GI- Esophagus & Pancreas Flashcards
Define Dysphagia
What are alarm symptoms?
Difficulty swallowing (vs. odynophagia- ow pain) If blood in stool, anemia, or weight loss preform endoscopy to rule out cancer.
What are the symptoms of hiatal hernia?
How is it diagnosed?
Heartburn, chest pain, dysphagia, obesity.
Diagnosis is made by endoscopy or barium study
What is the best initial treatment for hiatal hernia?
weight loss and PPIs.
If persist: Nissen Fundoplication.
Define Achalasia
symptoms?
Aperistalsis and inability of the lower esophageal sphincter to relax due to loss of the nerve plexus. Idiopathic or Chagas. Increased risk for esophageal carcinoma.
Intermittent dysphagia for solids and liquids but no heart burn (GEJ tightly closed)
All diagnostic testing for achalasia
- Birds Beak on Barium swallow.
- Manometry
- CXR widening os esophagus (not specific or sensitive)
- Endoscopy: normal mucosa (exclude malignancy)
Most accurate test for achalasia (aka confirms diagnosis)
Manometry: shows failure of LES to relax.
Treatment Achalasia
Calcium channel blockers.
Mechanical dilation:
- Pneumatic dilation (3% perforation. safer than surg, less effective)
- Surgical sectioning or myotomy (last resort)
-Botulinum Toxin injection (lasts 3-6 months)
Typical features of a patient with esophageal cancer
Age >50
Dysphagia: solids then liquids
Prolonged alcohol and tobacco use
>5-10 yr of GERD symptoms
Best initial test for esophageal cancer?
Most accurate?
Barium swallow
Endo with biopsy
Treatment for esophageal cancer
Surgical resection- curative
for lesions that can’t be resected stent placement can keep the esophagus open for palliation and improve dysphasia- not curative.
What are the two types of esophageal spasms?
Diffuse esophageal spasm
Nutcracker esophagus
Clinically indistinguishable from each other.
Additionally initially indistinguishable from atypical coronary artery spasm or unstable angina.
Symptoms of esophageal spasms?
- Sudden onset, severe chest pain.
- Precipitated by drinking cold liquids.
- irregular forceful esophageal contractions
- Normal EKG and stress test
- Normal esophagram and endoscopy
- Barium “corkscrew”
Most accurate test for diagnosis of esophageal spasms
MANOMETRY
shows a different pattern os abnormal contraction distinguishing between diffuse and nutcracker
Tx esophageal spastic disorders
- CCBs; TCA as alternative; if both fail sildenafil
- Nitrates (think Prinzmetal Tx)
- PPIs in some cases
- Surgery myotomy
Eosinophilic esophagitis
Symptoms
Tests
Hx of asthma or allergic diseases. Dysphagia, food impaction, heartburn.
Most accurate test: endoscopy with biopsy (multiple concentric rings)
Tx eosinophilic esophagitis
Best initial treatment is PPIs and elimination of allergenic foods
if no response swallowing steroid inhalers
What is the main organism responsible for esophageal infection?
> 90% of esophageal infections in patients with AIDS are caused by Candida.
CMV and herpes
(does not need to have oral thrush)
Tx esophageal candidiasis
Fluconazole
IV amphotericin for confirmed candidiasis (endoscope)
What are the possible findings for esophagitis in endoscope?
Large Ulcerations= CMV (tx foscarnet)
Small Ulcerations= HSV (tx acyclovir)
White plaque like lesions= Candida
Prolonged use of what medications can cause esophagitis?
Doxycycline
Alendronate
Potassium Chloride.
What is steakhouse syndrome?
Dysphagia from solid food caused by Schatzki rings
What is associated withs schatcki ring?
- Often caused by acid reflux
- Associated with hiatal hernia
- A type of scarring or tightening (“peptic stricture”) of the distal esophagus
- Intermittent dysphagia
What is associated with Plummer- Vinson syndrome
- Associated with Iron deficiency Anemia (not caused by blood loss)
- More proximal than Schatzki ring.
- easily detected on barium studies.
- rarely transform into SCC
Tx for Schatcki Ring and Plummer- Vinson syndrome
Schatcki- pneumatic dilation.
Plummer Vinson- Iron replacement
What is a Zenker Diverticulum?
out pouching of the posterior pharyngeal constrict muscles.
Symptoms of Zanker?
- Dysphagia
- Severe Halitosis and bad smell
- Regurgitation of food particles
- Recurrent Aspiration pneumonia
Testing and Tx of Zanker diverticulum
Barium study: Contrast esophagography. Risk of pneumonitis does not outweigh benefit.
Surgical repair (criocopharyngeal myotomy +/- diverticulectomy)
Can an NG tube or endoscopy be done on someone with a suspected Zanker diverticulum?
NO. may cause perforation
What is the best esophageal test for patients with scleroderma and esophageal symptoms?
Manometry
Mallory-Weiss vs Boerhaave
MW- non penetrating tear of only the mucosa
Boerhaave- full penetration of the esophagus.
both seen with vomiting and retching (alcoholics/ bulimics)
Tx Mallory- Weiss tear vs Boerhaave
MW: Resolve spontaneously; epinephrine injection or electrocautery
B: immediate surgical repair and drainage.
Hiatal Hernia vs Paraesophageal hernia
Hiatal Hernia is a Sliding hernia where the GEJ moves above the diaphragm and pulls the stomach. Causes GERD.
