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MDT Upper GI Flashcards

1
Q

What is Gastroesophageal Reflux Disease?

A

A condition that develops when the reflux of stomach contents causes troublesome symptoms or complications

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2
Q

What sphincter plays a vital role in frequency and severity of GERD

A
  • Lower esophageal sphincter
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3
Q

General pathophysiology of GERD?

A
  • Pain associated with GERD is secondary to stimulation and activation of mucosal chemoreceptors
  • Spicy, acidic, and salty foods exacerbate
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4
Q

Symptoms of GERD?

A
  • Heartburn 30-60 minutes after meals
  • Pt’s report relief from antacids or baking soda
  • Dysphagia (in 1/3 of Pt’s)
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5
Q

“Atypical” or “extraesophageal” manifestations of GERD?

A
  • Asthma
  • Chronic cough
  • Chronis laryngitis
  • Sore throat
  • non-cardiac chest pain
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6
Q

Complications of GERD?

A
  • Barret Esophagus

- Peptic Stricture

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7
Q

What is Barret Esophagus?

A

Squamous epithelium of the esophagus is replaced by metaplastic columnar epithelium containing goblet and columnar cells
- most serious complication Barret Esophagus is esophageal adenocarcinoma

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8
Q

What is Peptic Stricture?

A
  • Occurs within 5% Pt’s

- Manifested by the gradual development of solid food dysphagia progressive over months to years

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9
Q

Rad for GERD?

A

Endoscopy in complicated Pt’s

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10
Q

Treatment for mild GERD?

A
  • Lifestyle modification (smaller meals, discontinue acidic foods)
  • Weight loss
  • Antacids (Ranitidine, Famotidine)
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11
Q

Treatment for troublesome symptoms of GERD?

A
  • Protein Pump Inhibitors
  • Omeprazole (Prilosec)
  • Esomeprazole (Nexium)
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12
Q

When to refer for GERD?

A
  • Do not resolve with maximum empiric management with 3 months of twice-daily PPI therapy
  • Significant dysphagia
  • Barret’s or stricture
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13
Q

What is reflux esophagitis?

A

Subset of patients with GERD who have endoscopic evidence of esophageal inflammation

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14
Q

What is infectious esophagitis?

A

Esophagitis and thrush often occur together in immunosuppressed patients and presence of thrush may help determine the cause of esophageal symptoms
*absence of thrush does not preclude diagnosis of candida esophagitis

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15
Q

Medications that cause direct esophageal mucosal injury?

A
  • Tetracycline, Doxy, Clindamycin
  • Anti-inflammatory medications
  • Biphosphates
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16
Q

Signs and symptoms of medication-induced esophagitis

A
  • Retrosternal chest pain or heartburn
  • Odynophagia
  • Dysphagia
  • Rarely, may have hematemesis, abdominal pain, and weight loss
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17
Q

Candida Esophagitis symptoms?

A

Hallmark: Odynophagia (pain on swallowing)

  • Localize pain to discrete retrosternal area
  • Diagnosis made when white mucosal plaque-like lesions are noted on endoscopy
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18
Q

Labs for esophagitis?

A

If infection considered:

  • CBC
  • Specimen culture
  • Swab for candida
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19
Q

Rad for esophagitis?

A

Consider endoscopy

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20
Q

Treatment of pill-induced esophagitis?`

A

Stop taking offending medication

Take with water

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21
Q

Treatment of candida esophagitis ?

A

Evaluate for immunocompromised conditions: HIV, Cancer, Diabetes

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22
Q

Complications of esophagitis?

A
  • Peptic stricture
  • Esophageal Spams
  • Mallory-Weiss tear
  • Boerhaave
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23
Q

What are some causes of Esophageal Stricture?

A
  • Likely caused as a result to esophageal irritation from chronic GERD
  • Other causes (roughly 25%)
  • External beam radiation
  • Esophageal sclerotherapy
  • Caustic ingestions
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24
Q

Why do esophageal strictures form?

