Management Of Upper GI Conditions Part 1

Question 1

Red flags of heart burn

Answer 1

Vomiting
Bleeding (hematemesis, coffee ground emesis, melena)
Iron deficiency
Anorexia
Weight loss
Dysphagia

Question 2

GERD
Esophageal symptoms
Complications of reflux:

Answer 2

Typical reflux symptoms and chest pain

Esophagitis, stricture, Barret’s Esophagus, esophageal adenocarcinoma

Question 3

GERD
Extraesophageal symtpoms

Answer 3

Established associations:
- cough
- laryngitis
- asthma
- dental erosions

Proposed associations:
- pharyngitis
- sinusitis
- idiopathic pulmonary fibrosis
- recurrent otitis media

Question 4

How is GERD diagnosed?

Answer 4

Majority can be diagnosed by Hx alone
Others may need:
- endoscopy
- 24hr esophageal pH study
- 24 hour esophageal manometry
- barium x ray
- other

Question 5

Indications for endoscopy in patients with GERD

Answer 5

1) symptoms persistent or progressive despite medical Tx
2) dysphagia or odynophagia
3) involuntary weight loss >5%
4) evidence of GI bleed or anemia
5) a mass, stricture or ulcer is found on imaging
6) screening for Barrett’s esophagus in selected patients
7) persistent vomiting (7-10 days)
8) evaluation of patients before or with recurrent symptoms after endoscopic or surgical anti reflux procedures
9) placement of wireless pH monitoring

Question 6

24-hour esophageal pH study
- purpose
- when do we do it?
- how is it done?

Answer 6

Used to confirm diagnosis of GERD in patients with persistent symptoms (specifically is 2x daily PPI has failed)
- do it prior to anti-reflux surgery
- placed through nose or a wireless capsule-shaped device affixed to distal esophageal mucosa
- catheter pH electrode positioned 5cm above the manometrically defined upper limit of the LES
- tests are conducted within 24-hour period with patients advised to consume an unrestricted diet

Question 7

What can GERD lead to?

Answer 7

Erosive esophagitis
Peptic stricture
Barrett’s esophagus
Esophageal adenocarcinoma

Question 8

Reflux esophagitis
- define
- mechanism

Answer 8

Acid damage to the esophagus
Mechanism:
- increased abdominal pressure
- increased volume of regurgitate
- decreased esophageal clearance
- delayed emptying of the stomach

Question 9

Barrett’s Esophagus
- define
- histologically?
- why is it important to diagnose?

Answer 9

Definition:
- metaplastic columnar epithelium replaced stratified squamous epithelium normally lining the distal esophagus

Histologically via biopsy:
- reveal intestinal metaplasia characterized with goblet cells

Importance:
- increased risk of adenocarcinoma (0.5% per year or 1/200 Pt-years of follow up)

Question 10

Treatment of GERD

Answer 10

1) correct the underlying cause (reduce or stop exacerbating medications that reduce LES pressure)
2) lifestyle modifications:
- weight loss, smoking cessation, moderation in alcohol intake
3) medications
4) surgery

Question 11

Medications used to treat GERD

Answer 11

1) antacids
2) sucralfate
- stimulate angiogenesis and the formation of granulation tissue
- binds to injured tissue, delivering growth factors and reducing access to pepsin and acid
3) H2 receptor antagonists - inhibits acid production by blocking H2 receptors on parietal cells
4) PPI - inhibit H-K-ATPase irreversibly
5) prokinetic agents - increase rate of gastric emptying

Question 12

Different PPIs
- daily dose in mg

Answer 12

Omeprazole - 20mg
Pantoprazole - 40mg
Esomeprazole - 30mg
Lansoprazole - 30mg
Rabeprazole - 20mg

Question 13

Anti-reflux surgery
- indication
- post-op symptoms
- failure rate

Answer 13

Indicated for severe symptoms incompletely controlled by optimal medical therapy
- for extra-esophageal manifestations of GERD (chronic cough, hoarseness, laryngitis, wheezing, asthma, chronic bronchitis, aspiration, dental erosion)

• Post-Op symptoms of dysphagia and gas bloating
• failure rate of 10-15%

Question 14

Other causes of retrosternal pain?

