week 4- esophagus Flashcards
• What hx Q’s should you ask for GI cc?
o OPQRST for pain, psychological stress, diet, thorough PMHx, SHx, ROS
• What are alarm sxs with GI cc (require further eval)?
a. appetite (anorexia)
b. blood in stool/urine (gross or occult)
c. changes in skin (jaundice)
d. dysphagia
e. edema
f. fever
g. gaunt (weight loss)
h. heavy (Abdominal mass, organomegaly)
i. irrupt (N/V)
j. jolt (pain awakens pt)
• what is general PE for GI cc?
o general observations, signs of distress, orientation, nourished appearance?
o vitals, weight/BMI, pulse ox
o skin: rash or erythema? jaundice? pallor?
o Extremities: nail clubbing, contractures, liver flap?
• What HEENT PE should you look at with GI cc? Chest?
o eyes: jaundice in sclera, conjunctival pallor?
o mouth: lesions?
o LN: upper cervical and Virchow’s node
• How do you perform chest exam for GI cc?
o inspect for spider nevi, purpura, gynecomastia
o ausc heart and lungs
• how do you perform abdominal exam for GI cc?
o Inspection: lesions, masses, distention (7 Fs), scars, vessels, peristalsis
o Ausc: bowel sounds, bruits
o Percussion: mixed resonant/dull (norm), Hyper-resonance/tympany (gas), dull (solid organs, feces, fluid, tumors, shifts w ascites). Determine liver span in cm at MCL
o Palpation: 4 quad, superficial and deep, tenderness, mass, guarding. Liver, spleen, kidneys (tenderness, organomegaly, masses, enlarged AA)
o Special tests: Murphy’s sign (GB); McBurney’s (appendicitis), Rovsing’s sign, Psoas sign, Obturator sign
Digital rectal exam w occult blood
o Pelvic exam in women, male genitalia exam
• What are some general tests done for GI cc?
o UA
o Serum/Liver: LFT: ALP, AST, ALT, LDH, GGT, 5’ Nucleotidase, PT, INR, bili, albumin
o CMP: Bilirubin, total protein, albumin
o Serum imunoglobulins, anti-mitochondrial antibodies, α-fetoprotein
o General: ESR, CBC
o Pancreas: Amylase and lipase
• What tests and procedures are specific to upper GI cc (dependent on clinical findings)?
o acid tests: ambulatory pH monitoring, gastric analysis o endoscopy, Anoscopy, Sigmoidoscopy o laparoscopy o manometry o nuclear scans o x-ray, other contrast imaging o nasogastric, Intestinal Intubation o abdominal paracentesis o electrogastrography, electrical impedance test
• what is the first stage of digestion? Saliva?
o Smell food → saliva
o Saliva: water, 0.5% electrolytes, mucus, glycoproteins, enzymes, antibacterial (sIgA, lysozyme)
o moisten, lubricate food, form bolus, pass easily from mouth to esophagus
• what are some problems of the mouth?
o Mb involve the tongue, teeth, gingival or mucous membranes, local musculature, local nervous system, local exocrine glands (salivary)
o mb indicate local dz or systemic illness (dehydration, nutritional def, etc)
• what are the esophageal and swallowing dos?
o Dysphagia: oropharyngeal, esophageal o Cricopharyngeal incoordination o Obstructive dos: lower esophageal rings, esophageal webs, dysphagia lusoria o Motility dos: achalasia, symptomatic diffuse esophageal spasm o Esophageal diverticula o GERD o Hiatal hernia o Infectious esophageal dos: Mallory-weiss syndrome o Esophageal rupture o Tumors o esophageal varices o foreign bodies
• what is globus sensation?
o Feeling lump in throat
o Unrelated to swallowing (not dysphagia)
• What is oropharyngeal dysphagia? Ssx?
o difficulty emptying material from oropharynx to E
o ssx: hard to initiate swallowing, food stuck in throat, nasal regurgitation, cough/ choke w swallow, drool, unexplained wt loss, recurrent pneumonia, change in voice
• what are some causes of oropharyngeal dysphagia?
o Neurologic: stroke, PD, MS, motor neuron dos (ALS, progressive bulbar palsy), bulbar poliomyelitis
o Mulcular: myasthenia gravis, dermatomyositis, MD, cricopharyngeal incoordination
• What is esophageal dysphagia? Ssx?
