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GI II > Clinical Approach to the GI Patient: Atypical Chest Pain and Odynophagia > Flashcards

Clinical Approach to the GI Patient: Atypical Chest Pain and Odynophagia Flashcards

1
Q

When a patient presents with atypical chest pain, what 3 non-GI things should you rule out first?

A

MI, pulmonary embolism, aortic dissection

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2
Q

when a patient presents with atypical chest pain, what 3 GI things should you rule out first?

A

Boerhaave Syndrome, Iatrogenic Esophageal Perforation, and Peptic Ulcer Disease (PUD)

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3
Q

what are the 6 non-life threatening GI causes of atypical chest pain?

A

GERD, hiatal hernia, nutcracker esophagus, diffuse esophageal spasm, eosinophilic esophagitis, and esophageal impaction

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4
Q

what are the 5 risk factors for MI?

A

smoking, age, hypertension, diabetes mellitus, hyperlipidemia

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5
Q

What are the risk factors for atypical presentation of MI?

A

elderly, female sex, diabetes mellitus

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6
Q

What are 2 examples of atypical presentation of MI?

A

dyspepsia and epigastric pain

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7
Q

what are the risk factors for PE?

A

hypercoagulable state

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8
Q

what 4 things could cause a hypercoagulable state?

A

recent travel, surgery, cancer, genetics

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9
Q

what is the presentation of PE? (4)

A

sudden onset, pleuritic chest pain, shortness of breath, hypoxia

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10
Q

what might the vital signs look like like in a patient with a PE?

A

can have hemodynamic collapse–> tachypnea and tachycardia

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11
Q

what are the diagnostics used for PE? (4)

A

wells criteria, ECG (sinus tach vs S1Q3T3), CTA, lower extremity venous doppler ultrasound

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12
Q

what are the risk factors for aortic dissection? (5)

A

atherosclerosis, male sex, smoking, age, hypertension

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13
Q

what is the presentation like in a patient with aortic dissection (4)

A

sudden onset, “tearing or ripping” chest pain, can have some radiation to neck, Syncope

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14
Q

what are some common symptoms of an aortic dissection? (3)

A

CVA symptoms (hemiparesis), AMS, and “impending doom”

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15
Q

what might the vital signs look like in a patient with aortic dissection? (2)

A

high or low BP, asymmetrical pulses

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16
Q

what are the diagnostics used for aortic dissection? (2)

A

CXR with widen mediastinum or CT with contrast (definitive)

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17
Q

what is the etiology of PUD?

A

defensive factors (gastric mucus, bicarbonate, and prostaglandins) are overwhelmed by gastric acid, pepsin

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18
Q

What could cause the defensive factors to be overwhelmed by gastric acid, pepsin? (3)

A

H. pylori, NSAIDs or Zollinger Ellison Syndrome

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19
Q

what are the exacerbating factors to PUD? (3)

A

anxiety/stress, coffee, alcohol

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20
Q

How far do ulcers extend?

A

ulcers extend through the muscularis mucosa

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21
Q

What could be 2 symptoms of PUD?

A

epigastric pain, atypical chest pain

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22
Q

How is the epigastric pain seen in PUD described? (4)

A

gnawing, dull, aching, or “hunger-like”

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23
Q

What is the timing like in PUD?

A

symptomatic periods (several weeks) with intervals of pain free (months/years)

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24
Q

What is a more significant sign/ symptom of PUD?

A

Signs of GI bleeding

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25
Q

What are the signs of GI bleeding? (4)

A

“coffee ground” emesis, hematemesis, melena, hematochezia

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26
Q

What might the physical exam look like in a patient with PUD?

A

PE often normal in uncomplicated peptic ulcer disease; mild localized epigastric tenderness to deep palpation; hyperactive bowel sounds

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27
Q

PUD can be life threatening when there are complications; what are these complications? (4)

A

bleeding (erosion into artery), obstruction (from edema), perforation (referred shoulder pain, pneumoperitoneum), gastric adenocarcinoma or MALT-lymphoma

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28
Q

What are the diagnostics used for PUD?

A

H&H (anemia?), BUN/creatinine (UGIB= increase in BUN), EGD with biopsy (diagnostic and therapeutic)–> exclude malignancy in gastric ulcer; barium x-ray; x-ray/CT/MRI if suspect complication (perforation/obstruction); nasogastric lavage can be considered

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29
Q

what are 4 ways to detect H. pylori? What is the best way? what is the first way?

A

Fecal antigen test, urea breath test, IgA antibodies in serum, upper endoscopy with gastric biopsy; best= upper endoscopy with gastric biopsy; first: IgA antibodies

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30
Q

how can you confirm eradication of H. pylori? What is generally used?

A

fecal antigen test and urea breath test; urea breath test is generally used to confirm eradication

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31
Q

how do you treat/manage PUD?