Answer 14

Cardiac - Angina, MI, aortic dissection, pericarditis, etc.
Pulmonary - pulmonary embolism
Esophageal - esophageal spasm

Question 15

Causes of esophagtisis: differential diagnosis

Answer 15

Infection - CMV, HSV, candida
Inflammatory - eosinophilic esophagitis
Pill induced - antibiotics (doxycycline)
Esophagitis associated with immune disease - Chron’s, Bechet’s
Chemical induced esophagitis - acid or alkaline ingestion

Question 16

Eosinophilic esophagitis
- typical presentation
- association with allergies
- EGD findings
- biopsy findings

Answer 16

Young male with recurrent chronic solid food dysphagia, food bolus impaction

• Allergic History of asthma, allergic rhinitis, skin atopy

On EGD:
- subtle longitudinal furrowing, transverse ridges, whitish plaques or papules, fragility of esophageal mucosa, trachea-like esophagus

On biopsy:
- more than 15 eosinophils per high power field

We then treat

Question 17

Pill esophagitis
What is is?
Causes:

Answer 17

Esophageal abnormalities due to shallow ulcerations and direct esophageal mucosal injury from the pill

• systemic effects: disrupting the normal cytoprotective prostaglandin barrier

Causes:
- antibiotics
- anti-inflammatories (NSAIDs, aspirin)
- bisphophonates (alendronate, risedronate)
- ferrous sulfate (iron)
- Ascorbic acid (Vit C)
- potassium chloride

Question 18

Functional Dyspepsia
Functional Causes vs. Organic causes
Symptoms
Etiology

Answer 18

Causes: Functional 60% no organic causes and organic (40%)
Symptoms: ulcer like symptoms, dysmotility like symptoms
Etiology:
- impaired gastric motor function
- visceral sensitivity
- psychosocial factors

Organic causes:
V- MI, mesenteric ischemia
I - H. Pylori
T - trauma
A - cholelithiasis
M - diabetic gastropathy
I - pancreatistis
N - gastric cancer
O - celiac disease
D - antibiotics, NSAIDs

Question 19

Management for Dyspepsia

Answer 19

> 55 years or has alarm features - EGD

< 55 years old with no alarm features
- HP prevalence <10% —> PPI trial —> (if fails) test and treat H. Pylori —> (if fails) consider EGD
- HP prevalence >10% —> test and treat for H. Pylori —> (if fails) PPI trial —> if fails consider EGD

Question 20

When is endoscopy indicated in dyspepsia?

Answer 20

Age >50
Any age:
- abdominal mass, vomiting, bleeding, dysphagia, anemia, weight loss

Question 21

Biopsy may show for dyspepsia?

Answer 21

Gastropathy - epithelial cell damage and regeneration without inflammation (NSAIDs, bile reflux, or congestion, e.g. portal hypertensive gastropathy)

Question 22

What is gastropathy?

Answer 22

epithelial cell damage and regeneration without inflammation (NSAIDs, bile reflux, or congestion, e.g. portal hypertensive gastropathy)

Question 23

EGD shows in selected dyspepsia patients?

Answer 23

Gastritis - inflammation of gastric mucosa associated with injury (H. Pylori, autoimmune, alcohol)

Question 24

H pylori gastritis
- 2 types and explanations

Answer 24

Antral based - infection increases gastrin secretion —> increased parietal cell acid production —> duodenal damage —> gastric metaplasia in duodenum —> HP moves into duodenum —> duodenal ulcers

Corpus-predominant - strophic gastritis or pan-gastritis - genetically lower acid output —> easier for HP to move into body —> risk factor for gastric ulcer as well as intestinal metaplasia —> dysplasia and gastric cancer