Lecture 23 (DSA): GI Clinical Correlations Flashcards
What are things that need to considered/asked when a patient presents w/ nausea, vomiting, and/or abdominal pain?
- What medications they are taking, including NSAIDs, herbal supplements, and birth control
- If they are a women of childbearing age, pregnancy should ALWAYS be a differential diagnosis
What is Oropharyngeal dysphagia?
Someone is having difficulty swallowing. After chewing food they are having a hard time transferring food from their mouth to esophagus and initiating swallowing.
What are causes of Oropharyngeal dysphagia?
- Neurological disorders: MS, Parkinsons, Huntingtons
- Muscular and rheumatologic disorders: myopathies
- Metabolic disorders: thryrotoxicosis, Cushing disease, Wilson’s
- Infectious disease: polio, botulism, lyme’s, diptheria, syphilis
- Structural disorders: Zenker’s diverticulum, oropharyngeal tumor
- Motility disorders: UES dysfunction
What is Esophageal dysphagia?
Patients will complain of chest pain/discomfort and feel like food is getting stuck. This more of a mid- to lower-esophagus dysphagia.
What are causes of Esophageal dysphagia and which ones are linked to problems with swallowing solids vs. liquids or both?
Mechanical obstruction: solid foods worse than liquids
- Schatzki ring
- Peptic stricture
- Esophageal cancer
- Eosinophilic esophagitis
Motility disorder: probelms w/ both solids and liquids
- Achalasia
- Diffuse esophageal spasm
- Scleroderma
- Ineffective esophageal motility
What is primary acahlasia?
- Progressive dysphagia (months –> years) for solids and liquids due to impaired relaxation of the LES resulting from loss of nitric oxide-producing inhibitory neurons in the myenteric plexus
How is primary achalsia diagnosed (hint: there are 3 steps)?
- Barium esophagogram w/ “birds beak” distal esophagus
- After barium esophagram, EDG (endoscopy) is always performed to evaluate distal esophagis and gastroesophageal junction to exclude a mechanical obstruction (stricture or cancer)
- Esophageal manometry CONFIRMS the diagnosis
What is Secondary Achalasia?
- Chagas disease caused by the parasite = Trypansoma cruzi
- Should always be considered in patients from endemic regions
How is Secondary Achalasia diagnosed?
A peripheral blood smear w/ parasitic evidence
What can Secondary Achalasia lead to years later?
- Cardiomyopathy
- Megacolon
- Megaesophagus
- Romaña sign (peri-orbital swelling)
What are the alarm features and red flags of concern in dyspepsia and epigastric pain that indicate further workup needed?
- Progressive Dysphagia
- Odynophagia: painful swallowing
- Hematemesis: blood in vomit
- Melana: black tarry sticky stools
- Unintentional weight loss
- Persistent vomiting
- Constant/severe pain
- Unexplained iron deficiency anemia
- Family hx of upper gastrointestinal cancer
- Palpable mass
- Lymphadenopathy
What are the symptoms of a peptic ulcer?
- Epigastric pain that is: gnawing, dull, sharp, burning, aching, or “hunger-like”
- Most patients have sympotmatic periods lasting up to several wees w/ intervals of months to years in which they are pain free (periodicitiy)
What are the signs of GI bleeding?
“Coffee grounds” emesis, hematemesis, melena, or hematochezia
What is H. pylori associated with, which is more common, and which strain significantly increases risk of ulcers?
- Peptic ulcer disease (duodenal > gastric)
- Chronic gastritis
- Gastric adenocarcinoma
- Gastric mucosa associated lymphoid tissue (MALT) lymphoma
- Cag-A toxin positive strains significantly increase risk of ulcer
Where in stomach is chronic gastritis most common and what levels are increased?
Antrum of stomach –> increased gastrin (not above 1000 like Zollinger Ellison) –> increase in HCL production by parietal cells -> increased risk of duodenal ulcer
What 2 tests are used in the detection of H. pylori and what are the features of each?
