MGH PM - Gastroenterology I Flashcards
1
Q
Esophageal and gastric disorders - Dysphagia - 2 types:
A
- Oropharyngeal.
2. Esophageal.
2
Q
Oropharyngeal dysphagia - Definition:
A
Inability to propel food from mouth through UES into esophagus.
3
Q
Esophageal dysphagia - Definition:
A
Difficulty shallowing and passing food from esophagus into stomach.
4
Q
Achalasia - Etiologies:
A
- Idiopathic (MC).
- Pseudoachalasia (due to GE jxn tumor).
- Chagas.
5
Q
Achalasia - Sx:
A
- Dysphagia (solid and liquid).
- Chest pain (1/3 of pts).
- Regurgitation.
6
Q
Achalasia - Dx:
A
- Barium swallow ==> Bird beak.
- Manometry ==> Simultaneous, low amplitute contractions of esophageal body + Incomplete relax of LES (+/- LES HTN).
- EGD r/o pseudoachalasia (retroflex).
7
Q
Achalasia - Rx:
A
Expert pneumatic dilation (<4% eso perf).
Same results as HELLER MYOTOMY (NEJM 2011).
8
Q
Other esophageal disorders:
A
- Webs ==> Upper/mid esoph, congenital, GVHD, Fe-def anemia.
- Rings ==> Lower esoph; ? due to GERD.
- Zenker’s (pharyngoesoph jxn).
9
Q
Webs, rings, and Zenker’s - Dx:
A
W/ barium swallow.
10
Q
Webs, rings, and Zenker’s - Rx:
A
Endo/surg.
11
Q
Infxn esophagitis:
A
ODYNOPHAGIA > dysphagi.
==> Often immunosuppressed w/ Candida, HSV, CMV.
12
Q
Pill esophagitis:
A
ODYNOPHAGIA > dysphagia.
==> NSAIDs, KCl, bisphosp., doxy and tetracycline.
13
Q
Eosinophilic esophagitis (Clin Gastro and Hep 2012) - Seen in:
A
Yound, or middle-aged.
==> Mostly FEMALES.
14
Q
Eosinophilic esophagitis - Dx:
A
Req >15 eos/hpr on bx + EXCLUDE GERD (eg, empiric PPI trial.
15
Q
Eosinophilic esophagitis - Rx:
A
3Ds:
- Diet ==> Eliminate milk, soy, eggs, wheat, nuts, and fish.
- Drugs ==> Swallow inh steroids.
- Dilation.
16
Q
GERD - Pathophysio:
A
- Excessive TRANSIENT relaxations of LES.
- Incompetent LES.
- Mucosal damage (esophagitis) due to prolonged contact w/ acid can evolve to STRICTURE.
17
Q
GERD - Risk factors:
A
- Hiatal hernia.
- Obesity.
- Gastric hypersecretory states.
- Delayed emptying.
18
Q
GERD - Precipitants:
A
- Supine position.
- Fatty foods.
- Caffeine.
- Alcohol.
- Cigarettes.
- CCB.
- Pregnancy.
19
Q
GERD - Clinical manifestations - 2 categories:
A
- Esophageal.
2. EXTRAesophageal.
20
Q
GERD - Clinical manifestations - Esophageal:
A
- Heartburn.
- Atypical chest pain.
- Regurgitation.
- Water brash.
- Dysphagia.
21
Q
GERD - Clinical manifestations - Extraesophageal:
A
- Cough.
- Asthma (often poorly controlled).
- Laryngitis.
- Dental erosions.
22
Q
GERD - Diagnosis (Gastro 2008, Am J Gastro 2010, Annals 2012):
A
Based on hx and empiric trial of PPI (Se & Sp: 78% & 54%) (Annals 2004).
23
Q
GERD - Diagnosis (Gastro 2008, Am J Gastro 2010, Annals 2012) - EGD if:
A
- Failure to respond to bid PPI.
- Alarm features ==> dysphagia, vomiting, wt loss, evid of blood loss.
