GI: esophagus Flashcards
Esophageal Atresia
- RF
- CM
- diagnosis/how to confirm
- atenatal diagnosis?
- TX
- later life complications
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
Infantile Hypertrophic Pyloric Stenosis
- RF
- CM
- when does it start
- PE
- confirm diagnosis?
- definitive tx
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
palpable olive shaped mass in RUQ
hypertrophic pylorus
target sign on US
infantile hypertrophic pyloric stenosis
Infantile GERD
- CM
- complications
- diagnosed
- TX (1st, 2dn, 3rd)
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
Dysphagia
- CM
- mangement
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
PT has dysphagia with solids AND liquids–most likely due to?
motor disorder
- achalasia
- scleroderma
PT has dysphagia with only solids— most likely due to?
mechanical obstruction
- rings
- stricture
- CA
recent or rapid onset of dysphagia points to?
infections
persistent or intermittent dysphagia points to?
esophageal motility disorder
Progressive dysphagia points to?
progressive to just solids?
progressive to foods + liquid?
solids alone: stricture or esophageal CA
solids + liquids: scleroderma or achalasia
GERD
- CMs
- what are alarm symptoms?
- Diagnosis–1st line TOC
- treatment: 1st, 2nd, 3rd, refractory
- complictions from dz
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:
- Esophagitis
- stricture
- Barretts esophagus
- Esophageal adenocarcinoma
gastroparesis
CMs
TX
nausea
vomiting
abdominal pain
postprandial fullness or bloating
TX
- motility agents
- gastric “pacemaker”
Mallory Weiss Syndrome RF CM Diagnosis--TOC TX
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:
- not actively bleeding: supportive TX (PPIs, anti-emetics). Most resolve on their own
- Severe bleeding
* thermal coagulation
* hemoclips
* endoscopic band ligation (w or w.o epinephrine)
* balloon tamponade
Boerhaave Syndrome
- etiologies (MC?)
- mortality rate
- CM
- PE findings
- Diagnosis–TOC
- management: stable vs unstable
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:
- TOC–Esophagram with GASTROGRAFIN (not barium–bc it is caustic and will cause problems where it leaks out of esophagus)
- CXR or CT scan: left sided hydropneumothorax (MC), pneumomediastimum (air in mediastinum)
TX:
- Small and stable: IV fluids, NPO, BS ABX, H2 rec Blockers
- Large or severe: surgical repair
what is Hamman’s sign
indicative of?
crunching sound on ausculation when PT is in Left lateral decubitus position–pneumomediasteinum
Boerhaave Syndrome **
Medication/pill induced esophagitis
*CM
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
Infectious Esophagitis
- etiologies
- CM
- diagnosis and specific findings for each etiology
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
Eosinophilic esophagitis
*Mc in who
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
endoscopy of throat shows Corrugated rings with white exudates
Eosinophilic esophagitis
caustic esophagitis CM diagnosis complications tx
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*****
Barretts esophagus
*diagnosis + follow-up tx for each of the different findings o
Diagnosis: UPPER ENDOSCOPY w. BIOPSY
Follow up TXs:
1. Barretts esophagus only (metaplasia): PPIs + rescope every 3-5 yrs
- Low-grade dysplasia: PPIs and rescope every 6-12 MO
- High grade dysplasia: ablation with endoscopy or mucosal resection
Achalasia CM etiologies (3) diagnosis--most accurate test? tx--definitive?
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
- Manometry–MOST ACCURATE TEST– shows increased LES pressure and lack of peristalsis
- Endoscopy–usually performed prior to initiating TX to r/o esophageal squamous cell carcinoma (bc achalasia is a RF)
TX:
- decrease the LES pressure–botulinum toxin injections, nitrates, surgery is most effective
- Pneumatic dilation of LES
- Esophagomyomectomy (definitive)
- adaptive measures–chewing food fully b4 swallowing etc
CHAGAS DZ can cause
Achalasia
Birds beak appearance on esophagram
Achalasia
Achalasia is a RF for?
Squamous cell carcinoma in esophagus
+achalasia=7x increase risk
Zenker’s Diverticulum
MC in?
Diagnosis–TOC
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
halitosis think of?
zenker’s diverticulum
Distal/Diffuse esophageal spasm
CM
Diagnosis–definitive test?
tx: 1st, 2nd, 3rd
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
corkscrew apperance on esophagram
Distal/diffuse esophageal spasm
Hypercontracticle (nutcracker) esophagus
CM
Diagnosis–definitive?
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
of the two spastic esophageal dz.. which wil show a + barium swallow and which will show a - barium swallow
hypercontractile– NEG and is during peristalsis
Distal/diffuse–positive (corkscrew) and is NOT during peristalsis
esophageal web
CM
diagnosis–TOC
TX
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
Esophageal (shatzki) ring
RF
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
Squamous Cell Carcinoma Esophagus
- RF
- peak age
- protective factors
- CM
- Diagnosis–TOC
- Pretreatment staging
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:
- endoscopic US to look at LNs around eso–STAGING
- Preoperative bronchoscopy–to see if it MET to lungs
TX:
- esophageal resection with chemo
- ADANCED: palliative stentint to improve dysphagia
Adenocarcinoma RF age MC? CM Diagnosis--TOC pre tx steps tx
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:
- endoscopic US to look at LNs around eso–STAGING
- Preoperative bronchoscopy–to see if it MET to lungs
TX:
- esophageal resection with chemo
- ADANCED: palliative stentint to improve dysphagia
esophageal varices RF (MC in adults vs kids) CM Diagnosis--TOC TX: acute bleed ? 1st 2nd line 3rd *prophylaxis tx
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:
- endoscopic ligation intervention–initial tx of choice–
- Pharmacologic: Octreotide 1st line–vasocontrictor of splanchnic circulation very well–MC to use this and endoscopy together
* can also give vasopressin 2nd line - Balloon tamponade: (Temporary) stabilizes bleeding not controlled by endoscopic or pharmacologic interventions OR used in rapid bleeds
- 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)
