GI Re-Up #5 Flashcards
Explain what happens in distal (diffuse) esophageal spasms.
What are some symptoms of this?
-Severe, non-peristaltic esophageal contractions (uncoordinated contractions)
-Stabbing chest pain worse with hot or cold liquids or food (pain similar to angina but not exertional)
-Dysphagia to both solids and liquids simultaneously
What is seen on esophogram for DES?
What is the definitive diagnostic and what is seen?
-Corkscrew esophagus
-Manometry is definitive: increased simultaneous or premature contractions in distal esophagus
Treatment for DES
-Anti-spasmodics (CCB, Nitrates, TCAs) are first line
-Botox injections, Pneumatic dilation are second line
On the other hand, what is hyper contractile (jackhammer) esophagus?
Symptoms are similar to DES, what are they?
-increased pressure during peristalsis (AKA nutcracker esophagus)
-Dysphagia to both solids and liquids, CP similar to DES
What is seen on manometry with hyper contractile esophagus?
What is the treatment?
Increased pressure during peristalsis
Lower esophageal pressure: CCB***
Again, how do you differentiate hypercontractile esophagus from distal (diffuse) esophageal spasm?
Manometry
-Hypercontractile: increased pressure during peristalsis
-DES: increased simultaneous or premature contractions
Explain a Mallory-Weiss Tear (Syndrome)
What is the pathophysiology behind this condition?
Longitudinal superficial mucosal lacerations at the GEJ or gastric cardiac
Sudden rise in intraabdominal pressure from persistent retching or vomiting after ETOH binge
-May also be associated with hiatal hernias
Symptoms of a Mallory-Weiss Tear
What is the test of choice?
-Upper GI bleeding: hematemesis, melena, syncope, hematochezia, back pain, hydrophobia
Upper endoscopy
Treatment for a Mallory-Weiss Tear if
-Not actively bleeding
-Severe bleeding
-Not bleeding: supportive (PPI’s), most stop without treatment
-Severe bleed: thermal coagulation, hemoclops, endoscopic band ligation, balloon tamponade
On that same note, what is Boerhaave Syndrome?
What are some etiologies of this (similar to Mallory-Weiss tear)
-Full thickness rupture MC affecting left posterolateral wall of lower esophagus
-Iatrogenic perforation of esophagus during endoscopy (MC), repeat forceful retching or vomiting (bulimia, alcoholism)
Symptoms and exam findings of Boerhaave Syndrome
-Remember, there is a specific, named exam finding for this one..
-Retrosternal chest pain worse with deep breathing and swallowing, vomiting, hematemesis
-Crepitus on chest auscultation
-Hamman’s Sign: mediastinal crackling accompanying every heart beat in left lateral decubitus position
Diagnostic of choice for Boerhaave Syndrome
What is seen on chest CT/XR?
Contrast esophagram: Gastrograffin swallow preferred
Pneumomediastinum (air in space between lungs)
Treatment for Boerhaave Syndrome
-Small and stable
-Large or severe
-Small: IVF, NPO, ABX, H2 blockers
-Large: Surgical repair
An esophageal web is a non-circumferential thin membrane in which part of the esophagus?
Many patients are asymptomatic, however, what symptoms CAN they have?
What is the diagnostic of choice?
-Mid-upper esophagus
-Dysphagia especially to solids
-Barium esophagram (swallow)
Management for esophageal web
-Endoscopic dilation and then PPI to decrease recurrence rate
Plummer-Vinson Syndrome is MC in Caucasian women 30-60 years old. What triad of symptoms do these patients have?
-Iron deficiency anemia (atrophic glossitis, angular cheilitis, koilonychia, splenomegaly) + dysphagia + cervical esophageal webs
On the other hand, an esophageal (Shatzki) ring, is a circumferential diaphragm of tissue that protrudes into the esophageal lumen. Where does this MC occur?
What’s the biggest risk factor for this?
Lower esophagus (at squamocolumnar junction)
Hiatal hernia
Symptoms of an esophageal ring
What is the diagnostic of choice?
