Upper GI Flashcards
Dysphagia
Definition
- Subj sx of abnormal or difficulty swallowing
- Can be related to strx or mobility/ fx disorder
Oropharyngeal dysphagia vs. Esophageal dysphagia
- Oropharyngeal: functional impairment in initiation of swallowing
- Typically results from systemic neuro or myopic conditions
- Esophageal: fx or anatomical esophagus abnormality
Odynophagia
Pain w/swallowing
Globus sensation
nonpainful sensation of a lump, tightness, or fx in pharyngeal/cervical area
Associated symptoms w/Dysphagia
- Heart burn
- Wt. loss
- Hematemesis
- Anemia
- Regurgitation of food particles, and
- Respiratory symptoms
- Dry mouth
Dysphagia PE
- Thorough HEENT, neuromuscular including cranial nerves, cardiac, respiratory, signs of malnutrition/dehydration
Dysphagia Diagnostics: Modified Barium swallow
Assessment of oropharyngeal swallowing mech + aspiration risk (preferred → easier)
Dysphagia Diagnostics: Barium Swallow
- Assess esophageal swallowing function
- structural defects
- esophageal wave propulsion + clearance; reflux
Dysphagia Diagnostics (3 others besides barium swallows)
- CT Neck: Looking specifically for structural lesion or malignancy of neck impinging on swallowing function
- Upper endoscopy: assessment of esophageal mucosa, structure, cellularity/pathology, malignancy, eosinophilic presence
- Esophageal manometry: specifically measures relaxation of upper + lower esophageal pressures + pressure gradient of peristalsis in esophagus
Meds that cause dysphagia
Bisphosphonates, NSAIDs, K+, doxy/tetracycline
What to do if patient has acute symptoms of dysphagia?
UNABLE TO SWALLOW SOLIDS +/OR LIQUIDS → ED
GERD
Reflux
Definitions
- Reflux: Retrograde movement of gastric contents from stomach to esophagus
- Normal physiologic process
- GERD: when esophageal mucosa unable to tolerate caustic gastric contents → chronic pathologic s/s in oropharynx, larynx, esophagus, respiratory tract
Barrett’s esophagus
Definition
- Chronic exposure to gastric acid → esophageal cell changes
- Small increased risk of developing esophageal cancer
- If alarm features or risk of Barrett’s esophagus → upper endoscopy
- Barrett’s for many years → higher risk for precancerous changes
CLASSIC GERD S/S
- Asthma sx: Wheeze
- Bloating, belching
- Chronic cough, Chest pain
- Dyspepsia, Dysphagia
- Epigastric fullness
- Retrosternal burning sensation (heartburn) – typically pos-prandial
- Nausea
- Water brash
Extra-esophageal sx:
- Sore throat, Hoarseness
* Symptoms exacerbated by anything that ↑ pressures on LESph: laying down, bending over, large meals
* **Can frequently mimic ischemic cardiac p! – RULE OUT 1ST **
GERD Objective Findings
- Unremarkable
- Teeth/dental erosions from gastric acid coughing up
- Wheezing/signs a/w asthma
- Epigastric tenderness/adb masses
GERD Pathophysiology
Motor abnormalities
* Decreased LES tone
* Transient LES relaxations (TLESR)
* Most common cause
* Effected by endogenous hormones, medications, foods, smoking, etoh, caffeine
* Impaired esophageal acid clearance
* Dry mouth is a risk factor
* Delayed gastric emptying
* Commonly related to DM or connectvive tissue disorders
Anatomical Factors
* Hiatal Hernia
* Obesity
* Pregnancy
* Also increased levels of circulating estrogen and progesterone decrease LES tone*
GERD Diagnostics
- Can be made clinically w/classic sx + no alarm features or risk for Barrett’s
- In pts w/atypical sxs, other differentials must be r/o
- Labs:
- CBC
- IFOB/guiac (+/-)
- H. pylori
Common meds that REDUCE LESph tone:
DEFINITELY ON EXAM
- Anticholinergics
- BBs
- Benzos
- Bronchodilators
- CCBs
- Nitrates
- TCAs
- Theophylline
GERD Pharm meds
- Antacids (neutralize gas pH)
- H2 Blockers (inhibitor histamine 2 receptor on gastric parietal cells → lowering acid production)
- PPIs (most potent) binding to + inhibiting ATPase pump
- Best when taken 30 mins before 1st meal of day
- More effective vs. H2 at healing erosive esophagitis
If patient has had GERD for > (5-10yrs)…
…+ 1 additional RF indicates need for upper endoscopy
GERD nonpharm modifications
- Weight loss
- HOB elevation in ppl w/nocturnal or laryngeal sxs (blocks or wedge)
- Sitting up post meals + no meals 2-3 hrs prior to bedtime; no large meals
- Selective dietary changes
- Eliminate/cut down on caffeine, chocolate, spicy foods, food w/high fat content, carbonated beverages, peppermint, EtOH, No peppermint (lower tone)
- Smoking cessation
- Avoid tight fitting garments
- Chewing gum or lozenges → salivation → neutralize refluxed acid → esophageal acid clearance
- Adb breathing exercises to strengthen antireflux barrier to LES
How to R/O CARDIAC sxs for DX GERD?