A

acid suppression (proton pump inhibitor or H2 blocker); eradicate H. pylori; stop smoking (and alcohol); discontinue NSAIDs; endoscopic intervention (for active bleeding)

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32
Q

for gastric ulcers, what should you do for treatment/management?

A

exclude malignancy (follow endoscopically to healing: EGD with repeat biopsy of ulcer)

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33
Q

what type of disorder is reflux esophagitis?

A

a motility disorder: ineffective esophageal motility

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34
Q

what is occurring in reflux esophagitis?

A

the lower esophageal sphincter is allowing stomach acid to reflux

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35
Q

what are the risk factors for reflux esophagitis?

A

increased abdominal girth/obesity, pregnancy, hiatal hernia/scelroderma/Zollinger-ellison syndrome, fat-rich diet/caffeine/smoking/alcohol

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36
Q

what are the typical symptoms associated with reflux esophagitis?

A

pyrosis (heartburn), relationship to meals (30-60 minutes after eating), symptoms upon reclining, waterbrash, epigastric abdominal pain, esophageal dysphagia

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37
Q

what are the atypical symptoms/ extraesophageal manifestations of reflux esophagitis?

A

asthma, laryngitis, chronic cough, aspiration pneumonitis, chronic bronchitis, sleep apnea, dental caries, halitosis, hiccups, and hoarseness

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38
Q

what is the physical exam of someone with reflux esophagitis?

A

might be normal; epigastric pain? dental caries? hoarseness?

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39
Q

what are the alarming symptoms/features associated with reflux esophagitis?

A

unexplained weight loss, persistent vomiting (–> dehydration), constant and severe pain, dysphagia/odynophagia, palpable mass or adenopathy, hematemesis, melena, anemia

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40
Q

The alarming features of reflux esophagitis require further evaluation- what is this further evaluation?

A

endoscopy, directed radiographic abdominal imaging, surgical evaluation

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41
Q

how do you diagnose reflux esophagitis?

A

clinical: based on presentation, history, and PE; labs to consider: H&H and h.pylori testing

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42
Q

what can be done later to diagnose reflux esophagitis (aka not done initially)?

A

ambulatory 24-48 h esophageal pH recording and impedance testing; barium x-ray; EGD with biopsy

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43
Q

what if you have a 60 years or older patient presenting with reflux esophagitis symptoms that are not resolving with treatment?

A

a further workup is need–> EGD and imaging

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44
Q

what is the treatment/management of reflux esophagitis?

A

Empiric (if no alarm features present)- trial of acid suppression and lifestyle modification; surgical techniques; H.pylori eradication if indicated

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45
Q

what are the acid suppressions used for treatment/management of reflux esophagitis?

A

antacids, proton pump inhibitors> histamine receptor blockers

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46
Q

what lifestyle modifications can be made to treat reflux esophagitis?

A

decrease alcohol and caffeine, small low fat meals, bed at an incline, weight reduction, avoidance of smoking, chocolate, fatty food, citrus juices, and NSAIDs

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47
Q

what are the complications associated with reflux esophagitis?

A

barrett’s esophagus–> esophageal adenocarcinoma; Laryngopharyngeal reflux (LPR)

48
Q

what is a hiatal hernia?

A

herniation of the stomach into the mediastinum through the esophageal hiatus of the diaphragm

49
Q

what is a sliding hiatal hernia?

A

result of increased intraabdominal pressure from abdominal obesity, pregnancy and hereditary propensity of affected individuals to have GERD

50
Q

what are the symptoms/ presentation of a hiatal hernia?

A

atypical chest pain and Pyrosis (GERD)

51
Q

what is the physical exam like in a patient with a hiatal hernia?

A

can have but not limited to: increased abdominal girth (obesity/pregnancy)

52
Q

what are the diagnostics used for a hiatal hernia?

A

EGD- can see it; sometimes seen on chest x-ray; barium swallow x-ray

53
Q

what is the treatment/management of a hiatal hernia?

A

asymptomatic: no treatment; symptoms: surgical repair

54
Q

what is nutcracker esophagus?

A

hypertensive peristalsis–> swallowing contractions are too powerful (greater amplitude and duration)

55
Q

what occurs during nutcracker esophagus?

A

the lower esophageal sphincter relaxes normally, but has elevated pressure at baseline

56
Q

how does nutcracker esophagus present?

A

atypical chest pain, dysphagia to solids and liquids, intermittent, not progressive

57
Q

what is nutcracker esophagus associated with?

A

increased frequency of depression, anxiety, and somatization

58
Q

what are the diagnostics used for nutcracker esophagus?

A

manometry; EGD- used to exclude mechanical and inflammatory lesions

59
Q

what is the treatment/management of nutcracker esophagus?

