Internal Med- Gastroenterology Flashcards
What is a Hiatal Hernia?
Hiatal hernia is a protrusion on the upper part of the stomach into the chest, generally caused by obesity weakening the diaphragm.
What is the best way to Dx a Hiatal Hernia?
endoscopy or barium studies
What is the best initial therapy for a Hiatal Hernia?
Weight loss and PPIs
What are some of the alarm symptoms indicating endoscopy?
Weight loss
Blood in stool
Anemia
What is Achalasia?
is the inability of the lower esophageal sphincter (LES) to relax due to a loss of the nerve plexus within the lower esophagus.
What clinical picture would make Achalasia the most likely diagnosis?
Progressive dysphagia to both solids and liquids at the same time
What is the best initial test for Achalasia?
What is the most accurate test?
Barium esophagram will show a “bird’s beak” as the esophagus comes down to a point.
Manometry is the “most accurate test” and will show a failure of the lower
esophageal sphincter to relax.
What are some of the ways that Achalasia can be Mgx?
- Pneumatic dilation
- Surgical sectioning / myotomy
- Botulinum toxin injection (effects will wear off in about 3 to 6 months, requiring reinjection)
What set of clinival features would make Esophageal Cancer the most likely Dx?
- Age 50 or older.
- Dysphagia first for solids, followed later (progressing) to dysphagia for liquids.
- Association with prolonged alcohol and tobacco use.
- More than 5–10 years of GERD symptoms.
What is the best initial test when suspecting esophageal cancer?
What is the most accurate
Barium swallow
Biopsy (through Endoscopy)
What is the main use of a PET Scan?
It is often used to determine whether a cancer is resectable. Local disease is resectable, and widely metastatic disease is not.
How is esophageal cancer Mgx?
- No resection = no cure. Surgical resection is always the thing to try.
- Chemotherapy and radiation are used in addition to surgical removal.
- Stent placement is used for lesions that cannot be resected surgically just to keep the esophagus open for palliation and to improve dysphagia.
What are the 2 main forms of Esophageal Spasm?
What is the clinical difference between them?
Diffuse esophageal spasm (DES) and nutcracker esophagus
They are clinically indistinguishable. Both present with the sudden onset of chest pain that is not related to exertion.
What can precipitate Esophageal Spasm?
Drinking cold liquids
How can you distinguish between Diffuse esophageal spasm (DES) and nutcracker esophagus?
manometry- will show a different pattern of abnormal contraction in each of them.
How would you Mgx Esophageal Spasm?
calcium channel blockers and nitrates.
What is the relationship between Esophageal Spasm and Prinzmetal Angina in terms of Tx?
The Tx is similar
What clinical picture would make Eosinophilic Esophagitis the most likely Dx?
Swallowing difficulty, food impaction, and heartburn + a history of asthma and allergic diseases.
What is the best initial test for Eosinophilic Esophagitis?
What is the most accurate?
Endoscopy- showing multiple concentric rings.
A biopsy finding eosinophils
A 43-year-old man recently diagnosed with AIDS comes to the emergency department with pain on swallowing that has become progressively worse over the last several weeks. There is no pain when not swallowing. His CD4 count is 43 mm3. The patient is not currently taking any medications.
What is the most appropriate next step in management?
a. Esophagram.
b. Upper endoscopy.
c. Oral nystatin swish and swallow.
d. Intravenous amphotericin.
e. Oral fluconazole.
Oral candidiasis (thrush) need not be present in esophageal candidiasis. One does not automatically follow from the other. Although other infections such as CMV and herpes can also cause esophageal infection, over 90% of esophageal infections in patients with AIDS are caused by Candida. Empiric therapy with fluconazole is the best course of action. If fluconazole does not improve symptoms, then endoscopy is performed. Intravenous amphotericin is used for confirmed candidiasis not responding to fluconazole. Oral nystatin swish and swallow is not sufficient to control esophageal candidiasis. Nystatin treats oral candidiasis.
If a Pt presents with dysphagia and HIV CD4 <100, What is the next best step?
Empirically start with Fluconazole for candida.
If a Pt presents with dysphagia and HIV CD4 <100 and fails to respond to empirical therapy with Fluconazole What is the next best step?
Perform upper endoscopy;
1) If Large ulcerations=> CMV- Ganciclovir or Foscarnet
2) If Small ulcerations=> HSV- Acyclovir
What is the common factor between Schatzki ring and Plummer-Vinson syndrome?