- Female >50y w/ sx >5y + nocturnal sx, hiatal hernia, obesity, cigs.
24
Q
GERD - Diagnosis (Gastro 2008, Am J Gastro 2010, Annals 2012) - If dx uncertain + EGD nl …?
A
HIGH RES MANOMETRY w/ 24-h esoph pH monitoring +/- impedance.
25
GERD - Treatment (NEJM 2008) - 3 categories:
1. Lifestyle.
2. Medical.
3. Refractory cases.
26
GERD - Treatment (NEJM 2008) - Lifestyle:
1. Avoid precipitants.
2. Lose weight.
3. Avoid large and late meals.
4. Elevate head of bed.
27
GERD - Treatment (NEJM 2008) - Medical:
PPI achieve relief in 80-90% (titrate to lowest dose that achieves sx control.
==> surgery among pts who initially respond to acid suppression (JAMA 2011).
28
GERD - Treatment (NEJM 2008) - Refractory cases:
Confirm w/ pH testing.
1. If acidic or sx correlate w/ reflux episodes ==> Surgical fundoplication (implantation of magnetic esophageal sphincter device being studied) (NEJM 2013).
2. If nl pH or no sx correlation ==> TCA, SSRI or baclofen (Gastro 2010).
29
GERD - Complications (NEJM 2009, Gastro 2011):
1. Barrett.
| 2. Adenocarcinoma.
30
GERD - Complications (NEJM 2009, Gastro 2011) - Barrett:
DX by bx of intestinal metaplasia above GE jxn.
==> Screen for BE if >2 of the following risk factors:
1. >50y.
2. Male.
3. White.
4. Chronic GERD.
5. Hiatal hernia.
6. High BMI.
31
GERD - Complications (NEJM 2009, Gastro 2011) - Esophageal adenocarcinoma:
1. If BE ==> risk 0.12%/y.
2. If low-grade dysplasia ==> risk 2.3%/y.
3. If high-grade dysplasia ==> risk 6%/y.
==> 40% of pts w/ esoph adenoca report no hx of GERD sx.
32
GERD - Complications (NEJM 2009, Gastro 2011) - Management:
1. Barrett w/o dysplasia ==> Surveillance EGD q3-5 y.
2. Low-grade dysplasia ==> q6- 12mo.
3. 4 quadrant bx q 2cm.
==> Chemopreventive benefit of ASA under study.
33
GERD - Complications (NEJM 2009, Gastro 2011) - Management of HIGH grade dysplasia:
1. U/S to r/o invasive cancer.
| 2. Endoscopic mucosal resection of any visible mucosal irregularity + Ablation of dysplasia (RF or photodynamic).
34
Dyspepsia ("indigestion") - Definition:
Upper abdominal sx:
1. Discomfort.
2. Pain.
3. Fullness.
4. Early satiety.
5. Bloating.
6. Burning.
35
Dyspepsia - Etiologies - 2 Categories:
1. Functional ("nonulcer dyspsepsia" or NUD 60%).
| 2. Organic (40%).
36
Functional dyspepsia (60%):
Some combination of visceral afferent hypersensitivity + abnormal gastric motility (Rome III criteria in Gastro 2006; 130:1377).
37
Organic dyspepsia (40%):
1. GERD.
2. PUD.
3. Rarely gastric cancer.
4. Other ==> Meds, diabetic gastroparesis, lactose intolerance, biliary pain, chronic pancreatitis, mesenteric ischemia.
38
Dyspepsia - Alarm features:
Features that suggest ORGANIC CAUSE and warrant EGD.
39
Tx of functional dyspepsia (Gastro 2005, Alim Pharm Ther 2012):
1. H.pylori eradication ==> Empiric Rx if positive serology. NNT=14 (Cochrane 2006).
2. PPI effective in some (? misdx GERD), others: TCA, prokinetics, buspirone.
40
PUD - Epidemiology and etiologies (Lancet 2009) - Lifetime prevalence:
10%. (but incidence decreases ==> H.pyroli and potent acid suppression Rx).
