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1
Q

What is the term to describe difficulty swallowing and the term to describe pain with swallowing?

A

Dysphagia and Odynophagia

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2
Q

What do we mean by oropharyngeal dysphagia?

A

It involves aspiration of food into the lungs (liquids more than solids) which leads to coughing and choking.

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3
Q

Mentioned some causes of oropharyngeal dysphagia. (5)

A

Neurological and muscular cause such as Parkinson’s disease, stroke, myasthenia gravis, prolonged intubation and zenker’s diverticula.

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4
Q

What is Zenker’s diverticulum?

A

It is a pharyngeal pouch made of the mucosa of the pharynx just above the upper esophageal sphincter ( through the cricopharyngeus muscle)

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5
Q

How does zenkers diverticulum present?

A

Oropharyngeal dysphagia, regurgitation, halitosis or cough & chest pain.

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6
Q

What causes esophageal Dysphagia?

A

Either due to obstruction such as strictures, webs, Schatzki rings or carcinoma. In such case it is progressive and involves solids more than liquids.

OR due to motility disorder such as achalasia, scleroderma, esophageal spasm. In which case it involves both solid and liquid Dysphagia.

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7
Q

How do you diagnose oropharyngeal dysphagia, esophageal dysphagia and Odynophagia?

A

oropharyngeal dysphagia –> video fluoroscopy

esophageal dysphagia –> barium swallow (aka esophageal) followed by endoscopy, manometer and ph monitoring. If there’s an obstructive lesion, do endoscopy with biopsy right away

Odynophagia–> upper endoscopy

Don’t forget to examine for goiter or tumors and an atomic defects.

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8
Q

What are Schatzki rings?

A

A narrowing of the lower esophagus caused by a ring of mucosal or muscular tissue.

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9
Q

What are the 2 types of Schatzki rings?

A

A rings- those above esophagus/stomach junction.

B rings- those at the squamocolumnar junction in the lower esophagus

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10
Q

What is Plummer Vinson syndrome?

A

A rare disease characterized by a tetras of dysphagia, iron deficiency anemia, glossitis and esophageal webs.

+/- angular stomatitis, odynophagia.

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11
Q

How do you treat Plummer Vinson syndrome?

A

Iron supplementation and mechanical widening of esophagus.

Remember, it’s rare & mostly seen in postmenopausal women.

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12
Q

What type of muscles is there in the esophagus?

A

Skeletal in the upper third and smooth in the lower two thirds.

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13
Q

What type of esophagitis is an AIDS defining illness?

A

Candidal Esophagitis.

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14
Q

Mentioned three causes of infectious esophagitis.

A

Candida albicans, HSV, CMV.

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15
Q

What do you see in Candida albicans esophagitis on exam and on upper endoscopy?

A

On exam you see oral thrush

On upper endoscopy you see yellow-white plaques adherent to the mucosa.

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16
Q

How do you treat Candidal esophagitis?

A

Nystatin oral suspension or fluconazole PO

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17
Q

How does HSV esophagitis present on exam and on upper endoscopy?

A

On exam you see oral ulcers

On upper endoscopy you see small deep ulcerations, multinucleated giant cells with intranuclear inclusions on biopsy + Tzanck smear.

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18
Q

How do you treat HSV esophagitis?

A

IV acyclovir.

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19
Q

How does CMV esophagitis present on exam and on upper endoscopy?

A

On exam: retinitis & colitis

On upper endoscopy: large superficial ulceration, intranuclear and intracytoplasmic inclusions on biopsy.

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20
Q

How do you treat CMV esophagitis?

A

IV Ganciclovir.

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21
Q

Define defuse esophageal spasm. And what’s the other name for it?

A

It is a motility disorder where peristalsis is periodically interrupted by non-peristaltic contractions. Also known as nutcracker esophagus.

