Motility Disorders of the GI Tract

Question 1

How is Esophageal motor function assessed on esophageal manometry

Answer 1

By the amplitude and propagation of the pressure waves. These two parameters can be used to determine the presence and success rate of peristalsis.

Question 2

Describe esophageal manometry .

Answer 2

This test is performed using a transnasal, intraluminal catheter containing pressure sensors spaced closely together (1cm apart). Once positioned from the nares into the stomach, assessment of esophageal motility is made as patient swallows repeated small boluses of water.

Question 3

Achalasia is the prototypical esophageal motility disorder. Achalasia results from inflammatory destruction of neurons in the _______ of the esophagus

Answer 3

myenteric plexuses

Question 4

Loss of inhibition at the (lower esophageal sphincter) LES leads to the cardinal defect in ______ , the failure of appropriate LES relaxation after swallowing

Answer 4

achalasia

Question 5

what are the diagnostic findings in achalasia

Answer 5

Diagnostic findings are incomplete relaxation of the (LES) aperistalsis in the smooth muscle esophagus, seen on Esophageal manometry

Question 6

Scleroderma is associated with:

Answer 6

alterations of the microvasculature, the autonomic nervous system, and the immune system with a downstream consequence of fibrosis

Question 7

describe why 90% of patients with scleroderma have GI tract involvement.

Answer 7

Small vessel vasculitis -> vascular derangement -> smooth muscle atrophy -> fibrosis. The entire smooth muscle section of the GI tract is susceptible

Question 8

how can Scleroderma be distinguished from achalasia

Answer 8

presence of a weakened lower esophageal sphincter pressure in scleroderma (as opposed to a hypertensive LES with failure to relax after swallowing in achalasia).

Question 9

what are the 3 esophageal manifestations of scleroderma

Answer 9

1) dysphagia (difficulty swallowing)
2) GERD
3) Esophageal stricture (chronic GERD)

Question 10

what are the symptoms of Spastic Disorders of the Esophagus

Answer 10

Chest pain and difficulty swallowing

Question 11

Manometric abnormalities of spastic disorders

Answer 11

1) swallows associated with dramatically increased contractile vigor (high pressures over a broad esophageal length and for a long duration)
or
2) rapid/premature esophageal peristalsis (contraction of the esophagus that occurs to rapidly after initiation of a swallow).

Question 12

The 3 major digestive functions of the stomach are:

Answer 12

1. Storage of large amounts of food. The volume of the stomach can vary between about 50ml in an empty state to nearly 1500ml after eating.
2. Mechanical breakdown of larger particles into smaller particles (< 2 mm), known as chyme.
3. Slow delivery of chyme to the duodenum at a rate not to exceed the digestive and absorptive capacity of the small intestine.

Question 13

Gastric peristalsis originates in the ‘pacemaker-cells’ (_______) in the mid-portion of the body, and travel distally towards the pylorus at a frequency of about 3/minute

Answer 13

interstitial cells of Cajal

Question 14

what is Gastroparesis

Answer 14

a disorder of delayed gastric emptying in the absence of mechanical obstruction.

Question 15

what are the 7 classic symptoms of gastroparesis

Answer 15

early satiety, 
bloating, 
nausea, 
anorexia, 
vomiting, 
abdominal pain,
weight loss

Question 16

name 5 Common causes of gastroparesis

Answer 16

diabetes,
medications,
prior gastric or thoracic surgery (potential vagal injury), post-viral state
some neurologic or infiltrative disorders.

Question 17

When Scleroderma affects the stomach, delayed gastric emptying may result. As with the esophageal dysmotility seen in scleroderma this is related to _______

Answer 17

smooth muscle fibrosis.

Question 18

what is Receptive relaxation?

Answer 18

Swallowing-induced vagal response that relaxes the stomach (fundus and proximal corpus) facilitating food storage, allowing an increase in volume up to 15 times its empty state with very little increase in intragastric pressure

Question 19

how is Gastroparesis Diagnosed

Answer 19

scintigraphic gastric emptying (AKA a gastric emptying study)

Question 20

describe the scintigraphic gastric emptying (AKA a gastric emptying study)

Answer 20

technetium labeled egg (or substitute) is eaten as part of a standardized meal and the percentage of radiotracer left in the stomach after 4 hours is measured. Gastroparesis is described as mild, moderate or severe based on the percentage of the meal remaining (> 35% is severe gastroparesis).