- Get worse w/exertion (going up stairs)
- Cause dyspnea on exertion
- Radiate to jaw/arm
- EKG
- GI cocktail: Omeprazole, Mylanta, Lidocaine (if it helps = GERD)
Barrett’s RFS
- GERD 5 to 10yrs
- Age > 50
- Male sex
- White race
- Hiatal hernia
- Obesity
- Nocturnal reflex
- Tobacco use (past or current)
- 1st - degree relative w/ Barrett’s esophagus +/or adenocarcinoma
Pregnancy considerations GERD
- Progesterone relaxes uterus smooth mm + LES
- Heartburn (when 1st experienced): 52% 1st tri, 24% 2nd tri, 9% 3rd tri
- Tends to recur in subsequent pregnancies
- Sx therapy includes:
- Multiple small meals, avoid lying down for 2-3hr after meals, elevate HOB @ night
- Start w/ antacids → sucralfate → H2Ras → PPIs
GERD in elderly considerations
- Highest risk of complications
- Lower threshold for endoscopy
- PPIs safe, but need to be mindful of Rx interactions, (Cyto P450 path) most common)
- Major: WARFARIN (BLEED RISK)
- Minor: Benzos, CCBs, theophylline
GERD alarm sxs
Not in lecutre?
- New onset of dyspepsia in patient ≥ 60 years
- Evidence of gastrointestinal bleeding (hematemesis, melena, hematochezia, occult blood in stool)
- Iron deficiency anemia
- Anorexia
- Unexplained weight loss
- Dysphagia
- Odynophagia
- Persistent vomiting
- Gastrointestinal cancer in a first-degree relative
GERD Treatment Recommendations (Stepwise) Mild
Mild
Mild/Intermittent Symptoms
* Step Up Therapy
* Lifestyle/diet modifications then
* Fewer than 1 episode per week: PRN antacids
* Fewer than 2 episodes per week
* Stepwise therapy:
low dose H2 blockers x 2 weeks, if no improvement → standard dose H2 blockers for 2 weeks, if no improvement →
Once daily PPI
Successful treatment should continue for a minimum of 8 weeks*
GERD Treatment Recommendations (Stepwise) Severe
Severe/Frequent Symptoms OR Erosive Esophagitis on EGD
* Step Down Therapy → start with high dose then step down
* Lifestyle/diet modifications +
* Standard dose PPI x 8 weeks → Low dose PPI → H2 Blocker if intermittent symptoms
Acid suppression therapy should be discontinued EXCEPT in patient with Barrett’s Esophagus or severe erosive esophagitis → Maintenance PPI therapy
Safety Considerations: Long Term PPI usage
Overuse can change stomach medium + can facilitate growth of bacteria
* C. difficile diarrhea (mechanism unclear)
* ↑ risk of pneumonia, likely d/t decreased gastric acid secretion – easier colonization UGI tract
- Malabsorption – Mg, Ca, Vit B12, Iron
- Atrophic Gastritis, kidney disease, drug-induced lupus
- Large study showed long-term use of PPI a/w osteoporosis + hip fractures, although this is now in question; however, still FDA labeling on fracture risk
PPI Tapering education
- After at least 3 months symptom free on PPI, may taper
- Cut dose by half every week
- Once on lowest dose for one week, may stop
- Do not reduce or discontinue if patient has Barrett’s Esophagitis
- Patients receiving 4-8 wk treatment for acute duodenal or gastric ulcers do not require taper, nor do those being treated for H. pylori
PUD
Definition
- Erosion in either stomach or duodenum > 5mm AND penetrates into submucosa
PUD Causes
Most common?