Paraseophageal hernia: the GEJ stays below the diaphragm but the the stomach herniates through the diaphragm into the thorax. May become strangulated.
What clues suggest scleroderma as the cause of esophageal complaints?
Scleroderma can cause aperistalsis due to fibrosis and atrophy of the smooth muscle.
LES becomes incompetent and causes heartburn
Opposite of achalasia (aperistalsis without heartburn)
Other symptoms of scleroderma additional to esophageal complaints
Positive ANA, mask like facies, other autoimmune.
CREST Calcinosis Raynaud Esophageal dismotility Sclerodactyly Telangiectasias
What is the most common esophageal cancer?
Adenocarcinoma, second SCC.
Causes and location of adenocarcinoma of the esophagus
long-standing effects of gastric acid reflux and this occurs in the distal esophagus
Causes and location of SCC of the esophagus
usually caused by alcohol and tobacco (synergistic effect) Tumor in the proximal esophagus.
What is Barrett esophagus? Risks?
Barrett describes a columnar metaplasia of the normally squamous cell esophageal mucosa. Seen on endoscopy, confirmed with biopsy.
High risk for adenocarcinoma. Periodic biopsies to monitor development.
Causes of acute pancreatitis
I GET SMASHED
80% due to alcohol or gallstones.
I- idiopathic G- gallstones E- Ethanol T- trauma S- steroids M- malignancy or mumps (and other infections A- autoimmune S- scorpion H- hypertriglyceridemia or hypercalcemia E- ERCP D- Drugs / Drug Allergies
Drugs that cause pancreatitis
Isonizaid Simvastatin Steroids (estrogens) Azathioprine Pentamidine Didanosine
Sulfa allergy (furosemide, HCTZ)
What are the signs and symptoms of acute pancreatitis?
- Epigastric pain, radiates straight back
- Vomiting doesn’t relieve pain.
- Leukocytosis
- Elevated amylase and lipase
Severe
- Grey Turner Sign (blue-black flanks)
- Cullen sign (blue- black umbilicus)
- hypotension/ fever
What is that cause of Grey turner and Cullen signs in pancreatitis?
Due to a hemorrhagic pancreatic exudate. Indicate severe pancreatitis.
DDX perforated ulcer vs pancreatitis
both present with similar symptoms and labs. Free air with perf and history of PUD.
Tx acute pancreatitis
- NPO/ NG tube
- IV fluids
- Analgesics
- extensive necrosis: ABX (imipenem or meropenem) decrease mortality
- Surgery (severe infection & necrosis) prevent ARDS
Complications of acute pancreatitis
- Pseudocyst formation (drain surgically if sxm and persistent)
- Abscess or infection (abx and drain)
- chronic pancreatitis
Chronic pancreatitis- causes and findings
ALCOHOLISM (repeat acute pancreatitis).
May lead to: diabetes, steatorrhea, calcifications of pancreas, fat soluble vitamin deficiencies.
Minor risk increase for pancreatic cancer.
Tx chronic pancreatitis
alcohol abstinence
oral pancreatic enzyme replacement
fat soluble vitamin supplements
How is ERCP pancreatitis preventable
with rectal NSAIDs such as indomethacin
What indicates a worse prognosis for pancreatitis?
Low Calcium:
Severe damage causes low lipase release and fat malabsorption. Calcium binds fat (saponification).
Best initial test for acute pancreatitis
Most specific
BIT: Amylase and lipase elevates
Most specific: CT or MRI
- severity correlates to degree of necrosis seen on CT
- detects pseudocyst
- guided needle biopsy detects infection in extensive necrosis (>30%)
Analgesics of choice in acute pancreatitis
Narcotics (hydromorphone or fentanyl)
other pain options: meperidine (risk seizures), morphine (may cause sphincter of Oddi spasm)
Signs and symptoms of autoimmune IgG4- related Pancreatitis
Lacks alcohol or stones Recurrent Jaundice Weight loss Abd pain Mimics pancreatic cancer
What is IgG4 pancreatitis associated with
Sjogren syndrome
Autoimmune thyroiditis
Interstitial Nephritis
Sclerosing Cholangitis
Diagnostic test findings for IgG4 pancreatitis
CT: enlarged “sausage-shaped” pancreas
Elevated IgG4 levels
Lymphocitic and plasma cell infiltrates on biopsy
No ANA or RF
Tx autoimmune IgG4-related pancreatitis
Steroids!!
Never surgery!
Signs and Symptoms of Pancreatic cancer
- Painless Jaundice
- Weight loss
- Non-tender epigastric area
- Normal Amylase and lipase
- Elevated: bilirubin, alk phos, & gamma-glutamyltranpeptidase (GGTP)
- Depression
Types of pancreatic cancer
Cystic neoplasm: small chance turning of malignant over time
Mucinous Cystadenoma & Intraductal papillary mucinous:
- Elevated CEA and CA19-9
- invasive malignant potential 0-70%
- 5yr survival 5%.
- No Tx. chemo and radio do little
Prodromal features of pancreatic cancer
Depression
Anxiety
New- onset diabetes
Malignancy features of a pancreatic cyst
Large size >3cm
Solid components or calcifications
Main pancreatic duct involvement
Thickened or irregular cyst wall
Management of pancreatic cyst
Endoscopic u/s guided biopsy to rule out malignancy
Features of an uncomplicated pancreatic pseudocyst
Rounded
Well circumscribed
Fluid collection
Recent pancreatitis
