Pales CIS

Question 1

three types of dysphagia

Answer 1

oropharyngeal- choking
esophageal
- to solids only
- to solids and fluids

Question 2

dysphagia to solids only indicates

Answer 2

mechanical disruption

CREaP

Carcinoma
Ring (Schatski's/ webs)
Eosinophilic esophagitis
and
Peptic stricture

Question 3

dysphagia to solids AND liquds indicates

Answer 3

motility problem

SAD: Scleroderma, achalasia, diffuse esophageal spasm

Question 4

Oropharyngeal (transfer) dysphagia

Answer 4

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

Question 5

first choice test to determine cause of esophageal dysphagia

Answer 5

Barium swallow/ esophagram

Question 6

Achalasia

Answer 6

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

Question 7

How to treat achalasia

Answer 7

botox
pneumatic dilation
myotomy
esophagectomy

Question 8

What do we have to differentiate achalasia from?

Answer 8

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

Question 9

Diffuse Esophageal Spasm

Answer 9

etiology unknown
maybe related to deficiency of NO

symptoms: intermittent chest pain, dysphagia
dx: manometry, bariography

Corkscrew esophagus

Question 10

DES treatment

Answer 10

anticholinergic smooth muscle relaxants (Hyoscyamine)

Calcium channel blockers (Nifedipine)

Nitroglycerin

Sildenafil

Tricyclic antidepressants- imipramine

Botulinum toxin injections

Question 11

Esophagus dysmotility in systemic disorders

Answer 11

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

Question 12

Other motility disorders

Answer 12

Presby-esophagus (tertiary contractions) - old people

Jackhammer esophagus = nutcracker– hypertensive peristalsis

Hypertensive LES

Question 13

what dysphagia-causing condition may be associated with asthma?

Answer 13

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

Question 14

what conditions do eosinophylic esophagitis need to be differentiated from?

Answer 14

cancer, rings, and webs

Question 15

Rings

Answer 15

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

Question 16

Webs

Answer 16

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)

Question 17

Peptic strictures

Answer 17

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

Question 18

most common types of esophageal cancers

Answer 18

1. squamous cell

2. Adenocarcinoma

Question 19

Risk factors for squamous cell carcinoma of esophagus

Answer 19

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

Question 20

Most common type of esophagitis

Answer 20

from GERD

Question 21

How does Vitamin C impact esophagitis?

Answer 21

It is acidic

Question 22

what condition is pre-cancerous for adoncarcinoma of the esophagus?

Answer 22

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

Question 23

Differentiate squamous cell esophageal cancers from adenocarcinoma of the esophagus

Answer 23

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

Question 24

Infectious Esophagitis- types

Answer 24

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)

Question 25

Pill-induced esophagitis

Answer 25

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

Question 26

Pills that cause esophagitis

Answer 26

Antibiotics: tetracycline group, clindamycin, penicillin, rifampin some HIV meds bisphosphonates Chemotherapeutic agents NSAIDS Others: quinidine, potassium chloride, ferrous sulfate, ascorbic acid, multivitamins, theophylline

Question 27

caustic injury from

Answer 27

``` drain cleaners industrial strength cleaners hair relaxers oven and toilet bowl cleaners button batteries ``` results in chronic strictures increases risk for esophageal cancer

Question 28

Boerhaave syndrome

Answer 28

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

Question 29

esophageal emergencies

Answer 29

``` boerhaave synddrome mallory-weiss tear iatrogenic perforation foreign body impaction tracheo-esophageal fistula esophageal varices ```

Question 30

what is dyspepsia

Answer 30

epigastric pain or burning, early satiety, or postprandial fullness

Question 31

differential for dyspepsia

Answer 31

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

Question 32

Causes of chronic gastritis- infectious

Answer 32

H pylori H. heilmanni mycobacterium, syphilis, histoplasmosis, mucormycosis, blastomycosis, anisakiasis (raw fish or sushi) Srongyloides, schistosomiasis, diphyllobothrium, CMV, herpes virus

Question 33

causes of chronic gastritis- noninfectious

Answer 33

``` 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 ```

Question 34

erosive, hemorrhagic gastritis mnemonic

Answer 34

``` DASH Drugs (NSAID) Alcohol Stress portal Hypertensive gastropathy ```

Question 35

causes of stress gastritis

Answer 35

``` * 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)

Question 36

what do you order when you suspect B12 deficiency?

Answer 36

MMA- methylmalonic acid levels

Question 37

GI bleeding

Answer 37

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

Question 38

causes of upper GI bleeding

Answer 38

``` peptic ulcer (gastric or duodenal) gastric or esophageal varices erosive esophagitis upper GI tumors mallory-weiss tear gastric or duodenal erosions dieulafoy lesion ```

Question 39

portal hypertensive gastropathy

Answer 39

= snake skin or mosaic stomach usually in fundus and body with or without varices

Question 40

most common type of gastric cancer

Answer 40

adenocarcinoma

Question 41

gastric benign tumors

Answer 41

adenoma (polyp) leiomyoma gastrinoma (neuro-endocrine)

Question 42

gastric malignant tumors

Answer 42

``` adenocarcinoma- most common lymphomas leiomyosarcoma GI stromal tumor (associated with mutaiton of C-kit gene- similar to CML) Carcinoid ```

Question 43

gastric adenocarcinoma risk factors

Answer 43

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

Question 44

predisposing conditions for gastric adenocarcinoma

Answer 44

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

Question 45

treatment for GI bleedign

Answer 45

``` packed RBCs platelets DDAVP FFP Esomeprazole IV octreotide IV banding or TIPS ```