intro & Esophageal disorders Flashcards
Abd pain is a ____ not a _____
symptom, not a Dx
not all abd pain is of ____ origin
GI
Abdominal pain, if there area no alarm signs, what can you do?
its ok to watch and wait
4 common features in GI disorders
dysphagia (difficulty swallowing)
odynophagia (pain with swallowing)
regurgitation
heartburn-pyrosis (reflux)
older pt with new swallowing/heartburn complaint.. think?
RED FLAG
what SHOULD be gold standard test for esophageal disorders?
EGD (aka upper endoscopy)
who do you refer to for pharynx/swallowing problems?
ENT and/or speech pathology
are the sphincters of the esophagus true sphincters?
NO
physiological reflux is common, ____ and ____. what is usually the presenting symptom? what does the pathology include?
physiological reflux is common, short lived, and asymptomatic.
heartburn is usually the presenting symptoms to pathologic reflux.
-pathology includes symptoms (including nocturnal)
what percent of healthy people experience heartburn at least once a month? what percent develop mucosal damage?
44%
50%
GERD red flags/ alarm symptoms (5)
anemia, chest pain (not burning) , dysphagia, hematemesis, weight loss
*any chronic symptoms of GERD are bad
how can GERD cause asthma exacerbation?
microaspiration
cause of GERD
too much acid or poor LES (lower esophageal sphincter) function
-both show the same symptoms
GERD Dx: pursue a Dx eval if…
symptoms are chronic, refractory or if there are alarm symptoms
4 types of GERD Dx tests (2 major 2 minor)
major: endoscopy and ambulatory pH monitoring
minor: esophageal manometry (LES pressure)
and barium swallow
technical gold standard Dx test for GERD (and what is the one more commonly used?)
technically: pH ambulatory monitoring
real: EGD
what is pH ambulatory monitoring and who is it good for?
Useful in Pts who have not benefited from a trial of anti-secretory meds or have refractory problems, or has a normal endoscopy and cont’d symptoms.
results from both EGD nor pH monitoring …
do NOT correlate well with severity of symptoms
early/mild esophagitis vs erosive/severe
early: reddened
severe: has gone into submucosa
Goals for GERD txt
prevent reflux, lower acid secretion, prevent complications of esophagitis
txt for GERD
lifestyle modifications (diet, elevate bed with blocks) neutralize acid with meds (antacid, PPI, H2 blocker) surgery (fundoplication)
what is a Nissen fundoplication?
fold fundus of stomach and wrap around esophagus to prevent reflux (increase pressure)
antacids ____ but do not _____ acids.
neutralize but do not suppress
what are the antacids? antacids should be taken when?
Mg++, Al++, Ca++ salts
immediately after meals (when you have symptoms)
two drugs to help reflux, second-line to antacids.
H2 blockers
PPI (preferred)
what do H2 blockers do for GERD?
block production of acid by gastric parietal cells
when are PPIs taken?
before you eat (this is when the enzyme works best)
one downside to PPIs?
inc risk for infection cause its taking away the acid that normally neutralizes bacteria that comes with food.
___ have good healing action for ulcers (GERD)
PPIs
which GERD medication has diagnostic value? how is this applicable?
PPIs
take PPI (trial for a month) and symptoms go away…
and stay gone w/ discontinuance : mild problem
and come back w/ discontinuance : maybe something worse (peptic ulcer disease, stomach cancer, etc)
how do you take PPIs? efficacy between PPIs? usual starting dose?
step-up and step-down approach, taken before meals, no difference in efficacy among the PPIs
OTC omeprazole 20 mg qd is usual starting dose.
for severe disease, give PPIs …
BID for 2-4 weeks then qd
8-12 weeks
most will relapse at discontinuance w/out lifestyle modification
GERD complications: 4
esophageal stricture, esophageal ulceration, hemorrhage, barrett esophagus
what is barretts esophagus?
longterm acid exposure predisposes for adenocarcinoma
- metaplastic columnar epithelial cells replace squamous epithelium
- not a Cancer but neoplastic changes that inc. the risk for cancer
barretts esophagus presents in __% of people with longterm GERD
10
when to use endoscopy for barrett’s?
to ID barett:
screening after 5 years w/longstanding reflux
periodic re-assessment
txt for barrett’s
resection of that part of the esophagus (b/c does not get better with acid suppression, neoplastic change has already occurred)
what is a haital hernia? symptomatic?