A

nitrates (isosorbide dinitrate); calcium antagonists (nefedipine); treat concomitant mental health

60
Q

what is diffuse esophageal spasm?

A

multiple spastic contractions of the circular muscle in the esophagus; functional imbalance between excitatory and inhibitory postganglionic pathways; disrupting the coordinated components of peristalsis

61
Q

what is occurring in diffuse esophageal spasm?

A

uncoordinated esophageal contraction (long duration and recurrent)

62
Q

what are the causes of diffuse esophageal spasm?

A

primary (idiopathic); secondary due to GERD, emotional stress, diabetes, alcoholism, neuropathy, radiation therapy, ischemia, or collagen vascular disease

63
Q

how does diffuse esophageal spasm present?

A

atypical (retrosternal) chest pain, dysphagia to solids and liquids, intermittent, not progressive

64
Q

what is diffuse esophageal spasm associated with?

A

increased frequency of depression, anxiety, and somatization

65
Q

what are the diagnostics used for diffuse esophageal spasm?

A

manometry, EGD, barium swallow x-ray

66
Q

what is the gold standard for diagnosing diffuse esophageal spasm?

A

manometry: shows uncoordinated peristalsis

67
Q

what are the findings of a barium swallow x-ray in a patient with diffuse esophageal spasm?

A

“corkscrew esophagus” or “rosary bead esophagus”

68
Q

what is the treatment/management for diffuse esophageal spasm?

A

medical treatment is first line: nitrates (isosorbide dinitrate) and calcium antagonists (nifedipine); then treat concomitant mental health

69
Q

what is the etiology of eosinophilic esophagitis (EOE)?

A

etiology unknown: eosinophil chemokine?; GERD? PPI use? celiac disease? Crohn disease?

70
Q

how does eosinophilic esophagitis present in adults?

A

vague retrosternal chest pain, dysphagia, pyrosis, regurgitation of undigested food

71
Q

how does eosinophilic esophagitis present in children?

A

vague retrosternal chest pain, vomiting, difficulty feeding, dysphagia, failure to thrive (weight loss)

72
Q

what is the PMHx like in patients with eosinophilic esophagitis?

A

allergies or atopic conditions (>50% of patients)–> thought to stimulate inflammation; long history of dysphagia to solid foods; history of food bolus impaction

73
Q

what are the diagnostics used for eosinophilic esophagitis?

A

CBC with differential= eosinophilia; EGD

74
Q

what does the EGD look like in a patient with eosinophilic esophagitis?

A

loss of vascular markings (edema), longitudinally oriented furrows, and punctate exudate; multiple circular esophageal rings creating a corrugated appearance–> “feline esophagus” also been said to look like a trachea “tracheal esophagus”

75
Q

what does a biopsy of the esophagus look like in a patient with eosinophilic esophagitis?

A

squamous epithelial eosinophil-predominant inflammation

76
Q

what is the treatment/management like for eosinophilic esophagitis?

A

PPI, swallow inhaled (topical) glucocorticoids (corticosteroids); allergist referral; empiric elimination of common food allergies; esophageal dilation is very effective at relieving dysphagia

77
Q

when treating eosinophilic esophagitis with esophageal dilation, what do you have to be cautious of?

A

there is a risk of deep, esophageal mural laceration of perforation

78
Q

what are the complications associated with eosinophilic esophagitis?

A

esophageal stricture, narrow-caliber esophagus, food impaction, and esophageal perforation

79
Q

how can you prevent the complications that are associated with eosinophilic esophagitis?

A

by working on treating EOE early; careful dilation is needed to prevent iatrogenic esophageal perforation during EGD

80
Q

what is the etiology of esophageal impaction?

A

schatski ring, peptic stricture, webs, esophagitis (eosinophilic!), achalasia, cancer, accidental

81
Q

what is the typical presentation of someone with an esophageal impaction?

A

hypersalivation: inability to swallow liquids including their own saliva–> drooling/frothing/ foaming at the mouth; chest pain/ pressure (severe); dysphagia, odynophagia, sensation of choking, neck or throat pain, retching and emesis

82
Q

what are the diagnostics used for esophageal impaction?

A

emergent EGD

83
Q

what is the treatment/management for esophageal impaction?

A

pass spontaneously, endoscopically removed or pushed through lower esophageal sphincter, surgery

84
Q

what are the complications associated with esophageal impaction?

A

perforation and ulceration

85
Q

what is odynophagia?

A

pain on swallowing

86
Q

what are three things you should consider if a patient presents with odynophagia and atypical chest pain?

A

pill induced esophagitis, infectious esophagitis, caustic esophagitis

87
Q

what is the etiology of pill induced esophagitis?

A

medications–> direct, prolonged mucosal contact or mechanisms that disrupt mucosal integrity

88
Q

what medications commonly cause pill induced esophagitis?