==> However, hosp for complic unD'd in general and INCREASE in elderly, likely 2o to incr. NSAID use.
41
PUD - Epidemiology and etiologies (Lancet 2009) - H.pylori infection:
80% of DU and 60% of GU.
==> 50% of population colonized w/ H.pylori, BUT ONLY 5-10% will delevop PUD.
42
PUD - Epidemiology and etiologies (Lancet 2009) - ASA and NSAIDs:
1. 45% erosions.
2. 15-30% GU.
3. 0.1-4% UGIB.
43
PUD - Epidemiology and etiologies (Lancet 2009) - Hypersecretory states (often mult. recurrent ulcers):
1. Gastrinoma (Z-E, also p/w diarrhea, <1% of PUD).
2. Carcinoid.
3. Mastocytosis.
44
PUD - Epidemiology and etiologies (Lancet 2009) - Malignancy:
5-10% of GU.
45
PUD - Epidemiology and etiologies (Lancet 2009) - Other:
1. Smoking.
2. Stress ulcers.
3. XRT (X-ray therapy).
4. Chemo.
5. CMV/HSV (immunosupp).
6. Bisphosphonates.
==> STEROIDS alone generally NOT a risk factor, but may exacerbate NSAID-induced ulceration.
46
PUD - Clinical manifestations:
Epigastric abdominal pain ==> Relieved with food (DU) or worsened with food (GU).
47
PUD - Complications:
1. UGIB.
2. Perforation + Penetration.
3. Gastric outlet obstruction.
48
PUD - Diagnostic studies - Test for H.pylori:
1. Stool antigen or EGD + Rapid urease test ==> Now dx tests of choice + to confirm erad (4-6 wk post txment).
==> FALSE (-) if on abx, bismuth, PPI, so stop prior to testing if possible.
2. Serology ==> Decr. utility, useful only to exclude infection in low prevalence areas (most of U.S.).
49
PUD - Diagnostic studies - EGD:
Req to def make dx.
==> Consider if fail empiric Rx or alarm features.
==> Bx GU to r/o malig.
==> Relook in 6-12wk if apparently benign ulcer >2.5cm, complicated or sx persist.
50
PUD - Treatment (NEJM 2010, Gut 2012) - If H.pylori (+), eradicate:
1. Triple Rx: clarith + [amox, MNZ, or levoflox] + PPI bid x 10-14d (if clarith resist rate <20%).
2. Quadruple Rx: MNZ + TCN + Bismuth + PPI (if clarith resist rate >15% or amox allergy).
3. Sequential Rx: PPI + amox x 7d ==> PPI +clarith + MNZ x 7d (Lancet 2013).
==> BESIDES PUD, test and Rx if: gastric MALToma, atrophic gastritis, FHx gastric ca.
51
PUD - Treatment (NEJM 2010, Gut 2012) - If H.pylori (-):
Gastric acid suppression w/ PPI.
52
PUD - Treatment (NEJM 2010, Gut 2012) - Other:
1. Discontinue ASA + NSAIDs; add PPI.
2. Lifestyle changes: d/c smoking and probably EtOH; diet does not seem to play a role.
3. Surgery: if refractory to med Rx (1st r/o NSAID use) or for complications (see above).
53
PUD - Prophylaxis if ASA/NSAID required (JACC 2008):
1. PPI if: ==>
(a) h/o PUD/UGIB.
(b) also on clopidogrel (although ? decr. antiplt effect).
(c) At least 2 of the following: >60, steroids or dyspepsia; prior to start test & Rx H.pylori.
2. Consider misoprostol; consider H2RA if ASA monotherapy (Lancet 2009).
3. Consider Δ to COX-2 inhibit (decr. PUD and UGIB but incr. CV events) if low CV risk and not on ASA.
4. Stress ulcer: risk factors = ICU and coagulopathic, mech vent, h/o GIB, steroid use; Rx w/ PPI.
54
GI bleeding - Definition:
Intraluminal blood loss anywhere from the oropharynx to the anus.
