Pathophys Flashcards
When should you refer a GERD patient to a gastroenterologist?
- atypical or unresponsive symptoms
- ALARM features
- typical chronic GERD symptoms with no prior endoscopy
- Barrett’s screening (reflux for 5 or more yrs)
esophagitis
specific to GERD
alarm features in GERD
- change in chronic symptoms
- dysphagia, vomiting, weight loss, anemia
- family Hx CA, CA concerns
endoscopy for GERD
specific
NOT sensitive
SCREEN for Barrett’s
eosinophilic esophagitis
young male with Hx of atypical heartburn, intermittent dysphagia, recurrent food impaction
EOSINOPHILS
RINGS on endoscopy
Tx: PPI, topical steroids
Barrett’s esophagus
OVERWEIGHT, WHITE, MALE with longstanding heartburn
predisposes to: ADENOCARCINOMA
adenocarcinoma
MOST arise from Barrett esophagus
increase risk: tobacco, radiation
decrease risk: fruit, veggies, H. pylori if they cause gastric atrophy of corpus
prognosis: POOR if reaches submucosal lymphatic vessels
squamous cell carcinoma
older than 45, MALE, AA
risk factors: alcohol, tobacco, poverty, achalasia, esophageal injury, previous radiation
peptic ulcer
- pain- periodicity
- nocturnal waking with pain
- effect of food on pain
- effect of antacids/ acid-lowering meds
- other Sx
- INTERMITTENT EPIGASTRIC pain, long pain-free spells
- yes
- HELPS
- usually helpful
- none usually
H. PYLORI, NSAIDs
functional dyspepsia
- pain- periodicity
- nocturnal waking with pain
- effect of food on pain
- effect of antacids/ acid-lowering meds
- other Sx
persistent/recurrent pain/discomfort in upper abdomen with no cause that can be found 1. every day over long periods 2. unusual 3. WORSENS 4. sometimes helpful 5. BLOATING, FULLNESS, NAUSEA more common that PUD
Dx of peptic ulcer
- endoscopy and biopsy ulcer (take away from site of bleeding ulcer)
- H. pylori testing
serology: if never had H. pylori before
13C-urea breath test: can use even with a previously treated H. pylori infection
What peptic ulcers should be biopsied?
GASTRIC
not duodenal: rarely CA
Tx of peptic ulcer
- H. pylori
- NSAIDs
- clarithromycin and amoxicillin and PPI (for Sx; don’t need long term)
- PPI indefinitely (until stop NSAIDs which may be never); take off NSAID then reintroduce NSAID (in some cases can change to COX2 selective inhibitor)
What should be done after H. pylori Tx for peptic ulcer?
confirm eradication of H. pylori
with 13C-urea breath test (can’t use serology) due to low cure rate
once cured: recurrence low
- When would a patient have black tarry stool?
2. Most common cause?
- upper GI bleed
2. peptic ulcer
In what populations might peptic ulcer disease be asymptomatic?
older, NSAID use
may present with life threatening complication (bleeding) WITHOUT preceding Sx
NSAID: mechanisms of mucosal injury
- topical: intragastric pH less than 2.5: ionization of NSAID, inhibition of cell metabolism, increase cell permeability
- inhibition of protective PGs: reduce: mucosal blood flow, mucin, phospholipid, bicarb, cell restitution
- microvascular injury: inhibit NO, ischemia, free radicals
In what patient do you need to recheck an ulcer after Tx for healing/CA?
NSAID user that will need to stay on their NSAID
not for H. pylori if the disease has been eradicated
ulcerative colitis (UC)
- smoking
- parts of GI tract
- distribution
- distribution of inflammation
- granuloma
- fistula formation
- stricture formation
- risk of colon CA
- NEGATIVE association: occurs in NON-SMOKER
- COLON only
- CONTINUOUS
- mucosal
- no
- no
- no (suspect CA)
- INCREASED
other: BLOODY DIARRHEA, cramps, ulceration not req., weight loss
Crohn’s disease
- smoking
- parts of GI tract
- distribution
- distribution of inflammation
- granuloma
- fistula formation
- stricture formation
- risk of colon CA
- inconsistent, weak positive association
- anywhere: TERMINAL ILEUM
- SKIP LESIONS
- TRANSMURAL
- GRANULOMA (not required for Dx)
- FISTULA
- STRICTURE
- increased when colon is involved
other: non-bloody diarrhea, weight loss, colicky abdominal pain, ULCERATION common
inflammatory bowel disease Tx
- UC
- Crohn’s
- mesalamine (oral forever, rectal until bleed stops); if severe give short term glucocorticoids
- initially corticosteroids; ultimately will need immunosuppressant or disease modifying biological agent to maintain
Dx of ulcerative colitis
- stool studies: exclude infection
2. endoscopy: establish mucosal inflammation, distinguished UC from Crohn’s
What factors play a role in ulcerative colitis becoming dysplastic?
- duration: 8-10 yrs after onset sharp increase in risk
- extent: PANCOLITIS greater risk than left sided disease
- nature of inflammatory response: more NEUTROPHILS increase risk
What type of screening is required in UC?
When is colectomy considered?
- after 10 yrs of disease need colonoscopy every 2 years
2. removal of colon if find CA or dysplasia; can remove if Sx are uncontrollable
Signs of small bowel obstruction
severe periumbilical pain, vomiting, distended abdomen without palpable mass, hyperactive bowel sounds
Tx for small bowel obstruction
IV fluids (over days graduate to fluids by mouth then later solid food) nasogastric tube for decompression
irritable bowel syndrome (IBS)
recurrent abdominal pain or discomfort at least 3 days/mo. for 3 mo
must have 2 or more:
1. improvement of pain/discomfort with defecation
2. onset pain/discomfort associated with change in stool frequency
3. onset of pain/discomfort associated with change in stool consistency
Sx onset at least 6 mo. prior
associated with stress
possible Tx for IBS
pain: hyoscyamine, TCA
diarrhea: loperamide
possible counseling