Question 21

Describe accomodation

Answer 21

Smooth muscle relaxation elicited by mechanical distention of the stomach (Gastric mechanoreceptors)

Question 22

define Dyspepsia

Answer 22

Discomfort or pain centered in the upper abdomen

Question 23

what are the Sx’s of dyspepsia

Answer 23

postprandial heaviness,
early satiety,
epigastric pain or burning

Question 24

what is Functional Dyspepsia

Answer 24

When there’s dyspepsia and no organic etiologies

Question 25

what are 5 causes of dyspepsia

Answer 25

Peptic Ulcer Disease (PUD), 
atypical GERD, 
gastric/esophageal cancer, 
pancreatico-biliary disorders, 
food/drug (NSAIDs) intolerance

Question 26

40% of FD patients have impaired ________

Answer 26

gastric accommodation

Question 27

what is a smart pill?

Answer 27

Ingested capsule that wirelessly measures:
Temperature
pH
Pressure

Question 28

what can a smart pill assess?

Answer 28

Gastric emptying
Small bowel transit time
Colonic transit time

Question 29

what medications are used in MGMT of gastroparesis

Answer 29

Prokinetic agents

Antiemetics

Question 30

what is the Migating Motor Complex

Answer 30

Occurs during Fasting State
Sequential orderly short peristaltic waves
Stomach -> Caudally
Sweep gut between meals

Question 31

Characterize Small intestinal pseudo-obstruction

Answer 31

signs and symptoms of a mechanical obstruction of the small or large bowel in the absence of an anatomic lesion that obstructs or partially blocks the flow of intestinal contents.

Question 32

Pseudo-obstruction may be acute or chronic (CIPO) and is characterized by the presence of _______ on
imaging.

Answer 32

dilation of the bowel

Question 33

When there is evidence of chronic small intestinal motility disorder in the absence of bowel dilatation, the preferred term is ________

Answer 33

chronic intestinal dysmotility.

Question 34

what are the 3 most common Sx’s of CIPO

Answer 34

1) nausea/vomiting
2) Abd. Pain
3) Distention

Question 35

To maximize time for reabsorption, most colonic motility (approximately 95% of contractions) is ________

Answer 35

nonperistaltic

Question 36

what are the major constipation cause highlighted in class

Answer 36

DM,
Amyloid, 
Scleroderma
Hirschsprung’s
dyssynergic defecation

Question 37

Descibe a sitz marker study

Answer 37

A capsule containing 24 radioopaque markers is swallowed by the patient and an abdominal X-ray is obtained after 5 days. Less than 5 markers left in the colon is considered normal.

Question 38

describe the abnormal results from a Sitz study and what they mean

Answer 38

> 5 markers in recto-sigmoid suggests defecatory disorder

>5 markers scattered throughout colon = slow transit

Question 39

describe a scintigraphy as it relates to colonic transit studeis

Answer 39

Isotope in delayed-release capsule dissolves in alkaline pH of distal ileum
Gamma camera scans in 4,24, and 48 hours to show colonic distribution

Question 40

The reflex of stool causing distention of the rectum leading to internal anal sphincter relaxation is termed the _______ reflex (which is absent in _______ disease).

Answer 40

recto-anal inhibitory,

Hirschsprung’s

Question 41

describe anorectal manometry

Answer 41

A catheter with pressure sensors (similar to esophageal manometry) is placed traversing the anus and rectum. Resting pressure, simulated defecation, rectal sensation testing and recto-anal inhibitory reflex testing are all assessed.

Question 42

Describe Hirschsprung’s Disease

Answer 42

Congenital absence of myenteric neurons of the distal colon (always involving the internal anal sphincter). Results in lack of reflex inhibition of the internal anal sphincter following rectal distention. Anorectal manometry reveals absence of recto-anal inhibitory reflex.

Question 43

Describe dyssynergic defection

Answer 43

Disorder on coordination of pelvic floor musculature. Anorectal manometry reveals paradoxical contraction of the pelvic floor and external anal sphincter with attempts at defecation.

Question 44

what is the Tx of dyssynergic defection

Answer 44

Biofeedback (essentially re-learning how to have a bowel movement is effective).