55
GI bleeding - Classificatiion:
1. UPPER ==> Above the ligament of Treitz.
| 2. LOWER ==> Below the ligament of Treitz.
56
GI bleeding - Signs:
1. Hematemesis = Blood in vomitus (UGIB).
2. Hematochezia = Bloody stools (LGIB or rapid UGIB).
3. Melena = Black tarry stools from digested blood (usually UGIB, but can be anywhere above and including the right colon).
57
Etiologies of UGIB:
1. PUD (50%).
2. Varices (10-30%).
3. Gastropathy/gastritis/duodenitis (15%).
4. Erosive esophagitis/ulcer (10%).
5. Mallory-Weiss tear (10%).
6. Vascular lesions (5%).
7. Neoplastic disease ==> Esophageal, gastric, GIST.
8. Orophareyngeal bleeding and epistaxis ==> Swallowed blood.
58
Varices (10-30%):
Esophageal +/- gastric, 2o to portal HTN.
==> IF ISOLATED GASTRIC ==> r/o splenic vein thrombosis.
59
Gastropathy/gastritis/duodenitis (15%):
1. NSAIDs.
2. ASA.
3. Alcohol.
4. Stress.
5. Portal hypertensive.
60
Erosive esophagitis/ulcer (10%):
1. GERD.
2. XRT.
3. Infectious (CMV, HSV, Candida if immunosuppressed).
4. Pill esophagitis (bisphosphonate, NSAIDs; +/- odynophagia).
61
Vascular lesions (5%):
1. Dieulafoy's lesion.
2. AVMs, angioectasias, HHT ==> Submucosal, anywhere in GI tract.
3. Gastric antral vascular ectasia (GAVE).
4. Aortoenteric fistula.
62
Dieulafoy's lesion:
Superficial ectatic artery usually in cardia ==> SUDDEN + MASSIVE UGIB.
63
Gastric antral vascular ectasia (GAVE):
"Watermelon stomach", tortuous, dilated vessels;
a/w ==> cirrhosis, atrophic gastritis, CREST syndrome.
64
Aortoenteric fistula:
AAA or aortic graft erodes into 3rd potion of duodenum.
==> p/w "herald bleed"; if suspected, diagnose by endoscopy or CT.
65
LGIB - Etiologies:
1. Diverticular hemorrhage (33%).
2. Neoplastic disease (19%).
3. Colitis (18%).
4. Angiodysplasia (8%).
5. Anorectal (4%).
==> Other: postpolypectomy, vasculitis.
66
Diverticular hemorrhage - MC where?
60% of diverticular bleeding localized to right colon.
67
Neoplastic disease (19%)?
Usually OCCULT BLEEDING, rarely severe.
68
Colitis (18%):
1. Infectious.
2. Ischemic.
3. Radiation.
4. IBD (UC >> CD).
69
Angiodysplasia (8%):
Ascending colon + Cecum.
70
Anorectal (4%):
1. Hemorrhoids.
2. Anal fissure.
3. Rectal ulcer.
71
Clinical manifestations - UGIB > LGIB?
1. N/V.
2. Hematemesis.
3. Coffee-ground emesis.
4. Epigastric pain.
5. Vasovagal.
6. Melena.
72
Clinical manifestations - LGIB > UGIB:
1. Diarrhea.
2. Tenesmus.
3. BRBPR (Bright red blood per rectum).
4. Hematochezia.
(11% UGIB; Gastro 1988).
73
GI bleeding - Initial management - Assess severity:
1. Tachycardia (can be masked by bB use) suggests ==> 10% volume loss
2. Orthostatic hypotension ==> 20% loss.
3. Shock ==> >30% loss.
74
GI Bleeding - Initial management - Resuscitation:
Placement of 2 large-bore (18-gauge or larger) IV lines.
==> Volume replacement: NS or LR to achieve normal VS, UOP (Urine output), and mental status.