o Hard to pass food down E
o Ssx: sensation of food stuck throat/chest, regurg, drool, wt loss, recurrent pneumonia
• What are some causes of esophageal dysphagia?
o Motility dos: achalasia, DES, systemic sclerosis, eosinophilic E-it is
o Mechanical obstruction: peptic stricture, E CA, lower E rings, caustic ingestion, extrinsic compression (big LA, AA, aberrant subclavian artery, substernal thyroid, cervical bony exostosis, thoracic tumor)
• What PE is done for E dysphagia?
o nutritional status (include weight)
o Complete neuro: resting tremor, cranial nerves, ms strength, observe gait, test balance
o Skin: rashes, thickening
o Muscles: wasting, fasiculations, tenderness
o Neck: thyromegaly, masses
• What are some helpful findings and possible cause for dysphagia?
o Tremor, ataxia, balance disturbance: PD
o Focal easy fatigability (esp facial mm): Motor neuron dz, myopathy
o Rapidly progressive, constant dysphagia, no neuro finding: E obstruction, prob CA
o GERD sxs: Peptic stricture
o Intermittent dysphagia: LE rig, DES
o Slow progression (mos-yrs) of dysphagia to solids and liquids, mb nocturnal regurgitation: achalasia
o Neck mass, thyromegaly: Extrinsic compression
o Dusky, erythematous rash, muscle tenderness: dermatomyositis
o Raynaud’s, arthralgias, skin tightening/contractures of fingers: Systemic sclerosis
o Cough, dyspnea, lung congestion: Pulmonary aspiration
• What is the work-up for dysphagia?
o endoscopy to r/o CA
o Barium swallow (w solid bolus): May show obstruction, if negative or suggestive of motility do then order motility study
• What are red flags for dysphagia?
o Sxs of complete obstruction (drool, can’t swallow anything)
o → weight loss
o New focal neuro deficit, esp objective weakness
• What is cricopharyngeal incoordination? Etio, ssx, complications, tx?
o = upper E sphincter → Zenker’s diverticulum
o Etio: neuromuscular dos
o Ssx: choking, swallowing air, regurg fluid into nose, dysphagia w solids
o Comp: Repeated aspiration of material from diverticulum → chronic lung dz
o Tx: surgical section of the muscle
• What are lower E rings? Ssx? Work up?
o aka Schatski’s Ring
o 2-4mm mucosal stricture, prob congenital → ring-like narrowing of distal E at SCJ
o Ssx: intermittent dysphagia for solids, esp. meat and dry bread; can begin at any age, usu after 25
o Work-up : Barium swallow
• What are esophageal webs? Etio, ssx, work up, px?
o Seen in Plummer-Vinson Syndrome; Paterson Kelly Syndrome; Sideropenic Dysphagia
o thin mucosal membrane across lumen, usu in upper E
o Etio: rarely develop w severe untx IDA (Plummer-Vinson Syndrome)
o Ssx: Dysphagia for solids
o Work-up: barium swallow
o Px: usu resolve w tx anemia, can easily rupture during esophagoscopy. May increase risk for SCC of E
• What is dysphagia lusoria? Work up?
o Dt compression of E dt congenital abnormalities, usu dt aberrant R subclavian a
o Work-up: Barium swallow (extrinsic compression)
o Arteriography for absolute diagnosis
• What is achalasia? Etio of 3 types?
o aka Cardiospasm; Esophageal Aperistalsis; Megaesophagus
o Neurogenic E motility dio w impaired esophageal peristalsis, no LES relaxation on swallow, hi LE resting pressure
o Primary: loss ganglion cells in E myenteric plexus → denervation of E muscle (unknown etio, viral cause suspected)
o Secondary: Chagas dz
o Pseudoachalasia: malignancy, infiltrative dos, diabetes
• What are ssx of achalasia?
o Any age, usu 20-60
o insidious onset, gradual progression, mos-yrs
o Dysphagia for both solids and liquids is major sx
o Nocturnal regurg of undigested food in 33% → cough or pulm aspiration
o Chest pain (less common)
o Mild to moderate weight loss
• When should achalasia 2nd to a tumor of GEJ be considered?
o When weight loss is pronounced, particularly in an elderly pt whose sxs of dysphagia developed rapidly
• What is work-up for achalasia? Ddx? Px?