1) Urea breath test: great first line test, used to confirm eradication
2) Fecal antigen test: great first line, non-invasive test, sensitive, specific, and inexpensive. Can be used to confirm eradication
What is it important to have the patient do before testing for H. pylori?
Stop proton pump inhibitor medication (PPI) x 14 days before fecl and breath tests or high chance of a false negative test
What part of stomach are gastric ulcers typically found in, symptoms description, and treatment?
Location: lesser curvature of the antrum of stomach
Symptoms: sharp and burning epigastric pain, worsens with 30 min - 1 hour after eating
Tx: Proton pump inhibitor, eradicate H. pylori
What part of duodenum are duodenal ulcers typically found in, symptoms description, and treatment?
Location: proximal duodenum, if distal to 2nd portion (think ZES)
Symptoms: gnawing epigastric pain that worses 3-5 hrs after eating, may be temporarily relieved by food/eating
Tx: proton pump inhibitors, eradicate H. pylori
Differentiate a Cushing ulcer from a Curling ulcer
Cushing ulcer: secondary to intracranial lesion, injury
Curling ulcer: seoncdary to severe burns
When should ZES be considered?
- Ulcers in atypical locations
- Enlarged gastric folds
- Diarrhea
- Steatorrhea
- Weight loss
- Significantly elevated fasting gastrin level and positive secretin stimulation test
What is the most common location of gastrinomas?
- Most commonly in the duodenum (primary gastrinoma)
- Sometimes pancreatic
25% of gastrinomas are associated with?
Multiple Endocrine Neoplasia (MEN 1)
What is likely suggestive of ZES when GI imaging or endoscopy is performed?
Large mucosal folds
What is confirmatory of ZES/gastrinomas?
- Serum gastrin >1000 ng/L
- Positive secretin stimulation test (will be negative in the other causes of hypergastrinemia)
What are differential Dx of epigastric pain (dyspepsia)?
- Peptic ulcer disease (PUD)
- Functional dyspepsia
- Atypical gastroesophageal reflux
- Gastric cancer
- Food poisoning
- Viral gastroenteritis
- Biliary tract disease
Esphagogastroduodenoscopy (EGD)/Upper endoscopy is the study of choice for evaluating what pathologies?
- Persitent heartburn
- Dyshphagia
- Odynophagia
- Structural abnormalities detected on barium esophagography
Why is upper endoscopy considered diagnostic and therapeutic?
- Direct visualization
- Allows biopsy of mucosal abnormalities and of normal appearing mucosa
- Allows for dilation of strictures
Barium esophagography is useful for differentiating?
- Between mechanical lesions and motility disorders
- More sensitive for detecting subtle esophageal narrowing due to rings, achalasia, and proximal esophageal lesions
What pathology is shown here and what kind of study is this?
Lower esophageal ring on a barium x-ray
What pathology is shown here and what kind of study is this?
“Bird beak” in Achalasia from a barium x-ray
What pathology is shown here?
Zenker’s Diverticulum
What tests can be done for reflux and how can you test for both acid and nonacid liquid reflux?
- pH within the esophageal lumen may be monitored continously for 24-48 hours
- pH only recording provides info about the amount of esophageal acid reflux but NOT nonacid reflux
- Techniques using combined pH and multichannel intraluminal impedence allow assessment of acid and nonacid liquid reflux
What does esophageal manometry assess and when is it used?
- Assesses esophageal motility
- Manometry cathether measures pressure
- Establshed the etiology of dysphagia in patients in whom a mechanical obstruction cannot be found, especially if a diagnosis of achalasia is suspected by endoscopy or barium study
What is the X-ray showing?
Free-air due to possible perforated organ
What is shown by this X-ray?
Constipation and scoliosis
What is shown here on x-ray?
Air-fluid levels, dilated loops of small bowel, constipation = small bowel obstruction (SBO)
What is shown here?
Air lining the gallbladder wall = emphysematous cholecystitis
What is shown here?
Porcelain gallbladder from chronic cholecystitis
CT has no part in the primary detection of gastric ulcers, what is its role?
Detection of subphrenic and other collections that may occur after a perforation of a gastric ulcer
What is endoscopic ultrasound used for?