A

NSAIDs, potassium chloride, bisphosphonates for osteoporosis, iron, antibiotics

89
Q

when is pill induced esophagitis most likely to occur?

A

if pills are swallowed without water or while supine (hospitalized or bed bound patients are at increased risk)

90
Q

how does pill induced esophagitis present?

A

severe, retrosternal chest pain, odynophagia, and dysphagia

91
Q

what is the timing like of pill induced esophagitis?

A

several hours after taking a pill (may take longer); may occur suddenly and persist for days

92
Q

how might the elderly and some other patients present with pill induced esophagitis?

A

they may have relatively little pain, but they are presenting with dysphagia

93
Q

what are the diagnostics used for pill induced esophagitis?

A

history (ask medication history) and endoscopy- may reveal one to several discrete ulcers that may be shallow or deep

94
Q

if you suspect a patient has pill induced esophagitis and you perform an EGD on them, what might it show?

A

may reveal one to several discrete ulcers that may be shallow or deep

95
Q

what is the treatment/management for pill induced esophagitis?

A

stop medication; switch to different form (parenteral if possible or liquid form); healing occurs rapidly when the offending agent is eliminated; can consider adding PPIs

96
Q

how can you prevent pill induced esophagitis?

A

take pills with 4-8 oz of water and remain upright for 30 minutes after ingestion; known offending agents should not be given to patients with: esophageal dysmotility, dysphagia, or strictures

97
Q

what are the complications associated with pill induced esophagitis?

A

severe esophagitis with stricture, hemorrhage, perforation

98
Q

what are the most common pathogens that cause infectious esophagitis?

A

candida albicans, herpes simplex (HSV), CMV, and HIV

99
Q

what are the risk factors for getting candida infections?

A

uncontrolled diabetes, treated with corticosteroids, radiation therapy, systemic antibiotic therapy

100
Q

what might the presentation be in someone with infectious esophagitis?

A

sometimes asymptomatic; fever, odynophagia, dysphagia, substernal chest pain

101
Q

what are the diagnostics used for infectious esophagitis caused by CMV?

A

EGD; biopsy; check for HIV

102
Q

what does an EGD show on a patient with infectious esophagitis caused by CMV?

A

one to several large, shallow, superficial ulcerations; biopsy with inclusion bodies

103
Q

what does EGD show on a patient with infectious esophagitis caused by herpes simplex virus?

A

multiple small deep ulcerations; oral ulcers (herpes labialis) could be present

104
Q

what does EGD show on a patient with infectious esophagitis caused by candidal infection?

A

diffuse, linear, yellow-white plaques adherent to the mucosa

105
Q

what is the treatment for infectious esophagitis caused by CMV?

A

gancyclovir

106
Q

what is the treatment for infectious esophagitis caused by herpes simplex virus?

A

oral or IV acyclovir

107
Q

what is the treatment for infectious esophagitis caused by candida?

A

system therapy (example: fluconazole)

108
Q

what is the etiology of caustic esophagitis?

A

ingestion of liquid or crystalline alkali (drain cleaners) or acid

109
Q

what are the risk factors for caustic esophagitis?

A

accidental (usually children) or deliberate (suicidal)

110
Q

what are the major symptoms associated with caustic esophagitis?

A

dyspnea, dysphagia, odynophagia, oral burns (drooling), hematemesis, oropharyngeal lesions, severe burning and varying degrees of chest pain, gagging

111
Q

what does aspiration of liquid or crystalline alkali (drain cleaners) or acid cause?

A

stridor and wheezing

112
Q

what are the diagnostics used for caustic esophagitis?

A

initial examination: circulatory status- assessment of airway patency and the oropharyngeal mucosa, including laryngoscopy; chest and abdominal radiographs are obtained looking for pneumonitis or free air–> perforation

113
Q

what should you do for treatment of caustic esophagitis?

A

stabilize the patient, hospitalized in ICU, supportive care–> endotracheal tube, NPO, IV fluids, IV PPI, analgesics, antibiotics, NG tube; monitor for signs of deterioration–> emergent surgery; laryngoscopy in patients with respiratory distress to assess the need for tracheostomy; EGD is usually performed within the first 12-24 hours to assess the extent of injury

114
Q

what should you not do for treatment of caustic esophagitis?

A

nasogastric lavage and oral antidotes–> might re-expose the esophagus to the corrosive agent and produce additional injuries; oral corticosteroids and/or antibiotics are not recommended

115
Q

what are the complications associated with caustic esophagitis? short term

A

perforation–> pneumonitis, mediastinitis, peritonitis, bleeding, esophageal-tracheal fistulas

116
Q

what are the long term complications associated with caustic esophagitis?

A

esophageal strictures (serious cases): weeks to months after the initial injury- requiring recurrent dilations

GI II (20 decks)

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