Pales CIS Flashcards
three types of dysphagia
oropharyngeal- choking
esophageal
- to solids only
- to solids and fluids
dysphagia to solids only indicates
mechanical disruption
CREaP
Carcinoma Ring (Schatski's/ webs) Eosinophilic esophagitis and Peptic stricture
dysphagia to solids AND liquds indicates
motility problem
SAD: Scleroderma, achalasia, diffuse esophageal spasm
Oropharyngeal (transfer) dysphagia
due to the dysfunction of the striate muscles resulting from neurological or muscular disorders
Muscular: paraneoplastic anti-body-mediated syndromes, Thyroid disease, primary myopathies, drug-induced myopathy
Neurological diseases: stroke, Myasthenia gravis, brain stem tumors, amyotrophic lateral sclerosis, parkinson disease, alzheimer disease, postpolio syndrome, guillain barre, botulism
Dysphagia accompanied by: coughing, hoarseness, aspiration pneumonia
first choice test to determine cause of esophageal dysphagia
Barium swallow/ esophagram
Achalasia
most common between 30-60 years
lack of relaxation of hte LES and loss of esophageal pristalsis
Autoimmune destruction of innervations of LES and esoph. body
Typical Symptoms: dysphagia to both liquids and solids, regurgitation, chest pain
Atypical symptoms: heartburn, weight loss, aspiration pneumonia
DX: esophageal manometry, barium radiography, EGD (to exclude other causes),
Can be called Sigmoid Esophagus
How to treat achalasia
botox
pneumatic dilation
myotomy
esophagectomy
What do we have to differentiate achalasia from?
pseudo-achalasia can be caused by Chagas disease- infectious disease from South and Central America. Affects: CV - arrhythmias, cardiomyopathy, thromboembolism.
Megaesophagus, Megacolon
- from trypanosoma Cruzi, carried by triatomine bug
esophageal cancer in the right place
paraneoplasti syndrome (esp. with lung cancer) , ANNA-1
Diffuse Esophageal Spasm
etiology unknown
maybe related to deficiency of NO
symptoms: intermittent chest pain, dysphagia
dx: manometry, bariography
Corkscrew esophagus
DES treatment
anticholinergic smooth muscle relaxants (Hyoscyamine)
Calcium channel blockers (Nifedipine)
Nitroglycerin
Sildenafil
Tricyclic antidepressants- imipramine
Botulinum toxin injections
Esophagus dysmotility in systemic disorders
Scleroderma- aperistalsis of the distal 2/3 of the esophagus, main symptoms are GERD and esophageal
treated with PPI and lifestyle changes
CREST- Calcinosis, Raynauds, Esophageal, Sclerodactyly, Telangiectasias
Amyloidosis- changes in esophagus and symptoms are similar to scleroderma
Dermatomyositis- involves the striated muscle of the oropharynx and proximal esophagus.
Oropharyngeal or esophageal dysphagia
SLE
Crohn’s disease– ulceration, strictures, fissures, esophagobronchialfistulas, mediastinal abscesses, aphthoid lesions
Other motility disorders
Presby-esophagus (tertiary contractions) - old people
Jackhammer esophagus = nutcracker– hypertensive peristalsis
Hypertensive LES
what dysphagia-causing condition may be associated with asthma?
eosionphilic esophagitis.
Chronic inflammation (food and aeroallergens)
more common in kids and adolescents
Pts often have other allergic disorders
strong genetic predisposition
children present with dyspepsia
Adults present withs olid food dysphagia, food impaction, or chest pain
Dx made by endoscopy:
- linear furrowing
- white exudates
- multiple rings
- biopsy: eosinophilic infiltration
what conditions do eosinophylic esophagitis need to be differentiated from?
cancer, rings, and webs
Rings
concentric areas of narrowing
usually in the distal esophagus
Schatzki ring- narrowing at GE jxn. Causes: congenital, due to redundant mucosa, worsened by GERD
Muscular rings (several cm above the squamocolumnar junction) composed of mucosa, submucosa, and muscle.
