing food fully b4 swallowing etc
24
Q

CHAGAS DZ can cause

A

Achalasia

25
Q

Birds beak appearance on esophagram

A

Achalasia

26
Q

Achalasia is a RF for?

A

Squamous cell carcinoma in esophagus

+achalasia=7x increase risk

27
Q

Zenker’s Diverticulum
MC in?
Diagnosis–TOC

A

MC in males usually >60

CM:

  • dysphagia
  • regurgiation
  • cough
  • halitosis******* since the pouch can retain food and saliva

Diagnosis:
TOC: Barium esophagram with fluroscopy–>collection of dye behind esophagus at the pharyngoesphageal junction

*upper endoscopy is done for surgical evaluation and tx

TX:

  • Observation if small and asympto
  • diverticulectomy, cricopharyngeal myotomy
28
Q

halitosis think of?

A

zenker’s diverticulum

29
Q

Distal/Diffuse esophageal spasm
CM
Diagnosis–definitive test?
tx: 1st, 2nd, 3rd

A

CM:
*stabbing chest pain–worse with hot or cold liquids/food (pain is similar to angina but NOT exertional)
*feeling of food bolus getting “hung up” on the way down
liquid + solid dysphagia–worse with hot or cold
*
Diagnosis:
1. Barium esophagram–CORKSCREW apperance
2. manometry–definitive test–increased simultaneous or PREMATURE CONTRACTIONS in the distal esophagus with preservation of some normal peristaltic activity
****manometry is often combined with esophagram + endoscopy to r/o malig

TX:
1st line: CCBs, nitrates, Triclylic antidepressants–all anti-spasmatics
2nd line: botulinum toxin injection or pneumatic dilation
3rd: peroral endoscopic myotomy–refractory to meds

30
Q

corkscrew apperance on esophagram

A

Distal/diffuse esophageal spasm

31
Q

Hypercontracticle (nutcracker) esophagus
CM
Diagnosis–definitive?

A

CM

  • chest pain–sharp stabbing
  • dysphagia to both solids and liquids

Diagnosis:

  • mamometry DEFINITIVE–incr pressure during peristalsis
  • upper endoscopy and esophagram are usually normal

TX:
-need to lower the esophageal pressure with:
CCBs, nitrates, botulinum toxin injection

32
Q

of the two spastic esophageal dz.. which wil show a + barium swallow and which will show a - barium swallow

A

hypercontractile– NEG and is during peristalsis

Distal/diffuse–positive (corkscrew) and is NOT during peristalsis

33
Q

esophageal web
CM
diagnosis–TOC
TX

A

CM

  • dysphagia to SOLIDS–meat, breads etc
  • many asympto

Diagnosis:
-barium swallow test of choice–more sensitive than endoscopy

TX:

  • endoscopic dilation of area if symptomatic
  • PPI therapy after dilation may decrease risk of recurrence
34
Q

Esophageal (shatzki) ring

RF

A

RF:

  • hiatal hernias
  • corrosive esoph injury (acid reflux)
  • eosinophilic esophagitis

CM:

  • most are asympto
  • episodic dysphagia esp to SOLIDS
  • bolus of food can get stuck in the lower esoph (STEAKHOUSE SYNDROME)

Diagnosis:
TOC: barium esophagram–more sensitive than endoscopy
*upper endoscopy only done in PTs to biopsy the esoph for eosinophilic esophagitis

TX:

  • symptomatic: dilation, obliteration with biopsy forceps
  • If reflux present– anti-reflux surgery
35
Q

Squamous Cell Carcinoma Esophagus

  • RF
  • peak age
  • protective factors
  • CM
  • Diagnosis–TOC
  • Pretreatment staging
A

RF:

  • ***smoking
  • **ETOH
  • In US–MC in black ppl
  • worldwide–HPV, poor nutrition, drinking liquids at hot temps, atrophic gastritis, achalasia, Tylosis (rare autosomal dominant disease caused by a mutation in TEC–tumor suppressing gene)

Peak age:
50-70

Protective Factors

  • ASA
  • NSAIDs

CM:

  • often extensive dz as PT becomes symptomatic
  • HALLMARK: progressive dysphagia–start with solid–>then to liquid
  • odnyophagia
  • WT loss
  • anorexia
  • iron def anemia (from chronic blood loss)
  • CP
  • cough
  • hematemesis
  • reflux
  • hoarseness
  • Horner’s syndrome
  • ***hypercalcemia

Diagnosis

  • TOC: upper endoscopy w/ biopsy
    1. early: superficial plaques, nodules or ulcerations
    2. Advanced: strictures, ulcerated masses, circumferential masses or large ulcerations

Pre-treatment:

  1. endoscopic US to look at LNs around eso–STAGING
  2. Preoperative bronchoscopy–to see if it MET to lungs

TX:

  • esophageal resection with chemo
  • ADANCED: palliative stentint to improve dysphagia
36
Q 
Adenocarcinoma 
RF
age MC? 
CM 
Diagnosis--TOC 
pre tx steps 
tx
A

RF

  • Barrett’s Esophagus
  • smoking
  • obesity

age–>younger white males MC

CM:

  • often extensive dz as PT becomes symptomatic
  • HALLMARK: progressive dysphagia–start with solid–>then to liquid
  • odnyophagia
  • WT loss
  • anorexia
  • iron def anemia (from chronic blood loss)
  • CP
  • cough
  • hematemesis
  • reflux
  • hoarseness
  • Horner’s syndrome

Diagnosis

  • TOC: upper endoscopy w/ biopsy
    1. early: superficial plaques, nodules or ulcerations
    2. Advanced: strictures, ulcerated masses, circumferential masses or large ulcerations

Pre-treatment:

  1. endoscopic US to look at LNs around eso–STAGING
  2. Preoperative bronchoscopy–to see if it MET to lungs

TX:

  • esophageal resection with chemo
  • ADANCED: palliative stentint to improve dysphagia
37
Q 
esophageal varices 
RF (MC in adults vs kids) 
CM 
Diagnosis--TOC 
TX: acute bleed ? 1st 2nd line 3rd 
*prophylaxis tx
A

RF:

  • **Cirrhosis (MC in adults)
  • portal vein thrombosis MC in children

CM:

  • UGIB: hematemesis, melena, hematochezia
  • severe: can devlop s/s hypovolemia

Diagnosis:
TOC= upper endoscopy (diagnostic and therapeutic)

TX:

  • FIRST: stabilize patient: 2 large bore IV lines fluids/packed RBCs/FFP***
  • *THEN, move onto one of the four mainstay tx options:
  1. endoscopic ligation intervention–initial tx of choice–
  2. Pharmacologic: Octreotide 1st line–vasocontrictor of splanchnic circulation very well–MC to use this and endoscopy together
    * can also give vasopressin 2nd line
  3. Balloon tamponade: (Temporary) stabilizes bleeding not controlled by endoscopic or pharmacologic interventions OR used in rapid bleeds
  4. Surgical decompression: transiugular intrahepatic portosystemic shunt TIPS)
    - refractory to all other tx
    - can cause encephalopathy

***also give them ABX to prevent infections

prophylaxis
*nonselective BB (Nadolol or Propranolol)

Clin Med (52 decks)

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