o Barium Swallow: absence of progressive peristaltic contractions on swallow. Dilated E but narrow and beaklike at LES
o E Manometry: aperistalsis, inc LES pressure, incomplete relaxation
o Esophagoscopy: to r/o malignancy and other DDx
o Ddx: distal stenosing carcinoma, peptic stricture
o Px: based on Pulm aspiration or presence of CA
• What is symptomatic diffuse esophageal spasm? Ssx? Dx?
o Aka Spastic Pseudodiverticulosis; Rosary Bead or Corkscrew Esophagus
o Motility do w non-propulsive contractions, hyperdynamic contractions, hi LES pressure
o Ssx: Substernal chest pain (80-90%) mins-hrs; awaken from sleep; hot/cold liquids aggravate pain; often pain radiates to back; Dysphagia for both solids and liquids (30-60%); Heartburn (20%)
o Dx: Barium swallow, Manometry (best, but spasms may not occur during testing)
• What is esophageal diverticula? 3 types? Work-up?
o Outpouching of mucosa thru muscular layer of E
o Zenker’s (pharyngeal): posterior, sub/mucosa thru cricopharyngeal m; dt incoordination; regurg on bend/lie down; aspiration pneumonitis if regurg at night; rarely dysphagia, neck mass
o Midesophageal (traction): traction from mediastinal inflammatory lesions, or dt motility dos. Rare sx
o Epiphrenic: above diaphragm, usu w motility do (achalasia, DES). Rare sx
o Work up: Videotaped barium swallow
• What is causes GERD? Prevalence?
o Incompetent LES → gastric reflux into E, burning pain
o Factors: Wweight gain, fatty food, caffeine/carbonated drinks, alcohol, smoking
o Drugs: anticholinergics, antihistamines, TCAs, Ca channel blockers, progesterone, nitrates
o Prevalence: 30-40% of adults, often in infants, too
• What are ssx of GERD? Dx?
o Heartburn (mb regurg) o Infants: vomit, irritable, anorexia, chronic aspiration (cough, hoarse, wheeze) o Dx: usu clinical by hx, endoscopy (if refractory to empiric tx), 24-hr pH, Barium swallow (mb ulcers)
• What are complications of GERD and their sxs?
o Esophagitis: mb odynophagia, E hemorrhage (usu occult or massive)
o Peptic E ulcer: same pain as gastric/duodenal ulcers, local to xiphoid/high substernal region
o E stricture: progressive dysphagia, solids
o Barrett’s E: stratified squamous of distal E→ metaplastic, columnar , glandular, intestine-like mucosa w brush border, globlet cells
o BE may →E adenocarcinoma: 30-60x risk w GERD
• What is hiatus/hiatal hernia? Etio? Work-up? Complications?
o Stomach protrudes thru diaphragmatic hiatus
o Etio: unknown, mb stretch fascia bw E and diaphragm at hiatus
o Work-up: Barium Swallow. Large HH st found on x-ray
o Comp: occult or massive GI hemorrhage
• What are the 2 types of hiatal hernia?
o Sliding: most common. GEJ and stomach above diaphragm. Usu asx, chest pain, reflux
o Paraesophageal: normal GEJ, but some stomach in D hiatus. usu asx, may incarcerate and strangulate
• What are infectious esophageal dos? Work-up?
o Usu w HIV/AIDS, transplantation, alcoholics, diabetics, malnourished, CA
o Candida Albicans: (any)odynophagia, dysphagia, oral thrush lesions
o HSV, CMV (AIDS, transplant)
o Work-up: Endoscopy and culture
• What is Mallory-Weiss syndrome?
o Non-penetrating mucosal laceration of distal E and stomach, dt vomit, retch, hiccup
o 5% of GI hemorrhage
o bleeding usu resolve spontaneously, 10% require significant intervention
• what is an esophageal rupture? Cuases?
o EMERGENCY!!! o Usu at distal esophagus on left o Primary: iatrogenic (endoscopy, etc) o Spontaneous: (Boerhaave’s Syndrome), dt vomi, swallow large food bolus o GERD
• What are ssx of an E rupture? PE? Work-up?
o Chest, abdominal pain, vomit, hematemesis o PE: Mediastinal crunch (Hamman’s sign) crackling sound synchronous w HR o Work-up: Chest/abdominal x-rays (mediastinal air, pleural effusion, mediastinal widening) o Esophagography (confirms) w water-soluble contrast agent o Endoscopy: (may miss a small perforation)
What are the 7 Fs?
fat, fluid, feces, flatus, fatal growth, fetus, fibroid