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22
Q

How does diffuse esophageal spasm present? (Triad)

A

With chest pain, dysphagia & odynophagia. and is often preceded by ingestion of hot or cold liquids relieved by nitroglycerin.

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23
Q

How do you diagnose diffuse esophageal spasm?

A

Barium swallow and esophageal manometers.

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24
Q

What do you see on barium swallow and esophageal manometry in diffuse esophageal spasm?

A

Barium swallow: corkscrew shaped esophagus

Manometry: high amplitude simultaneous contractions.

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25
Q

How do you treat diffuse esophageal spasm?

A

Nitrates & Calcium channel blockers for symptomatic relief and surgery (esophageal myotomy) for severe cases.

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26
Q

There are two locations for dysphagia, what are they?

A

Oropharyngeal dysphagia and esophageal dysphagia

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26
Q

What is achalasia?

A

It is a motility disorder characterized by impaired relaxation of the lower esophageal sphincter (LES) and loss of peristalsis in the distal two thirds of the esophagus.

Results from degeneration of the inhibitory neurons in the myenteric (Auerbach’s) plexus

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27
Q

How does achalasia present?

A

With progressive dysphagia, chest pain, regurgitation of undigested food, weight loss and nocturnal cough.

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28
Q

How do you diagnose achalasia?

A

Barium swallow, manometry & Endoscopy.

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29
Q

What do you see on barium swallow in achalasia?

A

Esophageal dilation with a “bird’s beak” tapering of the distal esophagus.

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30
Q

What do you see on manometry in achalasia?

A

It shows increased resting lower esophageal sphincter (LES) pressure, incomplete LES relaxation upon swallowing & decreased peristalsis in the body of the esophagus.

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31
Q

What is endoscopy used for in achalasia?

A

To rule out mechanical causes of obstruction.

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32
Q

What is pseudo achalasia?

A

Achalasia due to malignancy

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33
Q

How do you treat achalasia?

A

Nitrates, CCBs or endoscopic injection of botulinum toxin into the LES for short term symptomatic relief.

Pneumatic balloon dilation and surgical (Heller) myotomy for definitive treatment.

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34
Q

How do you diagnose & treat Zenker’s diverticula?

A

Dx: barium swallow
Tx: myotomy of the cricopharyngeus to relieve the high pressure zone. If diverticulitis at another location ( not zenkers), surgical excision of the diverticula my.

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35
Q

What is The most common type of esophageal cancer worldwide and in the US?

A

Worldwide: squamous cell carcinoma

U.S.: Adenocarcinoma

36
Q

What are two risk factors for squamous cell carcinoma of the esophagus? And what is the risk factor for adenocarcinoma?

A

SCC: Tobacco smoking & alcohol
Adenocarcinoma: Barret’s esophagus ( columnar metaplasia of the distal esophagus secondary to chronic GERD)

37
Q

True or false esophageal cancer metastasized early? And why?

A

True because the esophagus lacks a serosa.

38
Q

How does esophageal cancer present?

A

Weight-loss, progress of dysphagia (initially to solids then to liquids), G.I. bleeding, odynophagia, GERD & vomiting.

39
Q

How do you diagnose esophageal cancer?

A

Barium swallow shows narrowing of the esophagus with an irregular border protruding into the lumen.

Biopsy confirms the diagnosis.

CT and endoscopic ultrasound are used for staging

40
Q

How do you treat esophageal cancer?

A

Chemoradiation and surgical resection for first line treatment.

and in high-grade Barrett’s displasia we also do resection

41
Q

What is the difference between squamous cell carcinoma and adenocarcinoma of the esophagus in location?

A

Squamous cell carcinoma tends to occur in the upper and middle thirds of the esophagus while adenocarcinoma occurs in the lower third.

42
Q

What is the cause of GERD?

A

Transient LES relaxation mostly. Also incomplete LES, gastroparesis or hiatal hernia.

43
Q

How does GERD present?

