oral and esophageal conditions

Question 1

What is the ddx for dysphagia?

Answer 1

neuromuscular disorders (achalasia, motility disorders, scleroderma) or obstruction (peptic strictures, esophageal webs or rings, CA, radiation fibrosis)

Question 2

What are secondary causes of achalasia?

Answer 2

chagas disease (may also have dilated cardiomyopathy), neoplasm, scleroderma

Question 3

What is the work up for achalasia?

Answer 3

manometry shows incr LES pressure, incomplete LES relaxation, decr peristalsis. barium swallow shows bird’s beak sign- you then need follow-up EGD to rule out cancer

Question 4

What is the tx for achalasia?

Answer 4

CCBs/nitrates potentially used, though have CV side effects

otherwise try pneumatic dilation, botulinum injection, or myotomy

Question 5

What is the treatment for diffuse esophageal spasms?

Answer 5

CCBs, nitrates, tricyclic antidepressants

Question 6

What is the treatment and potential complications of zenker diverticulum?

Answer 6

tx: cricopharyngeal myotomy or diverticulectomy, but EGD can perforate weakness in esophageal wall and can potentially cause vocal cord paralysis and mediastinitis

Question 7

What are the adverse effects of the antacids?

Answer 7

aluminum hydroxide can cause constipation; magnesium can cause diarrhea

Question 8

What are the the adverse effects of the H2 antagonists for GERD?

Answer 8

headache, diarrhea, rare thrombocytopenia. cimetidine may cause gynecomastia and impotence

Question 9

What are the adverse effects of PPIs?

Answer 9

may increase effects of warfarin, benzos, and phenytoin in some pts

Question 10

What are the complications that can result from a hiatal hernia?

Answer 10

incarceration of stomach in the herniation with the paraesophageal type

Question 11

What is gastritis?

Answer 11

inflammation of the gastric mucosa- may be acute or chronic

Question 12

Where does chronic gastritis occur?

Answer 12

antrum or fundus of the stomach

Question 13

What is type A gastritis and how is it treated?

Answer 13

atuoimmune disorder due to antibodies against parietal cells (decr. acid level and decr gastrin). causes pernicious anemia, achlorhydia, and thyroiditis.. tx requires B12 replacement

Question 14

What is type B gastritis and how is it treated?

Answer 14

casued by H. pylori infection and is associated with MALT lymphoma and gastric adenocarcinoma. treat with PPI, clarithromycin and either amoxicillin or metrodiazole for 1-2 wks

Question 15

What are radiographic findings that might suggest a malignant lesion associated with an ulcer?

Answer 15

barium swallow

see abnormal appearing mucosal folds, mass near the ulcer and irregular filling defects in the ulcer base

Question 16

What is the appropriate work-up for a patient with a suspected ulcer?

Answer 16

If under 40, try noninvasive testing
If over 40 or pts with previous ulcer need EGD
pts with sx concerning for active bleed or sx lasting more than 2 months also need EGD

Question 17

What is the tx for PUD?

Answer 17

address active bleeding, give PPI or H2 antagoist, protect mucosa with sucralfate, bismuth subsalicylate, or misoprostol, and eliminate H pylori. Acute perforations require surgical management. Persistent non-neoplastic ulcers may also require vagotomy or antrectomy

Question 18

What are the complications of PUD?

Answer 18

hemorrhage, esp posterior ulcers (can erode gastroduodenal artery), perforation (usually anterior ulcers), lmyphoproliferative disease

Question 19

What is zollinger ellison syndrome?

Answer 19

syndrome secondary to gastrin producing tumors most frequently located in the duodenum or pancreas; associated with malabsorption disorders

Question 20

When should I suspect zollinger ellison syndrome?

Answer 20

refractory PUD, possible with steatorrhea, possible hx of other endocrine disorders

Question 21

how is zollinger-ellison syndrome diagnosed?

Answer 21

increased fasting gastrin and positive secretin stimulation test (secretin causes higher than expected serum gastrin levels). gastrin sampling in the pancreas or abdominal veins can help localize the tumor. somatostatin receptor imaging with SPECT or angiography may also help localize tumors

Question 22

What is the treatment for zollinger ellison syndrome?

Answer 22

surgical resection if nonmetastatic with localizable tumor; PPI/H2 and octreotide (somatostatin analog) may help reduce symptoms in metastatic disease

Question 23

What are the complications of zollinger ellison?

Answer 23

occasionally seen with MEN1; 60% of lesions are malignant