Lecture 18 - Esophagus, Pancreas And Stomach Flashcards
What are some common chief complaints for GERD?
Odynphagia, pyrosis, CP, dysphagia, regurgitation, chronic cough, wheezing, sour taste, halitosis
What is the possible progression of GERD?
GERD —> reflux esophagitis —> esophageal stricture —> Barrett’s esophagus —> esophageal adenocarcinoma
What are the alarm sx for GERD?
New onset of sx >60 years of age
New IDA
Dysphagia, odynphagia, weight loss, evidence of bleeding (hematemesis, melena)
What are the sx of erosive esophagitis?
More severe than GERD sx
Odynphagia, retrosternal CP, dysphagia
Requires endoscopy for official diagnosis
How is GERD diagnosed?
Based off clinical hx and PE
Sx improve with empiric Tx (PPI, H2 blockers)
Ambulatory 24-48h pH monitoring
Endoscopy
What is the tx for GERD?
Lifestyle modifications
Acid suppression with PPI
Surgery
What is the tx for esophagitis?
Treat underlying cause (infectious, GERD, EoE)
PPI therapy
Sucralfate? Local anesthetic?
What is the tx for strictures?
Dilate with boogie Prevent recurrence (often time same cause as esophagitis)
What are some common chief complains for PUD?
Epigastric pain (DU pain awakening pt from sleep and hours after eating; GU mins after eating)
Bloating
Early satiety
N/V
Bleeding (hematemesis, hematochezia, melena)
What are the sx of gastroparesis?
Nausea, vomiting, abd pain (rarely predominant sx)
Early satiety
Bloating
What are the risk factors for PUD?
NSAIDs, H pylori, tobacco use, COPD, CKD, CAD
What are risk factors for gastroparesis?
DM, meds, viral (CMV, EBV, VZV, Norwalk, rotavirus)
Post surgical, scleroderma
Paraneoplastic dysmotility (small cell lung cancer)
What are the complications that can occur with PUD?
Bleeding (RF associated with poor outcomes include, >60 y/o, NSAID use, concomitant multi organ failure, pulmonary complications, malignancy)
Perforation
Gastric outlet obstruction (rare)
What can provide both diagnostic and therapeutic solutions for PUD?
EGD
What is the Tx for PUD?
Resuscitation if indicated (fluids and blood products)
Stop NSAIDs
Treat H pylori
PPI* (gold standard for tx)
Endoscopic therapy or surgical intervention
What imaging should be done for gastroparesis?
CT abd (initially ordered to rule out mechanical obstruction) Gastric scintigraphy
What supportive labs should be ordered for gastroparesis?
A1c (screen with diabetes)
ANA (underlying auto immune condition)
What is the Tx for gastroparesis?
Treat underlying disease Stop drugs that delay gastric emptying Dietary modifications (low fat diets, limit non digestible fiber) Prokinetic therapy (metocloperamide and erythromycin)
What are common chiefs complaints for pancreatitis?
Epigastric pain +/- radiation to the back or other parts of the abd (typically severe, sharp, stabbing pain in nature)
N/V (commonly secondary to hypomotility)
Abd distention (with guarding or rigidity)
What is the MCC of pancreatitis?
Gallstones
2nd MC alcohol
What’s the PE for pancreatitis pts?
Low grade fever, Tachycardia (very common), Hypotension (due to hypovoloemia, cytokine release, digestive enzymes in circulation)
Anxious, some level of distress
Pleural effusions possible
Epigastric/periumbilical pain
What are some skin signs of pancreatitis?
Grey turners sign (bruising on the flanks)
Cullen’s sign (bruising around the umbilicus —> necrotizing pancreatitis with retro or intraperitoneal bleeding)
Panniculitis (inflammation of subQ fat, resulting in necrosis)
What are the diagnostic labs for pancreatitis?
Serum amylase and lipase** Supportive labs (leukocytosis, elevated Hb/Hc, elevated BUN)
Describe plain radiograph for pancreatitis
Insensitive, not good for detecting pancreatitis
May show stigmata of disease such as ileus or pleural effusion
Describe abd US for pancreatitis
May reveal signs of pancreatitis (increased volume of pancreas, decreased echogenicity)
Good for ID of gallstones, thrombosis, necrosis
What is the gold standard for diagnosis of pancreatitis?
Abdominal CT
Can show necrosis, abscess, hemorrhage, calcifications (chronic) or pancreatic mass
What is MRCP?
Magnetic resonance cholangiopancreatography
Non invasive
Motion/gas artifact can be an issue
Used to visualize pancreatic ducts and biliary tree esp in cases where history is not suggestive of RF
Describe endoscopic ultrasound (EUS) for pancreatitis
Invasive
Used to evaluate biliary tree, pancreatic ducts, cysts and masses
Provides ability to biopsy and perform additional procedures
What is required for a dx of pancreatitis?
Requires 2 of the 3 following findings
- Abd pain consistent with pancreatitis
- Serum lipase or amylase 3 times ULN
- CT or MRI imaging findings consistent with pancreatitis
What is the tx for pancreatitis?
IV fluid resuscitation
Pain control
NPO
ERCP
What are the predictors for negative outcomes of pancreatitis?
Age >60 years old Obesity (BMI >30) Long term heavy alcohol use Elevated BUN/Cr (AKI), hemoconcentration, elevated inflammatory markers (CRP) Elevated scoring system (APACHE II)
What is the prevention for pancreatitis?
Removing gallbladder (gallstone pancreatitis)
EtOH cessation
Hypertriglyceridemia management
Review med list
What are the sympathetic for upper GI?
T5-10
What is the parasympathetics for heart, lungs, esophagus, upper GI, small intestine, kidneys, ascending and transverse colon, upper ureter?
Vagus nerve (OA,AA)
What are some OMT that can be done for the upper GI?
Sympathetic inhibition (rib raising, paraspinal inhibition) Parasympathetics (suboccipital release) Treat Chapman reflex points
What are the contraindications for Chapman’s points?
Emergence medical care needed
Pt refuses
Relative contraindications (fracture, malignancy or other urgent issues needing to be addressed)
Study
Upper GI Chapman points