A

Heartburn that commonly occurs 30 to 90 minutes after a meal (worsens with reclining improves with antacids, sitting, or standing). Sour taste “water brash”, a globe a sensation, unexplained cough & morning hoarseness.

44
Q

Remember GERD can mimic…..(what disease)?

A

Cough variant asthma

45
Q

How do you treat GERD?

A

1-Start with lifestyle modification: weight-loss, elevation of bed, small but frequent meals, avoid late night meals.
2- Pharmacologic: start with antacids use H2 receptor antagonists or PPIs
3-Surgical: Nissen fundoplication for severe disease

46
Q

What are some complications of GERD? 5

A

Erosive esophagitis, esophageal peptic stricture, aspiration pneumonia, upper G.I. bleeding, Barrett’s esophagus.

47
Q

What is hiatal hernia? what are the three types of it? And which of them is the most common?

A

Herniation of stomach into chest through diaphragm.

Sliding (95%), para esophageal (5%) & mixed hiatal hernia (rare).

48
Q

What is the difference between sliding and paraesophageal hiatal hernia?

A

Sliding hiatal hernia: The gastroesophageal junction and a portion of the stomach are displaced above the diaphragm.

Para esophageal hiatal hernia: The gastroesophageal junction remains below the diaphragm while the fundus herniates into the chest.

49
Q

How do you treat sliding hernia and paraesophageal hernia?

A

Sliding: medical therapy & lifestyle modification to decrease symptoms of GERD

Paraesophageal: surgical gastropexy ( attachment of the stomach to the reclusive sheath and closure of the hiatus) to prevent gastric volvulus.

50
Q

Give two examples on H2 receptor antagonist and two examples of PPI’s

A

H2 antagonists: cimetidine and ranitidine

PPIs: omeprazole and lansoprazole

51
Q

A gastric adenocarcinoma that metastasizes to the ovary is called…..?

A

Krukenberg tumor

52
Q

What is gastritis?

A

Inflammation of gastric mucosa.

54
Q

What are the two types of gastritis?

A

Acute and chronic

55
Q

Chronic gastritis has two types, what are they? and which is more common?

A

Type A (10%) & Type B (90%).

56
Q

What causes type A chronic gastritis? And what part of stomach does it affect?

A

Occurs in the fundus & is caused by autoantibodies to parietal cells. It causes/is associated with pernicious anemia.

Remember it increases risk of gastric Adenocarcinoma & carcinoid tumors.

57
Q

What causes type B chronic gastritis? And what part of stomach does it affect?

A

Occurs in Antrum. Caused by NSAIDs or H pylori.

Remember it increases risk of PUD & gastric cancer.

58
Q

How do you diagnose H pylori infection?

A

Urease breath test, serum IgG antibodies (indicate history of infection & not current infection), H pylori stool antigen (indicates CURRENT infection) or endoscopic biopsy.

59
Q

How do you diagnose gastritis?

A

Upper endoscopy to visualize gastric mucosa and detection of H pylori infection

60
Q

How do you treat gastritis?

A

1) Decrease causative agents. Symptomatic relief.

2) Administer triple therapy ( amoxicillin, clarithromycin, omeprazole).

61
Q

Which patients are at risk of stress ulcers and require the prophylactic PPIs?

A

ICU patients.

62
Q

What is Krukenberg tumor?

A

A gastric Adenocarcinoma that metastasizes to the ovary.

63
Q

Stress ulcers are two types; curling and cushing ulcers. What is associated with each?

A

Curling ulcers associated with burns. And Cushing ulcers with traumatic brain injuries.

64
Q

What is the only malignancy that can be cured with antibiotic?

A

MALT (Mucosa associated lymphoid tissue) lymphoma. A rare gastric tumor that presents in patients with chronic H pylori infection. Treated with triple therapy.

65
Q

What is gastric cancer? how is its prognosis? where is it common?

A

It is a malignant tumor with poor prognosis. common in Korea and Japan

66
Q

Most gastric cancers are adenocarcinomas, which exhibit to morphological types. what are they?