Visualizing and biopsying pancreatic masses
What is endoscropic retrograde cholangiopancreatography (ERCP) used for?
- Invasive way to visualize the hepatobiliary and pancreatic ducts; can provide intervention via: diagnostic and therapeutic techniques
- Can help us visualize where stones may be lodged
What is a non-invasive way to visualize the hepatobiliary and pancreatic ducts?
Magnetic Resonance Cholangiopancreatograhy (MRCP)
What are true liver function tests?
- PT/INR
- Albumin
- Cholesterol
What does a CBC w/ differential give us that a CBC doesn’t?
Percent and absolute differential counts (PMN, lymph, baso, eos, mono)
What can a comprehensive metabolic panel tell us that a BMP can’t?
- Albumin:Globulin (A:G) ration
- Albumin
- Alkaline phosphatase
- Aspartate amino transferase (AST)
- Alanine aminotransferase (ALT)
- Bilirubin, total
- Globulin, total
- Protein, total
What GI labs to consider when looking for pancreatitis?
- Lipase
- Amylase
What GI labs to consider when assessing the liver?
- Gamma-glutamyl transferase (GGT)
- Fractionate bilirubin (conjugated vs. unconjugated)
- PT/INR (helpful to know bleeding risk before procedure)
What are the sympathetic spinal levels for: appendix, esophagus, stomach, liver, gallbladder, small intestine, colon, and pancreas?
Appendix: T12
Esophagus: T2-T8
Stomach: T5-T9
Liver, Gallbladder: T6-T9
Small intestine: T5-T9, T9-T12
Colon: T9-L2
Pancreas: T5-T11
What are the PNS levels for the upper portion and lower portion?
Upper: Esophagus - Transvers colon
- OA, AA (vagus n.)
Lower: descending colon, sigmoid, rectum
- S2-S4 (pelvic splanchnic n.)
What are common etiologies of abdominal pain in the LUQ?
- Gastric ulcer
- Ruptured spleen
- Pyelonephritis
- Perforated colon
What are common etiologies of pain in the RUQ?
- Hepatitis
- Pyelonephritis
- Gallstone disease
- Duodenal ulcer
What are the common etiologies of pain in the RLQ?
- Appendicitis
- Perforated cecum
- Ectopic pregnancy
- Strangulated hernia
- Chron’s disease
- Renal colic
- Meckel’s Diverticulum
What are the common etiologies of pain in the epigastric region?
- Pancreatitis
- Peptic ulcer
- Perforated esophagus
- MI
- Gallstone disease
What are common etiologies of pain in the umbilicus/peri-umbilical region?
- Intestinal obstruction
- Pancreatitis
- AAA
- Mesenteric thrombosis
- Early appendicitis
Differential Dx’s for severe epigastric pain?
Atypical for peptic ulcer disease: unless there has been perforation
- Acute pancreatitis, cholecystitis
- Choledocholithiasis
- Esophageal rupture
- Gastric volvulus
- Gastric or intestinal ischemia
- Ruptured aortic aneurysm
- Myocardial ischemia
Differential Dx of Upper GI bleed; where are these?
- Proximal to the Ligament of Treitz
- Peptic ulcer disease
- Erosive gastritis
- Arteriovenous malformations/angioectasis
- Mallory-Weiss tear
- Esophageal varices
What conditions should you think of for hematemesis (red or coffee ground emesis)?
ulcer or varice
What conditions should you think of for melena (black/tarry) stool
UGIB
What conditions should you think of for hematochezia?
LGIB or massive UGIB
What conditions should you think of for acholic stool?
due to lack of bile
bile obstruction (adult) or congenital biliary atresia (baby)
Diet/medicines causing black/red stool
bloack licorice, blueberries, blood sausage
iron pills, activated charcoal, pepto-bismol (will cause + guiac)
beets, red dye (- guiac)
What 3 parts of the history do you want to know for nausea/vomit complaints?
- appearance/content: blood, coffee grounds, food, feculent (SBO)
- frequency? persistent is red flag
- Projectile? pyloric stenosis causes projectile vomiting in children