protrusion of portion of the stomach through the haitus of the diaphragm into the thoracic cavity
- usually asymptomatic
if you have ___ and ____, GERD symptoms are usually worse
hiatal hernia and reflux
what is achalasia?
esophageal motality disorder, absence of peristalsis in lower 1/2 of esophagus (LES failure)
- leads to progressive dysphagia, regurg, spasm
- weight loss and halitosis (b/c food gets trapped)
best for Dx of achalasia?
barium swallow- dilated tapering to “birds beak” appearance of esophagus
txt for achalasia?
balloon dilation of LES
Ca++ channel blockers or botox (block hyper-reactive smooth muscle reaction)
myotomy (cuts in muscle)
smooth muscle spastic disorder: what is it? what does it feel like? symptoms are progressive or intermittent?
diffuse esophageal spasm
feels like “non-cardiac chest pain”
dysphagia w/ non-coordinated contractions
sympt: intermittent
txt for smooth muscle spastic disorder
nitroglycerine (same as for angina)
also Ca++ blocker and anti-depressants
what is scleroderma?
subQ tissue becomes progressively calcified and stiffened.
- peristalsis wave defect
- reduced LES pressure
what % of patients with scleroderma have GI issues?
90%
txt for scleroderma?
depends on symptoms (txt with reflux or motility medications)
pill-induced esophagitis: what is it and what pills usually cause it?
caused by delayed transit time in esophagus
ASA, NSAIDS, Ferrus Sulfate,
Tetracyclines*** (alendronate/fosamax)
caustic esophagitis
strong alkali and acids (drano, lye, bleach)
- alkali injury generally worse than acid
- can lead to death, strictures, etc.
txt for caustic esophagitis
IV H2 blockers
NG tube
(don’t try to neutralize, just flush out)
eosinophilic esophagitis: what is it and how does it present?
allergy in esophagus
- almost always present with dysphagia/regurg/food impaction with GERD-like complaints
who gets eosinophilic esophagitis?
men>women, often presents in children, STRONG FH, with atopy (eczema, asthma, allergies)
txt: eosinophilia esoph. on Bx responds to ___ better than _____. But how will we txt?
steroids better than PPIs
but… txt with PPIs then topical ICS if poor response (swallow the spray!)
only test of cure for eosinophilia esoph. is what?
re-biopsy, so we often just txt symptoms
infectious esophagitis, commonly seen in what people? common pathogens?
immunosuppressed patients
Herpes, Candida, CMV
symptoms for infectious esoph.
dysphagia and odynophagia (very painful)
txt for infectous esoph.
txt underlying condition, appropriate anti-infectives
esophageal rings: what are they? etiology? Sx? Txt?
thin, diaphragm-like membranes - mucosal and (mostly) muscular
- etiology: varied (reflux, hernia, etc)
- Sx: intermittent dysphagia
- txt: dilation and txt underlying cuase
esophageal webs are more ___ while rings are more ____
webs: mucosal
rings: muscular
what is a schatzki ring? what does it cause?
mucosal ring oropharyngeal dysphagia (disfunctional swallowing)
esophageal diverticula (aka ____)
Zenker’s : caused by motility d/o of upper esophagus; relaxation/contraction problems, causes high pressures that result in diverticuli (pouches/herniation in muscular wall of pharynx)
symptoms of esophageal diverticula? txt?
regurg and really FOUL breath
txt: excision
risk factors for esophageal cancer
men, smokers, alcohol.
___ year abstinence of smoking and alcohol reduce risk for esophageal cancer by ___ %
10 year
10 %
risk factors for AC esophageal cancer
barretts and GERD
increased BMI
esophageal cancer is uncommon but…
lethal!
esophageal cancer: presentation & Dx
late with no symptoms of early disease
Dx: endoscopy, CT to evaluate metastasis/nodal involvement, PET scan
txt for esophageal cancer
early detection and prevention, major surgery for resection, maybe radiation/chemo, brachytherapy (palliative radiation), stenting for dysphagia
esophageal varicies
dilation of esophago-gastric venous plexus (from elevated portal HTN)
mallory-weiss syndrome
Mucosal lacerations at the gastro-esophageal junction or gastric cardia
Hematemesis associated with persistent retching and vomiting, often following an alcoholic binge
Distension of the nondistensible lower esophagus causes tears
mallor weiss syndrome: tear: Majority of patients ______ _______ with only minor blood loss, but ~__% may have more serious sequelae
Monitor for …
heal spontaneously
10%shock, need for transfusion
