Kaplan IM - Gastroenterology Flashcards
What is the presentation of GERD?
- Substernal chest pain without cardiac disease
- Chronic cough
- Belching
- Metallic or sour taste
- Wheezing without reactive airway disease
Mention some major risk factors for GERD.
- Obesity –> BMI>28.
- Hiatal hernia
- Hypercalcemia –> Ca is 2nd messenger for gastrin.
- Zollinger-Ellison
- Medications –> Prednisone
- Motility disorders –> Scleroderma, gastroparesis (DM neuropathy)
- Cigarette smoking
- Xerostomia
What is the best initial test for GERD?
PPI administration –> also therapeutic.
What happens if after 4-6 weeks treatment failure of GERD with PPIs occurs?
The most accurate test is a 24h pH monitoring.
What indicates endoscopy in GERD?
When symptoms persist after maximal therapy + In alarm symptoms:
- Dysphagia
- Odynophagia
- GI bleeding or anemia
- Weight loss
When is 24h pH monitoring indicated?
- Asthma begins as an adult in the setting of GERD.
- Hoarseness persists for a prolonged duration.
- Sleep apnea is a comorbid finding
- Medical treatment has failed.
What are the 3 steps in the treatment of GERD?
- Lifestyle modifications
- Medical therapy
- Surgical treatment
What lifestyle modifications can be done to treat GERD?
- Elevate the head of the bed
- Stop tobacco, caffeine, chocolate, alcohol, and peppermint
- -> ALL reduce lower esophageal sphincter pressure. - Don’t sleep within 3 hours of a meal, when acid production in the stomach is at a peak.
- Lose weight.
What is the medical therapy for GERD?
PPIs and H2 blockers.
What percentage of patients is treated with H2 blockers?
Only 50-70%.
What do the antacids provide?
Short-term relief in only 20% of cases.
What is the surgical treatment of GERD?
- Nissen fundoplication
2. Transoral incisionless fundoplication (TIF) endoscopically rebuilds the LES through the esophagus.
What is the difference between dysphagia and odynophagia?
Dysphagia –> Difficulty shallowing.
Odynophagia –> Painful shallowing.
What is the probably the underlying cause of dysphagia in young patients and in old ones?
Young –> Secondary to a motility disorder.
Old –> Stroke is a more common cause.
What is probably the underlying cause in odynophagia?
Typically in the setting of an infectious process and requires biopsy during EGD.
Mention some causes of dysphagia.
- Achalasia
- Cancer
- Peptic strictures - rings from acid exposure.
- Zenker diverticulum - halitosis.
- Esophageal spasm
What is the type of dysphagia in achalasia?
Solids and liquids.
What is the etiology of achalasia?
Idiopathic and Chagas.
What is the best initial test in achalasia?
Barium shallow with a “Bird’s beak” sign + massively dilated esophagus.
What is the most accurate test in dysphagia caused by achalasia?
Esophageal manometry shows high LES pressure with shallowing and peristalsis.
What is the best therapy for dysphagia caused by achalasia?
- Pneumatic dilation
- LES injections of botulinum toxin type A
- Heller myotomy
What type of dysphagia do we see with esophageal cancer?
Progressive worsening from solids to liquids.
What is the etiology of esophageal cancer?
- Long-standing GERD
- Alcohol
- Tobacco
What is the best initial test for dysphagia caused by esophageal cancer?
EGD with biopsy and further imaging (CT scan, PET, ultrasound) for staging.
What is the most accurate test for dysphagia caused by esophageal cancer?
EGD - in cancer tissue biopsy only if definitive.
What is the best therapy for dysphagia caused by esophageal cancer?
Surgical resection and 5-fluorouracil therapy +/- radiation.
What type of dysphagia do we see with peptic strictures (rings from acid exposure)?
Solids or liquids.
What is the etiology of peptic strictures?
Long standing GERD.
What is the best initial test for dysphagia associated with peptic strictures?
Barium study.
What is the most accurate test for dysphagia associated with peptic strictures?
EGD is diagnostic and therapeutic.
What is the best therapy for dysphagia associated with peptic strictures?
Pneumatic dilation.
What type of dysphagia is associated with Zenker diverticulum (associated with halitosis)?
Solids and liquids.
What is the etiology of Zenker diverticulum?
Congenital.
What is the best initial test for Zenker diverticulum?
Barium study.
What is the most accurate test for dysphagia associated with Zenker diverticulum?
Barium study.
What is the best therapy for dysphagia associated with Zenker diverticulum?
Surgical resection or endoscopic stapling.
What type of dysphagia is associated with esophageal spasm?
Acute difficulty in shallowing solids and liquids with chest pain.
What is the etiology of esophageal spasms?
Diffuse, uncoordinated esophageal contractions.
What is the best initial test for dysphagia associated with esophageal spasms?
Barium study at time of attack showing a “corkscrew” esophagus.
What is the most accurate test for dysphagia associated with esophageal spasms?
Manometry in the setting of clinical symptoms.
What is the best therapy for esophageal spasms?
Ca channel blockers.
Mention some causes of esophagitis.
- Candidiasis
- CMV
- HSV
- Pill esophagitis
- Eosinophilic esophagitis
What are the signs and symptoms of esophagitis due to candida?
Dysphagia + Odynophagia.
What is the diagnostic test for esophagitis due to candida?
Treat patients with AIDS who have <100 CD4 cells with fluconazole.
What are the signs and symptoms of esophagitis due to CMV?
Dysphagia and odynophagia in an immunocompromised patient.
What is the diagnostic test for CMV esophagitis?
EGD with biopsy with viral cultures.
What is the best therapy for CMV esophagitis?
Ganciclovir or foscarnet.
What are the signs and symptoms of HSV esophagitis?
Dysphagia and odynophagia in an immunocompromised patient.
What is the diagnostic test for HSV esophagitis?
EGD with biopsy with viral cultures.
What is the best therapy for HSV esophagitis?
Acyclovir.
What are the signs and symptoms of pill esophagitis?
New-onset dysphagia and odynophagia in a patient on biphosphonates or doxycycline.
What is the diagnostic test in pill esophagitis?
EGD to rule out other causes.