-Episodic dysphagia especially to solids, bolus of food gets stuck in lower esophagus (steakhouse syndrome)
Barium esophagram (circumferential ridge a few cm above hiatus of diaphragm)
Treatment for an esophageal ring
Dilation (pneumatic or bougie)
What is an esophageal varice? What is the MCC in adults vs children?
Dilation of submucosal veins as a complication of portal vein hypertension
-Adults: Cirrhosis
-Kids: Portal vein thrombosis
Symptoms of an esophageal varices
What is the diagnostic of choice?
-Upper GI bleed: hematemesis, melena, hematochezia.
Upper endoscopy (both diagnostic and therapeutic)
Management of an acute variceal bleed
-What do you do first?
-Initial treatment?
-Initial pharm treatment?
-Surgery?
-Stabilize patient: 2 large bore IV lines, IVF
-Endoscopic variceal ligation (initial)
-Octreotide (first line) causes vasoconstriction of portal venous flow
-Vasopressin (second line)
-Balloon tamponade if no improvement with above
-Transjugular intrahepatic portosystemic shunt (TIPS) if bleeding does not stop after other treatments
What medications do you give the patient to prevent a rebleed of esophageal varices?
-Nonselective BB (Nadolol or Propanolol)
What is Zollinger-Ellison Syndrome (Gastrinoma)?
Where is this MC seen?
When should you suspect ZES in a patient?
-Gastrin-secreting neuroendocrine tumor leading to PUD and diarrhea
-MC seen in duodenal wall
-Suspect gastrinoma if severe, recurrent, multiple, or refractor ulcers + diarrhea
Once endoscopy confirms presence of an ulcer, what can you do to establish the diagnosis of ZES?
Elevated basal or stimulates gastrin levels (> 1,000)
What is the confirmatory test for ZES?
Gastrinoma is also associated with increased ______ and therefore, you can do this test, which is the most sensitive for tumor localization and to detect primary or secondary lesions.
-Confirmatory: secretin test (persistent gastrin elevations in gastrinoma). Normally, gastrin release is inhibited by secretin.
-Somatostatin receptors scintigraphy. Associated with increased somatostatin receptors.
If the ulcer with ZES is metastatic and unresectable, what should you give the patient lifelong?
High dose PPIs (blocks acid production)
Carcinoid tumors are rare, well-differentiated neuroendocrine tumors that arise from enterochromaffin cells. 50% of these occur where?
Although many are asymptomatic, what is carcinoid syndrome that they CAN have?
50% occur in GI tract
Carcinoid Syndrome: periodic episodes of diarrhea (serotonin release), flushing, tachycardia, and bronchoconstriction (histamine release) and hemodynamic instability (hypotension)
What lab study can be done for carcinoid tumors (it is the end product of serotonin metabolism)?
-24 hour urinary 5-hydroxyindoleacetic acid/5-HIAA excretion
MC type of gastric carcinoma
What is the biggest RF, along with other risk factors?
-Adenocarcinoma
H. Pylori biggest risk factor
-Others: Males, > 40, preserved foods, obesity, pernicious anemia, Non-Hodgkin Lymphoma
Symptoms of gastric carcinoma
Name some physical exam findings as well (there are a LOT that have certain names)
-Most are advanced at time of presentation
-Weight loss, persistent abdominal pain, early satiety, abdominal fullness, post-prandial vomiting, dysphagia, iron deficiency anemia
-Exam Findings:
–Supraclavicular Lymph Nodes (Virchow’s Node)
–Umbilical Lymph Node (Sister Mary Joseph’s Node)
–Ovarian Mets (Krukenburg Tumor)
What is the initial diagnostic done for gastric carcinoma?
True or false: this type of cancer has a poor prognosis?
Upper endoscopy with biopsy
Poor prognosis (usually present late in disease)
Risk factors for hepatocellular carcinoma (liver cancer)
-Chronic liver disease (HBV, HCV, HDV, cirrhosis)
-Aflatoxin B1 exposure (Aspergillus)
Many patients with hepatocellular carcinoma are asymptomatic, but they can have general symptoms such as malaise, weight loss, jaundice, hepatosplenomegaly.