Both give dysphagia.
What is Schatzki ring?
This is a type tightening (also called peptic stricture) of the distal esophagus (squamocolumnar junction).
What is the best initial diagnostic test for Schatzki ring?
Barium swallow
What is the best initial Tx for Schatzki ring?
Bougie dilator/ Ballon dilation + a PPI
What clinical features would make Plummer-Vinson syndrome the most likely Dx?
A triad of Dysphagia, Upper esophageal webs and Fe-deficiency anemia.
Between Pts with Schatzki ring and Pts with Plummer-Vinson syndrome, which group will have an increased risk of developing squamous cell carcinoma?
Plummer-Vinson syndrome Pts
Between Pts with Schatzki ring and Pts with Plummer-Vinson syndrome, which group is associated with acid reflux and hiatal hernia?
Schatzki ring Pts
What is Steakhouse syndrome?
Dysphagia from solid food associated with
Schatzki ring
What is Zenker Diverticulum?
It is an outpocketing of the posterior pharyngeal constrictor muscles.
What are some of the clinical features of Zenkers Diverticulum?
Dysphagia, severe halitosis, and regurgitation of food particles. Some
patients suffer from aspiration pneumonia
What is the best initial Dx test for Zenkers Diverticulum?
Barium swallow (lateral projection- dorsal protruding pouch at level C5/C6
What is the best initial Tx test for Zenkers Diverticulum?
Surgery. There is no medical therapy.
Which 2 procedures are contraindicated in Zenkers Diverticulum? Why?
Nasogastric tube placement and Upper endoscopy.
They may cause perforation
When would Scleroderma be the likely cause of reflux?
A patient who presents with symptoms of reflux and have a clear history of scleroderma, or progressive systemic sclerosis.
What would be the best initial Dx test to show that reflux in a Pt is caused by Scleroderma?
Manometry would show decreased lower esophageal sphincter pressure from an inability to close the LES.
How would you Mgx reflux in a Pt caused by Scleroderma?
PPIs as it would be for any person with reflux symptoms
What clinical scenario would make a Mallory-Weiss Tear the most likely Dx?
Upper gastrointestinal bleeding after prolonged or severe vomiting or retching. Repeated retching is followed by hematemesis of bright red blood, or by black stool.
How would you Mgx a Pt with a Mallory-Weiss Tear?
There is no specific therapy, and it will resolve spontaneously. Severe cases with persistent bleeding are managed with an injection of epinephrine to stop bleeding or the use of electrocautery.
What is the difference between Boerhaave syndrome and a Mallory-Weiss Tear?
Boerhaave syndrome is full penetration of the esophagus.
Mallory-Weiss is a nonpenetrating tear of only the mucosa.
A 44-year-old woman comes to see you because of pain in her epigastric area for the last several months. She denies nausea, vomiting, weight loss, or blood in her stool. On physical examination, you find no abnormalities.
What is the most likely diagnosis?
a. Duodenal ulcer disease.
b. Gastric ulcer disease.
c. Gastritis.
d. Pancreatitis.
e. Non-ulcer dyspepsia.
f. Pancreatic cancer.
E. This is often a very hard question for the average medical student. This is because of the selection bias of which cases you, as a student, see admitted to the hospital. Non-ulcer dyspepsia is, by far, the most common cause of epigastric pain and at a minimum accounts for 50% to 90% of all cases of epigastric pain. This is particularly true in patients under the age of 50.
In the hospital, you will see far more patients with ulcer disease, pancreatic disorders, or cancer because those are the ones who are admitted. Non-ulcer dyspepsia is virtually never a reason to be admitted to hospital.
What would be the most likely Dx in a Pt with epigastric pain presenting with one of the following;
- Pain worse with food
- Pain better with food
- Weight loss
- Tenderness
- Gastric ulcer
- Duodenal ulcer
- Cancer, gastric ulcer
- Pancreatitis
What would be the most likely Dx in a Pt with epigastric pain presenting with one of the following;
- Bad taste, cough, hoarse
- Diabetes, bloating
- Nothing
- Gastroesophageal reflux
- Gastroparesis
- Non-ulcer dyspepsia
Which diagnostic test would help best understand the etiology of epigastric pain from ulcer disease?
Endoscopy
What could be some of the causes of Right Upper Quadrant (RUQ) pain?
Cholecystitis
Biliary colic
Cholangitis
Perforated duodenal ulcer
What could be some of the causes of Left Upper Quadrant (LUQ) pain?
