Management Of Upper GI Conditions Part 1 Flashcards
Red flags of heart burn
Vomiting
Bleeding (hematemesis, coffee ground emesis, melena)
Iron deficiency
Anorexia
Weight loss
Dysphagia
GERD
Esophageal symptoms
Complications of reflux:
Typical reflux symptoms and chest pain
Esophagitis, stricture, Barret’s Esophagus, esophageal adenocarcinoma
GERD
Extraesophageal symtpoms
Established associations:
- cough
- laryngitis
- asthma
- dental erosions
Proposed associations:
- pharyngitis
- sinusitis
- idiopathic pulmonary fibrosis
- recurrent otitis media
How is GERD diagnosed?
Majority can be diagnosed by Hx alone
Others may need:
- endoscopy
- 24hr esophageal pH study
- 24 hour esophageal manometry
- barium x ray
- other
Indications for endoscopy in patients with GERD
1) symptoms persistent or progressive despite medical Tx
2) dysphagia or odynophagia
3) involuntary weight loss >5%
4) evidence of GI bleed or anemia
5) a mass, stricture or ulcer is found on imaging
6) screening for Barrett’s esophagus in selected patients
7) persistent vomiting (7-10 days)
8) evaluation of patients before or with recurrent symptoms after endoscopic or surgical anti reflux procedures
9) placement of wireless pH monitoring
24-hour esophageal pH study
- purpose
- when do we do it?
- how is it done?
Used to confirm diagnosis of GERD in patients with persistent symptoms (specifically is 2x daily PPI has failed)
- do it prior to anti-reflux surgery
- placed through nose or a wireless capsule-shaped device affixed to distal esophageal mucosa
- catheter pH electrode positioned 5cm above the manometrically defined upper limit of the LES
- tests are conducted within 24-hour period with patients advised to consume an unrestricted diet
What can GERD lead to?
Erosive esophagitis
Peptic stricture
Barrett’s esophagus
Esophageal adenocarcinoma
Reflux esophagitis
- define
- mechanism
Acid damage to the esophagus
Mechanism:
- increased abdominal pressure
- increased volume of regurgitate
- decreased esophageal clearance
- delayed emptying of the stomach
Barrett’s Esophagus
- define
- histologically?
- why is it important to diagnose?
Definition:
- metaplastic columnar epithelium replaced stratified squamous epithelium normally lining the distal esophagus
Histologically via biopsy:
- reveal intestinal metaplasia characterized with goblet cells
Importance:
- increased risk of adenocarcinoma (0.5% per year or 1/200 Pt-years of follow up)
Treatment of GERD
1) correct the underlying cause (reduce or stop exacerbating medications that reduce LES pressure)
2) lifestyle modifications:
- weight loss, smoking cessation, moderation in alcohol intake
3) medications
4) surgery
Medications used to treat GERD
1) antacids
2) sucralfate
- stimulate angiogenesis and the formation of granulation tissue
- binds to injured tissue, delivering growth factors and reducing access to pepsin and acid
3) H2 receptor antagonists - inhibits acid production by blocking H2 receptors on parietal cells
4) PPI - inhibit H-K-ATPase irreversibly
5) prokinetic agents - increase rate of gastric emptying
Different PPIs
- daily dose in mg
Omeprazole - 20mg
Pantoprazole - 40mg
Esomeprazole - 30mg
Lansoprazole - 30mg
Rabeprazole - 20mg
Anti-reflux surgery
- indication
- post-op symptoms
- failure rate
Indicated for severe symptoms incompletely controlled by optimal medical therapy
- for extra-esophageal manifestations of GERD (chronic cough, hoarseness, laryngitis, wheezing, asthma, chronic bronchitis, aspiration, dental erosion)
- Post-Op symptoms of dysphagia and gas bloating
- failure rate of 10-15%
Other causes of retrosternal pain?
Cardiac - Angina, MI, aortic dissection, pericarditis, etc.
Pulmonary - pulmonary embolism
Esophageal - esophageal spasm
Causes of esophagtisis: differential diagnosis
Infection - CMV, HSV, candida
Inflammatory - eosinophilic esophagitis
Pill induced - antibiotics (doxycycline)
Esophagitis associated with immune disease - Chron’s, Bechet’s
Chemical induced esophagitis - acid or alkaline ingestion
Eosinophilic esophagitis
- typical presentation
- association with allergies
- EGD findings
- biopsy findings
Young male with recurrent chronic solid food dysphagia, food bolus impaction
- Allergic History of asthma, allergic rhinitis, skin atopy
On EGD:
- subtle longitudinal furrowing, transverse ridges, whitish plaques or papules, fragility of esophageal mucosa, trachea-like esophagus
On biopsy:
- more than 15 eosinophils per high power field
We then treat
Pill esophagitis
What is is?
Causes:
Esophageal abnormalities due to shallow ulcerations and direct esophageal mucosal injury from the pill
- systemic effects: disrupting the normal cytoprotective prostaglandin barrier
Causes:
- antibiotics
- anti-inflammatories (NSAIDs, aspirin)
- bisphophonates (alendronate, risedronate)
- ferrous sulfate (iron)
- Ascorbic acid (Vit C)
- potassium chloride
Functional Dyspepsia
Functional Causes vs. Organic causes
Symptoms
Etiology
Causes: Functional 60% no organic causes and organic (40%)
Symptoms: ulcer like symptoms, dysmotility like symptoms
Etiology:
- impaired gastric motor function
- visceral sensitivity
- psychosocial factors
Organic causes:
V- MI, mesenteric ischemia
I - H. Pylori
T - trauma
A - cholelithiasis
M - diabetic gastropathy
I - pancreatistis
N - gastric cancer
O - celiac disease
D - antibiotics, NSAIDs
Management for Dyspepsia
> 55 years or has alarm features - EGD
< 55 years old with no alarm features
- HP prevalence <10% —> PPI trial —> (if fails) test and treat H. Pylori —> (if fails) consider EGD
- HP prevalence >10% —> test and treat for H. Pylori —> (if fails) PPI trial —> if fails consider EGD
When is endoscopy indicated in dyspepsia?
Age >50
Any age:
- abdominal mass, vomiting, bleeding, dysphagia, anemia, weight loss
Biopsy may show for dyspepsia?
Gastropathy - epithelial cell damage and regeneration without inflammation (NSAIDs, bile reflux, or congestion, e.g. portal hypertensive gastropathy)
What is gastropathy?
epithelial cell damage and regeneration without inflammation (NSAIDs, bile reflux, or congestion, e.g. portal hypertensive gastropathy)
EGD shows in selected dyspepsia patients?
Gastritis - inflammation of gastric mucosa associated with injury (H. Pylori, autoimmune, alcohol)
H pylori gastritis
- 2 types and explanations
Antral based - infection increases gastrin secretion —> increased parietal cell acid production —> duodenal damage —> gastric metaplasia in duodenum —> HP moves into duodenum —> duodenal ulcers
Corpus-predominant - strophic gastritis or pan-gastritis - genetically lower acid output —> easier for HP to move into body —> risk factor for gastric ulcer as well as intestinal metaplasia —> dysplasia and gastric cancer
