GI system Flashcards
What is achalasia?
Derangement of the myenteric motor plexus (coordinates motility)
S/s of achalasia
- Dysphagia for BOTH solids and liquids
- Regurgitation of food
- Severe halitosis
-WEIGHT LOSS, cough
Similar between achalasia and GERD and different?
BOTH have regurgitation
GERD produces a sour taste but not achalasia
Tests for diagnosing achalasia
- CXR lateral upright: absence of gastric bubble, bird beak sign and air-fluid levels in posterior mediastinum
- Barium swallow- distal bird’s beak sign
- Esophageal motility (aka manometry) study- nonperistaltic contractions, incomplete LES relaxation after swallowing, inc LES resting tone
- SCOPE to rule out mass lesions or strictures, biopsy
Treatment
- Nitrates or CCBs- relax the LES
- Local botox
- Surgery: esophagomyotomy with incision of the DISTAL tunica muscularis (DON’T completely divide the LES)
- Endoscopic dilatation an option but less success and more complications (perf)
Complications of achalasia?
Risk of SCC is up to 10% in ppl w/ long-standing achalasia
-Reflux/aspiration can cause PNA, bronchiectasis, asthma
Diffuse esophageal spasm?
Myenteric plexus dysfunction.
Distal 2/3 of esophagus and is caused by uncoordinated large-amplitude contractions of smooth muscle
Secondary causes of DES?
Diabetes neuropathy, collagen vascular dz, reflux esophagitis, obstruction
S/s of esophageal spasm? Associated illnesses?
- Dysphagia for both solids/liquids (like achalasia)
- CHEST PAIN similar to MI! Acute onset, retrosternal, may be radiating to arms/jaw/back
INTESTINAL DISORDERS like IBS and spastic colon
Key about esophageal spasm vs. achalasia?
NO REGURGITATION IN DES.
Diagnosing DES?
Barium swallow- corkscrew appearance; may be TOTALLY NORMAL if it’s not catching the spasm at the time. LES normal diameter
-Esophageal manometry- swallow-induced LARGE uncoordinated contractions
DES treatment?
Nitrates or CCBs
NOT usually esophagomyotomy
Esophageal varicies s/s?
- Bleeding stops spontaneously in 50% of cases
- Rebleeding risk is high
Treatment of unruptured esoph varicies?
Medical: drugs that decrease portal blood flow- vasopressin, octreotide, somatostatin.
Beta-blockers decrease portal pressure
Rx for ruptured esoph varicies?
pRBCs, NS NG suction Endoscopic sclerotherapy Endoscopic band ligation (these have 90% success)
Balloon tamponade can cause perf
TIPS/portocaval shunt, liver transplant
Ddx of esoph rupture?
Aortic dissection/MI
Spontaneous pneumothorax
Pancreatitis
Perforated peptic ulcer
How to diagnose esophageal rupture?
CXR: L-sided pleural effusion, mediastinal or subcutaneous emphysema
Esophagogram w/ water-soluble contrast (shows extravasation of contrast)
S/s esophageal cancer
GRADUAL dysphagia first solids then liquids (it takes 60% occlusion to have sx)
Wt loss, fatigability, weakness
Diagnosis?
- Barium swallow showing mass
- CXR w/ hilar LAD
- EGD to look at mass/biopsy it
- CT scan of thorax for spread
Treatment?
Usually caught after widespread/metastasis so <40% candidates for surgery; many post-op complications
Epiphrenic/pharyngoesophageal (Zenker’s) cause?
Elevated pressure
Both are FALSE
Zenker’s is the one most likely to be symptomatic
Treatment of Zenker’s?
Cervical esophagomyotomy with resection of diverticulum
Esophageal stricture s/s?
Small may be asx, otherwise progressive dysphagia
Esophageal stricture dx?
SCOPE bc it MUST BE EVALUATED for malignancy
Stricture rx?
Dilators passed thru stricture
What drugs can cause PUD? Why?
NSAIDs, acetazolamide, alpha blockers, alcohol
They inhibit bicarb secretion into the mucous gel
Which drugs reduce gel thickness?
NSAIDs, steroids
PGE increases it
Complications of PUD?
Bleeding 20%
Perforation 7%
Gastric outlet obstruction from scarring and edema
52 yo lady pw 3 months of early satiety, wt loss, and non-bilious vomiting
Gastric outlet obstruction
What does an anterior perforation of duodenal ulcer look like?
Free air under the diaphragm 70%
Posterior perf od duodenal ulcer?
Pain radiating to back
Pancreatitis
GI bleed
Duodenal ulcer causes
- H pylori (being colonized doesn’t mean you’ll get an ulcer…only 10-20% of ppl do)
- NSAIDs/steroids
- Zollinger-Ellison (2/3 are malignant ulcers; diarrhea common)
Duodenal ulcer sx?
Burning epigastic pain when stomach empty; food relieves within 30min
N/V
Nighttime awakening
(Weirdly assoc with blood type O)
Dx duodenal ulcer?
Give treatment and see if it resolves; no need for biopsy
H. pylori- endsocopy w/ bx, serology H. pylori IgG, urease breath test
Zollinger-Ellison-
Serum gastrin level >1000pg/mL
SECRETIN STIM TEST–> paradoxical rise in serum gastrin
Rx of duodenal ulcers?