- H. Pylori responsible for 60% of PUD in US
- Causes increased acid secretion
- Increases inflamm
- Downregulates mucosal defense system
- NSAIDs (4x inc risk)
- Smoking
- EtOH
- Genetics
PUD clinical manifestations
- 70% asymptomatic
- Gnawing or burning epigastric pain
- Bloating, abd fullness, nausea, early satiety, GERD
- Establish relationship w/eating
- Duodenal: Pain worse 2-5hrs post eating
- Gastric: Pain worse soon after eating
- Nocturnal pain relieved w/food, antacids
PUD Objective Signs
- Hx should assess for prior Hx of H. pylori, NSAID use, RFs, alarm features
- PE normal
- +/- epigastric tenderness
PUD confirmation of eradication
- Confirmation should be performed on all pts treated for H. Pylori d/t abx resistance
- Should be performed at least 4wks after completion of abs treatment
- Can use either urea breath test, stool antigen test or endoscopy based testing
- DO NOT use serologic testing; does not distinguish between past + present
Cholecystitis Etiologies
Cholelithiasis, Choledocholithiasis, Cholangitis Definitions too
- Gallstones can block tube (cystic duct) leading out of gallbladder → cholecystitis
- Bile buildup can → inflamm
- Bile duct problems, tumors, serious illness, infection (E. coli, enterococcus, Klebsiella, Enterobacter)
- More serious complications may occur when a gallstone passes → cystic duct → common bile duct
Cholelithiasis
* Appearance of gallstones w/in gallbladder or cystic duct
* Choledocholithiasis – common bile stones
* Cholangitis – inflamm of common bile duct – via bact infxn
Cholecystitis Diagnostics
Imaging
- **1st line Abd U/S (practical) **– not contraindicated in preg
- Can’t determine if stone passed out of gallbladder → bile duct
- Look for thickening of gallbladder wall - acute
- HIDA scan
- CT scans: if unclear picture
- MRCP: for current choledocholithiasis in pts w/acute cholecystitis; noninvasive for evaluating intrahepatic + extrahepatic bile ducts
Common complication with cholecystectomy
Bile duct injury is most common complication of laparoscopic cholecystectomy
* Can have post-surgical diarrhea
* D/t ↑ bile acid entering large intestine causes laxative effect
* Usually resolves but can treat w/immodium or cholestyramine
Pancreatitis Objective Findings
- ↑ HR, RR, + temp
- Low skin turgor, dry mucous membranes (dehydrated)
- Diaphoretic
- HoTN
- Tender abd w/diminished bowel sounds
- Mild rigidity w/o rebound tenderness
- Jaundice possible
- Cullen sign (+)
- Grey Turner sign (+)
Abdominal / inguinal hernia
Definition
- Protrusion of abd viscera through abnormal opening in mm wall
Diagram of hernia locations
Inguinal Hernia - indirect
Definition
- Etiology – congenital; patent processes vaginalis
- Incidence decreases with age
- Location – lateral side of spermatic cord
- Protrudes through internal inguinal ring, lateral to inferior epigastric artery
- Can contain sac of peritoneum, omentum, or bowel
- Medium likelihood of strangulation
Indirect inguinal hernia passes through the inguinal canal or the groin
Inguinal hernia - direct
Definition
- Etiology – acquired, weakness in the posterior floor
- Incidence increases with age
- Location – directly forward thru posterior wall of the inguinal canal
- Protrudes through external inguinal ring, medial to inferior epigastric area
- Can contain periorbital fat, bowel, peritoneal sac
- Low likelihood of strangulation
A direct inguinal hernia shows a bulge from the posterior wall of the inguinal canal
Femoral hernia
Definition
- Incidence: more common in women, later in life
- Location: femoral canal, fossa ovalis – medial to the femoral pulse
- More common on the right side
- Protrudes through femoral ring, medial to femoral sheath, which containes femoral artery
- Likelihood of strangulation – high; nearly half of patients are unaware of their femoral hernia before strangulation occurs; groin pain and tenderness may be absent
Obturator Hernia
Definition
- Rare
- Women affected > men 6:1, likely due to larger, more triangular obturator canal
- R side more common
- BL hernias & concurrent femoral hernias are rare but documented
- Greatest incidence in patients in their 70s and 80s weighing < 40 kg
- Decreased muscle and fat
- 1/3rd of pts have history of previous attacks
- Watch for symptoms of bowel obstruction, present in greater than 80% of cases
Hernia Physical Exam
- Male patient stands to start
- R hand = pt R side
- L hand = pt L side
- Invaginate loose scrotal skin w/index finger
- Off note – not able to in women
- Need to palpate mass or painful area