75
GI bleeding - Initial management - Transfuse:
1. Blood bank sample for type and cross.
2. Use O-neg if emerg.
3. Transfuse as needed.
==> For UGIB (esp. w/ portal HTN) use more RESTRICTIVE Hb goal (eg, 7g/dL) (NEJM 2013).
76
GI bleeding - Initial management - Reverse coagulopathy:
FFP and Vit K to normalize PT.
==> Plts to keep count >50.000.
77
GI bleeding - Initial management - Triage:
Consider ICU if unstable VS or poor end organ perfusion.
==> Intubation for emergent EGD, if ongoing hematemesis, shock, poor resp status, Δ MS.
==> OutPt management if SBP >110, HR <100, Hb >13 (male) or >12 (female), BUN <18, melena, syncope, heart failure, liver disease (Lancet 2009).
78
GI bleeding - Workup - History:
WHERE (anatomic location) + WHY (etiology).
1. Acute or chronic, prior GIB, # of episodes, other GI dx.
2. Hematemesis, vomiting PRIOR to hematemesis (Mallory-Weiss), melena, hematochezia.
3. Abdominal pain, wt loss, anorexia, Δ in stool caliber.
4. Gastric irritants (ASA/NSAIDs), antiplatelet drugs, anticoagulants, known coagulopathy.
5. Alcohol (gastropathy, varices), cirrhosis, known liver disease, risk factors for liver disease.
6. Abdominal/rectal radiation, history of cancer, prior GI or aortic surgery.
79
GI Bleeding - Physical exam:
==> VS most important, orthostatic Ds, JVP.
1. Localizable abd tenderness, peritoneal sings, masses, LAN, signs of prior surgery.
2. Signs of liver disease (HSM, ascites, etc).
3. Rectal exam: masses, hemorrhoids, anal fissures, stool appearance, color, occult blood.
4. Pallor, jaundice, telangiectasias (alcoholic liver disease or HHT).
80
GI bleeding - Lab studies:
1. Hct (may be normal in first 24h of acute GIB before equilibration).
==> Down 2-3% ==> 500mL blood loss.
==> Low MCV ==> Fe def and chronic blood loss.
2. PT, plt, PTT, BUN/Cr (ratio >36 in UGIB b/c GI resorption of blood +/- prerenal azotemia).
3. LFTs.
81
GI bleeding - Diagnostic studies - NGT:
Can aid localization:
1. FRESH blood ==> Active UGIB.
2. Coffee-grounds ==> Recent UGIB.
3. Nonbloody bile ==> Lower source, but does not exclude active UGIB (15% missed).
==> (+) occult blood test of NO value.
82
GI bleeding - Diagnostic studies - UGIB:
1. EGD w/in 24h for dx and poss Rx.
2. Decr. LOS and need for surgery, consider erythro 250mg IV 30 min prior ==> Empty stomach of blood ==> Incr. Dx/Rx yield.
(Am J Gastro 2006).
83
GI bleeding - Diagnostic studies - LGIB:
1. FIRST r/o UGIB before attempting to localize presumed LGIB ==> (10-15% actually UGIB, 3-5% small bowel).
2. THEN colonoscopy (identifies cause in >70%).
3. Consider rapid purge w/ PEG solution 4L over 2h.
4. No clear benefit of colonoscopy w/in 12 vs 36-60h (AJG 2010).
5. CT angio promising (Radiology 2010).
84
GI bleeding - Unstable or recurrent UGIB/LGIB:
1. Tagged RBC scan ==> Localize bleeding rates >0.1mL/min for surg but UNRELIABLE.
2. Arteriography ==> Can localize if bleeding rates >0.5mL/min and can Rx (coil, vaso, glue) emergent exploratory laparotomy (last resort).