DC NSAIDS, steroids, smoking cessation
PPIs better than H2 blockers
H PYLORI ERADICATION: PPI, clarithromycin, amoxicillin/mtz for 14 days
Surgical rx of duodenal ulcers?
HIGHLY SELECTIVE VAGOTOMY
Cut middle of nn, spare the most distal branches; lowest rate of dumping after but highest recurrence which depends on the site of the ulcer. PREPYLORIC ulcers highest recurrence.
Rarely needed!
Only if refractory to 12 wks medical rx, or hemorrhage, obstruction, perf
Surgical complications for rx of PUD?
- Dumping syndrome
- Afferent loop syndrome
- Postvagotomy diarrhea
- Duodenal stump leak
- Efferent loop obstruction
- Marginal ulcer (ulcers that develop at the margins of a gastrojejunostomy)
- Chronic gastroparesis
- Postgastrectomy stump cancer
Gastric ulcer? RFs?
Decreased protection against acid
Smoking
What do they all need?
Biopsy bc 3% are malignant
Dx with endoscopy
Types for gastric ulcers and their treatments?
I- Lesser curvature
II- Gastic and duodenal ulcer
These get antrectomy
III- Prepyloric ulcer= highly selective vagotomy
IV- ULCER IN CARDIA
Subtotal gastrectomy then Roux-en-Y esophagogastrojejunostomy
Dumping syndrome
From unregulated movement of gastric contents from stomach to intestine
Rx: avoid excessive water intake or high sugar food. Severe- octreotide
What is Billroth II used for? What is it?
Refractory PUD and gastric adenocarcionma
CBD gets sewn to duodenum then gastrojejunostomy
BILLROTH II=GASTROJEJUNOSTOMY
What is afferent loop syndrome? Rx?
Obstruction of afferent limb (the duodenum pouch to the stomach) of Billroth II
Mostly present within 1st wk post-op
Vomiting relieves postprandial RUQ pain/nausea
Steatorrhea
Rx: surgical revision
Endoscopic balloon dilatation
Gastritis s/s?
Burning/gnawing pain
Pain worse w/ food and relieved by antacids
Gastritis dx?
Endoscopy
Gastritis rx?
Stop NSAIDs, triple therapy, stop smoking/EtOH, H2 blockers
Gastric outlet obstruction causes? Dx? Rx?
Obstructing duodenal or gastric ulcers!
Tumor in head of pancreas or stomach
Endoscopy or barium swallow x-ray
Endoscopic balloon dilatation
Surgical resection: 7 days NG decompression and antisecretory rx then truncal vagotomy+pyloroplasty
What’s a good drug for upper GI hemorrhage?
Somatostatin- inhibits gastric, intestinal, and biliary motility and dec visceral blood flow
How often is a laparotomy needed for a UGI bleed?
5%
Undersew the vessel on either side of the bleeding vessel
Gastric ulcers are 3x more likely to rebleed than duodenal
Types of gastric bypass?
Vertical banded gastroplasty
Signal to hypothalamus that you’re full when proximal pouch is distended
Roux-en-Y gastric bypass-
More complications but greater weight loss
Best diagnostic test for gastric cancer?
Upper GI endoscopy (bc you biopsy duh)
S/s of gastric cancer?
Adenocarcinoma is 95%
Krukenberg’s tumor- mets to ovaries
Blumer’s shelf- mets to pelvic cul-de-sac felt on DRE
Virchow’s node- L supraclavicular
Sister mary joseph’s- mets to umbilical LNs
Gastric lymphoma
Men more, 5% of gastric cancers
HIV 5x risk
Treatment of low vs high grade MALT? Poor prognosis?
Men more, low grade- H pylori rx
High grade- Radiation/chemo
Lesser curvature involvement bad
Why do you need to do a biopsy to definitively diagnose MALT?
Bc you can’t distinguish from adenocarcinoma by simple inspection
Carney triad?
Gastric leiomyosarcoma
Pulm chondromas
Extra-adrenal paraganglioma
Seen in women <40
How many neoplasms of stomach are malignant? benign?
90% malignant
10% benign
MC benign tumors of stomach? When do you NEED to biopsy them
Adenomatous polyps
Biopsy >5mm to check for cancer
Menetrier’s disease
BENIGN! Can look like cancer on barium study but do monitor closely bc increased risk of cancer
Autoimmune w/ hypertrophic gastritis that causes PROTEIN-LOSING ENTEROPATHY
Definitive dx: Endoscopy w/ DEEP MUCOSAL BIOPSY (barium swallow shows thickened rugae)
Rx: Anticholinergics, H2 blockers, HIGH PROTEIN DIET, severe may need gastrectomy
Dieulafoy’s lesion?
Mucosal end artery that doesn’t branch like it should. Causes pressure necrosis, erodes into stomach, and ruptures
Massive/recurrent painless hematemesis
Dx: Upper GI endoscopy
Rx: Endoscopic sclerosing therapy or electrocoag
Wedge resection
Gastric volvulus cause?
Paraesophageal hernia usually
Can’t vomit, NG tube can’t pass, intermittent severe epigastric pain/distention
Dx: Upper GI contrast study
Rx: Gastropexy (tack stomach to anterior abdominal wall), fix the hernia