What diagnostic is usually done (there are a few)
Contrast enhanced CT or MRI for liver lesion evaluation
Liver biopsy
Management for hepatocellular carcinoma
-Surgical resection if not associated with cirrhosis and if it is confined to a lobe
Surveillance for hepatocellular carcinoma (what is done, how often, and who it’s done in)
-US every 6 months with or without alpha-fetoprotein
-High risk patients (active hepatitis B with high AST for example)
Hepatic Vein Obstruction (Budd-Chiari Syndrome), the MCC of _____________, is hepatic venous outflow obstruction leading to decreased liver drainage with subsequent portal hypertension and cirrhosis.
There is a classic triad associated with this condition. What is it?
MCC of portal hypertension in children
Triad: ascites + hepatomegaly + RUQ abdominal pain
There are two types of hepatic vein obstruction
-Primary:
-Secondary:
-Primary: hepatic vein thrombosis (MC)
-Secondary: hepatic vein or inferior vena cava occlusion
Initial screening diagnostic of choice for hepatic vein obstruction?
What is the gold standard?
US initially
Venography (not commonly performed though)
Treatment for hepatic vein obstruction
-Shunt decompression of liver (TIPS)
-Angiography with stenting
-Diuretics, low sodium diet, paracentesis for ascites
Cirrhosis, which is mostly irreversible liver fibrosis with nodular regeneration secondary to chronic liver disease, has a MCC of ________
Other causes include…
Chronic Hepatitis C is MCC
Alcohol, HBV, HDC, Obesity, DM, Hemochromatosis, Primary Sclerosing Cholangitis
Symptoms of cirrhosis
-General Symptoms: fatigue, weakness, weight loss, anorexia
-Ascites, Gynecomastia, spider angioma, telangiectasias, caput medusa, muscle wasting, jaundice, Dupuytren’s Contracture
-Hepatic Encephalopathy: confusion and lethargy (increased ammonia levels toxic to the brain)
-Asterixis (flapping tremor with wrist extension)
-Esophageal varices
How do you generally manage cirrhosis?
-Avoidance of alcohol and hepatotoxic meds, weight reduction, vaccination for HAV and HBV
-Treat underlying cause
-Liver transplant definitive
Regarding the symptoms for cirrhosis, what meds should be given if:
-Encephalopathy:
-Ascites:
-Pruritis:
-Lactulose or Rifaximin for Encephalopathy
-Diuretics (Spironolactone, Furosemide) for ascites
-Cholestyramine (reduces bile salts in skin) for pruritus
Again, how are you monitoring the patient with cirrhosis for hepatocellular carcinoma?
What staging is used for cirrhosis (it has a specific name)
-US every 6 months with or without alpha-fetoprotein
-Child-Pugh Classification
One complication of cirrhosis, spontaneous bacterial peritonitis, is infection of ascitic fluid WITHOUT perforation of the bowel. What is the MCC organism?
E. Coli
Symptoms of spontaneous bacterial peritonitis?
What is the diagnostic of choice?
What is the most accurate though?
-Fever, chills, abdominal pain, increasing girth, diarrhea
-Ascites (shifting dullness, fluid wave), abdominal tenderness
-Diagnostic of choice: Paracentesis (cell count 250 cell/mm3 determines need to treat)
-Most accurate: culture
What medication is used for treatment of spontaneous bacterial peritonitis?
What should be used for lifelong prophylaxis due to risk of recurrence)
-Cefotaxime or Cetriaxone
-Lifelong prophylaxis with Bactrim or Norfloxacin
Nonalcoholic fatty liver disease, an extremely common cause of mildly abnormal liver function tests, can be caused by what kinds of things?
What is the most accurate test and what is seen?
Obesity, hyperlipidemia, glucocorticoid use, DM
-Biopsy: micro vesicular fatty deposits similar to alcoholic liver disease WITHOUT the history of heavy EtOH