A

To reduce the volume of reflux in the esophagus to reduce the symptoms of GERD

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25
Signs/Symptoms of esophageal stricture?
- Localized substernal chest pain - Heartburn - Dysphagia (cardinal feature)
26
Rad for esophageal stricture?
- Endoscopy | - Barium study
27
Treatment for mild and severe esophageal stricture?
- Mild: treat for GERD - Severe: consider MEDEVAC for potential surgery - Refer all Pt's to Gastroenterology for Dilation and evaluation
28
What is esophageal spasm?
Idiopathic motility disorder which causes loss of peristalsis in the distal two-thirds of the esophagus and impaired relaxation of the LES
29
Signs and symptoms of esophageal spasm?
- Gradual onset of dysphagia with solid foods and some liquids - Can be present for months - Substernal discomfort/chest pain - Regurgitation is common
30
Rad for Esophageal Spasm?
- CXR - Barium Esophagography - Edoscopy
31
Treatment of Esophageal Spasm?
- PPI for GERD - Symptom reduction - Smaller bites of food - Invasive procedures (endoscopic injection of botulinum toxin)
32
Where are Peptic Ulcers located?
Stomach and Duodenum
33
How does a peptic ulcer occur?
When the balance between the aggressive factors and the defense mechanisms is disrupted
34
What is the diagnostic procedure of choice for peptic ulcer?
Upper endoscopy with gastric biopsy for H pylori
35
What is a peptic ulcer?
A break in the gastric or duodenal mucosa that arises when normal mucosal defense factors are impaired or are overwhelmed by aggressive luminal factors such as acid or pepsin
36
Where are peptic ulcers five times more common?
In the duodenum
37
Duodenal ulcers most commonly occur in what age group?
30-55
38
Gastric ulcers most commonly occur in what age group?
55-70
39
What are the 3 major causes of peptic ulcer disease?
- NSAIDS - Chronic H pylori infection - Acid hypersecretory states
40
The risk of NSAID complications is greater for peptic ulcers:
- Within the first 3 months of therapy - Have a history of ulcer disease - Take NSAIDS in combination with aspirin, corticosteroids, or anticoagulants
41
Symptoms of Peptic Ulcer?
- Hallmark: Dyspepsia ( epigastric pain) - Nausea - Anorexia - Physical exam often normal in uncomplicated, may have localized epigastric tenderness
42
Rad for peptic ulcer?
Upper endoscopy procedure of choice for the diagnosis of duodenal and gastric ulcers
43
Treatment for peptic ulcer?
- Eat balanced meals at regular intervals - Discourage smoking - NSAID causing: PPI 4-6 weeks - H pylori causing: 10-14 days PPI (continue for 4-6 wks), antibiotic
44
Disposition for peptic ulcer?
- Retain on board unless any red flags or not responsive to PPI
45
What is the anatomical landmark that separates upper and lower GI
Ligament of Treitz
46
What is occult GI bleeding?
No visible evidence of blood loss. Only present on fecal occult test or iron deficiency anemia
47
What is the most common cause of lower GI bleeding?
Colon carcinoma | - often occult, but not always
48
What is overt GI bleeding?
Blood loss visible to clinician or Pt
49
What is Hematemesis?
Vomiting of blood
50
A "coffee-ground" black color of blood in hematemesis indicates a bleed from what location?
At or distal to the stomach
51
A bright redin color of blood in hematemesis indicates a bleed from what location?
At or proximal to the LES
52
A melena (dark black, "tar-like") color of blood in hematemesis indicates a bleed from what location?
Upper GI bleed
53
What is hematochezia and what type of bleed does it indicate?
- Bright red blood in stool | - Likely lower GI bleed
54
What are the two most common presentations of Upper GI bleed
- Hematemesis - Melena - May present with hematochezia
55
Rads for GI Bleeding?
- Upper endoscopy - CT angiogram and nuclear scintigraphy - X-ray and conventional CT scan has little value
56
Labs for GI Bleeding?
- Labs are of little value, can be helpful identifying severity and aggravating factors - CBC, PT, PTT, INR
57
Can Nasogastric Tubes be helpful in diagnosing GI Bleeds?
Yes, should be inserted in Pt with suspected active upper GI bleed - Aspiration of red blood or "coffee grounds" confirms upper GI source of bleed
58
Assessing NG Tube in upper GI Bleed?
- Systolic BP <100 identifies a patient who has sustained severe blood loss (30-40% blood volume) - HR >100 bpm with systolic BP >100 indicative of moderate blood loss (15-29%) -
59
What type of intravascular blood volume replacement should be used in severe blood loss associated with upper GI bleeds?
Fresh Whole Blood
60
Pharmacotherapy for upper GI Bleeds?
- IV PPI (Omeprazole/Pantoprazole) | - IF tolerating PO, PPI orally can be good for long term care
61
Disposition for upper GI Bleeds?
- MEDADVICE minimum | - MEDEVAC depending on presentation and response to Tx
62
Common causes of lower GI bleeding?
- Diverticulosis/Diverticulitis - IBD - Anorectal disease - Hemorroids - Fissures
63
What stool color suggests a colonic source in lower GI bleeds?
Bright red blood
64
What stool color suggests a lesion on right colon or small intestine in lower GI bleeds?
Maroon stools
65
What stool color suggests a source proximal to the ligament of Treitz in lower GI bleeds?
Black tarry stools (melena)
66
Management of lower GI bleed?
- Initial stabilization - Blood replacement - Triage - Treating underlying cause is goal of therapy - Will likely need colonoscopy
67
What are two conditions that may result in upper GI bleed?
- Mallory-Weiss syndrome | - Boerhaave syndrome
68
What is Mallory-Weiss Syndrome?
Characterized by a non-penetrating vertical mucosal tear/laceration at the gastroesophageal junction
69
Pertinent information regarding Mallory-Weiss Syndrome?
- Caused by sudden increase in intraabdominal pressure (vomiting/retching/lifting) - Heavy alcohol use - Bleeding more severe when associated with portal hypertension and esophageal varices
70
What is Boerhaave's syndrome?
More severe laceration of the anterior esophagus associated with a full perforation of the esophagus into the mediastinum
71
Pt presentation for Mallory-Weiss?
- Heavy alcohol user - S/S upper GI bleed - Hematemesis with or without retching - History of retching/vomiting/straining - Possible hypovolemia
72
Pt presentation for Boerhaave's syndrome?
- Hartman's sign (crunching sound heard on mediastinum) | - Possible crepitus with palpation on test
73
Diagnosing Mallory-Weiss or Boerhaave's?
- CBC to rule out anemia - Upper endoscopy - CXR * Normal in mallory-weiss * Mediastinal air may be present in boerhaave's
74
Treatment for Mallory-Weiss?
- Most Pt's stop bleeding spontaneously and require no therapy - NPO - IV PPI - IV/IM antiemetic - Surgical intervention
75
Treatment for Boerhaave's?
- NPO - IV PPI - IV/IM antiemetic - IV ertapenem - Surgical intervention
76
Disposition for Mallory-Weiss or Boerhaave's?
MEDEVAC

Gastrointestinal (6 decks)

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