dx by barium radiography or EGD
treatment: dilation and PPI
Webs
Thin, eccentric, membranous areas of narrowing
Most common in the proximal esophagus
ass’ted with bullous skin disorders, chronic graft vs host disease, iron deficiency anemia (Vinson-Plummer syndrome)
Peptic strictures
common in older pts with long-standing reflux
sequella of severe inflammation, which leads to fibrosis, scarring, esophageal shortening, and loss of compliance of the lumen
endoscopic biopsy and cytology are critical for distinguishing benign from malignant causes of srictures.
Treated with dilation (repeated) and PPI
most common types of esophageal cancers
- squamous cell
2. Adenocarcinoma
Risk factors for squamous cell carcinoma of esophagus
tylosis palmaris et plantaris (desquamating disease o the hands, feet and esophagus)
Plummer-Vinson syndrome (glossitis, cervical esophageal webs, and iron deficiency anemia)
smoking,
alcohol
Deficiencies of vitamins A, B12, C, and E, folic acid, and certain minerals- zinc, selenium, molybdenum
lye ingestion
celiac sprue
HPV inection
radiation injury
Most common type of esophagitis
from GERD
How does Vitamin C impact esophagitis?
It is acidic
what condition is pre-cancerous for adoncarcinoma of the esophagus?
Barrett Esophagus
Metaplasia in the lining of the distal esophagus (squamous epithelium is preplaced by a columnar epithelium)
caused by damage to the epithelium by bile and/ or acid
associated with adenocarcinoma of the esophagus
5-15% of patients with GERD
75% are pts with GERD
Risk actors inclulde frequent and long-standing reflux episodes, smoking, male gender, older age, and central male parttern obesity.
asymptomatic except for symptoms of underlying GERD
Patiets require surveillance EGDs regularly
Differentiate squamous cell esophageal cancers from adenocarcinoma of the esophagus
Squamous cell– mostly men and blacks, mid to lower esophagus, and risk factors = ETOH, smoking, HPV, nitrates, lye, achalasia, hot liquids, tylosis, and PV syndrome
Adenocarcinoma of the esophagus- lower esophagus- GERD, Barretts and obesity
Infectious Esophagitis- types
HIV esophagitis- affects mostly immunocompraised patients but may also occur in immunocompetent hosts. Predominantly involves distal esophagus
Esophageal candidiasis immunsuppressive state (HIV, leukemia, immunosuuppression), diabetes mellitus, corticosteroids (oral or inhaled), esophageal stasis (advanced achalasia or scleroderma)
CMV esophagitis- exclusively immunocompromised patients (HIV, chemo/ immunosuppression)
Pill-induced esophagitis
Pills can damage esophagus by:
producing a caustic acid solution- ascorbic acid and ferrous sulfate
producing a caustic alkaline solution- alendronate
placing a hyperosmolar solution in contact with mucosa- potassium chloride
causing direct drug toxicity to mucosa- tetracycline
Predisposing factors:
strictures
prominent aortic arch that compresses the esophagus
Improper ingestion of the pill- inadequate fluid, improper positioning
Pills that cause esophagitis
Antibiotics: tetracycline group, clindamycin, penicillin, rifampin
some HIV meds
bisphosphonates
Chemotherapeutic agents
NSAIDS
Others: quinidine, potassium chloride, ferrous sulfate, ascorbic acid, multivitamins, theophylline
caustic injury from
drain cleaners industrial strength cleaners hair relaxers oven and toilet bowl cleaners button batteries
results in chronic strictures
increases risk for esophageal cancer
Boerhaave syndrome
spontaneous rupture of the esophagus
caused by sudden rise in intraesophageal pressure during forceful vomiting
most commonly in the lower third of the esophagus
presents with vomiting, lower thoracic pain, subcutaneous emphysema
In severe cases– pleural effusions, tachypnea, abdominal rigidity, fever, and hypotension.