A

Intestinal type & diffuse type.

67
Q

What is the intestinal type of gastric cancer?

A

Differentiated cancer that originates from the intestinal metaplasia of gastric mucosal cells.

68
Q

What are some risk factors for intestinal type of gastric cancer?

A

High nitrites and salt diet that’s low in fresh vegetables, colonization with H pylori, chronic gastritis.

69
Q

What is diffuse type of gastric cancer? Its risk factors?

A

Undifferentiated cancer not associated with H pylori or chronic gastritis. Risk factors are unknown.

70
Q

What causes acute gastritis?

A

NSAIDs, alcohol, H pylori infection & stress from burns or CNS injury.

71
Q

What is characteristic of diffuse type gastric cancer on biopsy?

A

Signet ring cells on biopsy are characteristic.

72
Q

How do you diagnose gastric cancer? And how do you treat it?

A

Upper endoscopy & biopsy.

Surgical resection

73
Q

Gastric cancer may present with…..?

A

Virchow’s node ( an enlarged left supraclavicular LN)

74
Q

Pain before and after meal is associated with different ulcers. mention them.

A

after a meal, pain from a Gastric ulcer is Greater. Whereas Duodenal pain Decreases.

75
Q

All gastric ulcers must be biopsied to rule out…..?

A

Malignancy

76
Q

What is the mechanism behind peptic ulcer disease and what is the most common causative factor? Mention other risk factors.

A

Impaired mucosal defense and/or increased acidic gastric content. H pylori. Other risk factors include corticosteroids, NSAIDs, smoking.

77
Q

Who is affected with PUD more males or females?

A

Males

78
Q

What drug can help patients with PUD who require an NSAID therapy (like patients with arthritis)?

A

Misoprostol

79
Q

How does acute perforation present?

A

With rigid abdomen, rebound tenderness & guarding.

80
Q

How do you Dx PUD?

A

1- Rule out perforation.
2- upper endoscopy with biopsy to rule out active bleeding or gastric Adenocarcinoma (10% of gastric ulcers)
3- Test for H pylori
4- In recurrent or refractory cases, check serum gastric levels to screen for Zollinger-Ellison syndrome.

81
Q

How do you rule out perforation?

A

With gastric ulcers: Upright chest X-ray reveals air under diaphragm.

With duodenal ulcers: CT with contrast shows air in the retro peritoneal space. Order CBC to detect any GI bleeding.

82
Q

How do you Tx PUD if perforation is suspected?

A

Confirm with CT with IV contrast. Do surgical laparotomy and monitor BP. Don’t forget to rule out active bleeding by rectal vault exam, NG lavage & serial hematocrit.

83
Q

What’s the long term management of no complicated PUD?

A
  • Antacids, PPIs, H2 blockers.
  • If active H pylori infection present, Triple therapy.
  • Discontinue using exacerbating agents.
  • in severe cases, surgical therapy is indicated ( partial cell vagotomy)
84
Q

What is Zollinger-Ellison syndrome?

A

A rare condition characterized by gastrin producing tumors in the Dueodnum and/or pancreas leading to oversecretion of gastrin -> increased gastric acid production -> stomach & duodenal ulcers.

85
Q

In 20% of cases, gastrin imams are associated with…..?

A

MEN type 1

86
Q

How does Zollinger-Ellison present?

A

Recurrent gnawing (chewing, biting), burning abdominal pain, diarrhea, N/V, weight loss, weakness and GI bleeding.

87
Q

How do you diagnose zollinger?

A

High fasting gastrin levels and high gastrin with the administration of secretin are diagnostic. CT is indicated to characterize and stage the disease.

88
Q

How do you Tx zollinger?

A
  • PPIs to control symptoms.

- Surgical resection of gastrinoma after localization by CT or octreotide scan to identify suspected carcinoid tumors.

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