85
GI bleeding - Rx - Varices (Hep 2007, NEJM 2010) - Pharmacologic:
1. Octreotide 50μg IVB ==> 50μg/h infusion (84% success). Usually x5 d, but most benefit w/in 24-48h.
2. Abx: cirrhotics w/ any GIB should receive prophylaxis: Cftx IV or norfloxacin PO (Hep 2004, Gastro 2006).
86
GI bleeding - Rx - Varices (Hep 2007, NEJM 2010) - NON pharmacologic:
1. Endoscopic band ligation (>90% success).
2. Arteriography with coiling/glue occasionally for gastric varices.
3. Balloon tamponade mainly rescue procedure and bridge to TIPS.
4. TIPS for refractory esoph variceal bleed (consider early if persistent bleed on EGD or Child-Pugh C; NEJM 2010), or for persistent gastric variceal bleed; c/b enceph, shunt occl.
5. Surgery (portocaval/ splenorenal shunts) rarely used now.
87
GI bleeding - Rx - PUD (AJG 2012) - If active bleeding or nonbleeding visible vessel (NBVV) on EGD:
1. PPI (eg omeprazole 80mg IVB ==> 8mg/h) before EGD ==> Decr. need for endoscopic Rx and decr. LOS continue IV dose x 72h following EGD: Decr. rebleed rate.
==> Convert to PO after 72h.
2. ? Octreotide if no access to EGD.
88
GI bleeding - Rx - PUD (AJG 2012) - If active bleeding or nonbleeding vissible vessel (NBVV) on EGD - Endoscopic therapy (ET):
1. Epi inj + Either bipolar cautery or hemoclip; rebleeding risk: 43% (NBVV) to 85% (active bleed) w/o ET vs. 15-20% w/ ET vs. <7% w/ ET + PPI (most w/in 48h).
2. Clear liquids 6h after ET if hemodynamically stable.
3. Arteriography w/ vasopressin or embolization; surgery (last resort).
89
GI bleeding - Rx - PUD (AJG 2012) - If adherent clot:
PPI as above +/- endo removal of clot (if experienced ctr) to r/o NBVV; rebleeding risk 22% w/o ET vs 5% w/ ET.
90
GI bleeding - Rx - PUD (AJG 2012) - If flat, pigmented spot or clean base:
No endo Rx indicated; rebleed risk <10% oral PPI bid.
==> Consider early hospital d/c (see criteria in NEJM 2008).
91
GI bleeding - Rx - PUD (AJG 2012) - If pt on ASA for CV disease and PUD GIB endoscopically controlled, ...?
Resume ASA with hemostasis (BMJ 2012).
92
GI bleeding - Rx - Mallory-Weiss:
Usually stops SPONTANEOUSLY.
==> Endoscopic Rx if active.
93
GI bleeding - Rx - Esophagitis/gastritis:
PPI, H2-blockers.
94
GI bleeding - Rx - Diverticular disease:
Usually stops spontaneously (75%).
==> Endoscopic Rx (eg epinephrine injection, cautery, banding or hemoclip), arterial vasopressin or embolization, surgery.
95
GI bleeding - Rx - Angiodysplasia:
Usually stops spontaneously (85%).
==> Endo Rx (cautery or argon plasma), arterio w/ vasopressin, surgery.
96
Obscure GIB (Gastro 2007, GIE 2010) - Definition:
Continued bleeding (melena, hematochezia) despite (-) EGD + colo.
==> 5% of GIB.
97
Obscure GIB (Gastro 2007, GIE 2010) - Etiologies:
1. Dieulafoy's lesion.
2. Small bowel angiodysplasia.
3. Ulcer or cancer.
4. Crohn.
5. Aortoenteric fistula.
6. Meckel's diverticulum (2% of pop., remnant of vitelline duct w/ ectopic gastric mucosa).
7. Hemobilia.
98
Obscure GIB (Gastro 2007, GIE 2010) - Diagnosis:
Repeat EGD w/ push enteroscopy/colonoscopy when bleeding is ACTIVE.
==> If (-), video capsule to evaluate small intestine (Gastro 2009).
==> If still (-), consider 99mTc-pertechnetate scan ("Meckel scan"), enteroscopy (single-balloon, double-balloon or spiral), tagged RBC scan and arteriography.