If not treated immediately- leads to mediastinitis
esophageal emergencies
boerhaave synddrome mallory-weiss tear iatrogenic perforation foreign body impaction tracheo-esophageal fistula esophageal varices
what is dyspepsia
epigastric pain or burning, early satiety, or postprandial fullness
differential for dyspepsia
Food or drug intolerance- overeating, eating too quickly, high-fat foods, eating during stressful situations, medications
functional dyspepsia (“IBS of stomach”)
Luminal GI tract dysfunction:
PUD, GERD, Gastritis, gastric or esophageal, gastroparesis, lactose intolerance, malabsorptive conditions, parasitic infection (giardia, strongyloides, anisakis)
Pancreatic disease- chronic pancreatitis, pancreatic cancer
Biliary tract disease- cholecystitis, cholelithiasis
Other conditions- diabetes mellitus, thyroid disease, chronic kidney disease, myocardial ischemia, intra-abdominal malignancy, gastric volvulus, hiatal hernia, chronic gastric or intestinal ischemia, pregnancy
Causes of chronic gastritis- infectious
H pylori
H. heilmanni
mycobacterium, syphilis, histoplasmosis, mucormycosis, blastomycosis, anisakiasis (raw fish or sushi)
Srongyloides, schistosomiasis, diphyllobothrium,
CMV, herpes virus
causes of chronic gastritis- noninfectious
autoimmune chemical (NSAIDs, ASA, bile reflux) Uremic Crohn's, sarcoid, wegener's, CGD, eosinophilic granuloma, etc. lymphocytic (Celiac disease) eosinophilic radiation graft vs host ischemic menetrieres
erosive, hemorrhagic gastritis mnemonic
DASH Drugs (NSAID) Alcohol Stress portal Hypertensive gastropathy
causes of stress gastritis
* mechanical ventilation > 48 hrs trauma burns shock sepsis liver and kidney disease CNS injury multiorgan failure * coagulopathy (platelets under 50,000; INR > 1.5)
- Prophylaxis: enteral feeding, H2 blockers, sucralfate suspension
- Bleeding: PPIs (esomeprazole)
what do you order when you suspect B12 deficiency?
MMA- methylmalonic acid levels
GI bleeding
Upper GI: esophagus, stomach and duodenum above the ligament of treitz
presents with hematemesis and melena
if fast and extensive, may present with hematochezia
Lower GI bleeding- hematochezia
causes of upper GI bleeding
peptic ulcer (gastric or duodenal) gastric or esophageal varices erosive esophagitis upper GI tumors mallory-weiss tear gastric or duodenal erosions dieulafoy lesion
portal hypertensive gastropathy
= snake skin or mosaic stomach
usually in fundus and body
with or without varices
most common type of gastric cancer
adenocarcinoma
gastric benign tumors
adenoma (polyp)
leiomyoma
gastrinoma (neuro-endocrine)
gastric malignant tumors
adenocarcinoma- most common lymphomas leiomyosarcoma GI stromal tumor (associated with mutaiton of C-kit gene- similar to CML) Carcinoid
gastric adenocarcinoma risk factors
environmental: H pylori, excess slat nitrates/ nitrites, carbs
deficiency of fresh fruit, vegetables, vitamins A and C, refridgeration
low socioeconomic status
cigarette smoking
Genetic
familial gastric cancer (rare)
associated with hereditary nonpolyposis colorectal cancer
Blood group A
predisposing conditions for gastric adenocarcinoma
chronic atrophic gastritis, pernicious anemia, intestinal metaplasia, gastric adenomatous polyps (> 2 cm), postgastrectomy stumps, gastric epithelial dysplasia, menetrier’s disease (hypertrophic gastropathy), chronic peptic ulcer
treatment for GI bleedign
packed RBCs platelets DDAVP FFP Esomeprazole IV octreotide IV banding or TIPS