Splenic rupture
Splenic flexure syndrome
What could be some of the causes of Right Lower Quadrant (RLQ) pain?
Appendicitis
Ovarian torsion
Ectopic Pregnancy
Cecal diverticulitis
What could be some of the causes of Left Lower Quadrant (LLQ) pain?
Sigmoid volvulus
Sigmoid diverticulitis
Ovarian torsion
Ectopic Pregnancy
What could be some of the causes of Midepigastrium pain?
Pancreatitis
Aortic dissection
Peptic ulcer disease
What is the best initial empiric therapy for epigastric pain? What other medications can be used?
Proton pump inhibitors (PPIs) are always a good place to start in the therapy of epigastric pain. There is no difference in the efficacy of different PPIs. H2 blockers (ranitidine, nizatidine, cimetidine, famotidine) are not as effective, but will work in about 70% of patients. Liquid antacids have roughly the same efficacy as H2 blockers.
What clinical features will make GERD the most likely Dx?
- Epigastric burning pain
- Sore throat
- Bad taste in the mouth (metallic)
- Hoarseness
- Cough
A 42-year-old man comes to the office with several weeks of epigastric pain radiating up under his chest which becomes worse after lying flat for an hour. He also has a “brackish” taste in his mouth and a sore throat.
What is the most appropriate next step in the management of this patient?
a. Ranitidine.
b. Liquid antacid.
c. Lansoprazole.
d. Endoscopy.
e. Barium swallow.
f. 24-hour pH monitoring.
*C.
Lansoprazole is a PPI that should be used to control the symptoms of GERD. When the diagnosis is very clear (such as in this case), with epigastric pain going under the sternum, bad taste, and sore throat, confirmatory testing is not necessary. H2 blockers such as ranitidine are effective in about 70% of patients, but are clearly inferior to PPIs. Endoscopy does not diagnose GERD and is certainly not necessary when the diagnosis is so clear. Barium swallow shows major anatomic abnormalities of the esophagus and is worthless in GERD.
When is a 24-hour pH monitor indicated in GERD?
Pt with an unclear Dx
How would you Mgx GERD?
Lifestyle modifications + :
1) Mild or Intermittent Symptoms- liquid antacids or H2 blockers.
2) Persistent Symptoms or Erosive Esophagitis- PPIs
When is surgery indicated in GERD and what types of surgical interventions can be performed in GERD?
Patients who do not respond to medical therapy.
- Nissen fundoplication: wrapping the stomach around the lower esophageal sphincter
- Endocinch: using a scope to place a suture around the LES to tighten it
- Local heat or radiation of LES: causes scarring
Briefly explain how Barrett Esophagus occurs
Long-standing GERD leads to histologic changes in the lower esophagus with columnar metaplasia. Columnar metaplasia usually needs at least 5 years of reflux to develop.
How is Barrett Esophagus Dx?
Why is this diagnostic measure indispensable?
Endoscopic biopsy
This is indispensable because the biopsy drives therapy
How is Barrett Esophagus Mgx according to the biopsy findings?
1) Metaplasia- PPIs and rescope every 2–3 years
2) Low-grade
dysplasia- PPIs and rescope every 6–12 months
3) High-grade
dysplasia- Ablation with endoscopy: photodynamic therapy, radiofrequency ablation, endoscopic mucosal resection
Which clinical features and history findings will make Gastritis the most likely Dx?
Gastrointestinal bleeding without pain. Pain if severe erosive gastritis.
NSAIDs or alcoholism in the history
What on the CBC can indicate Atrophic Gastritis?
Anemia (Vitamin B12 deficiency)
How is Gastritis Dx?
Upper endoscopy
What is the next best step after Dx Gastritis?
Testing for Helicobacter pylori
When testing for H.pylori, what is(are) the main advantage(s) and disadvantage(s) of:
1) Endoscopic biopsy
2) Serology
1) Adv: The most accurate of all the tests
Dis: Requires an invasive procedure such as endoscopy
2) Adv: Inexpensive, easily excludes infection if it is negative; no complications or
procedures required
Dis: Lacks specificity; a positive test does not easily tell the difference between current and previous infection
When testing for H.pylori, what is(are) the main advantage(s) and disadvantage(s) of:
1) Urea C13 or C14 breath testing
2) H. pylori stool antigen
1) Adv: Positive only in active infection; noninvasive
Dis: Requires expensive equipment in office
2) Adv: Positive only in active infection; noninvasive
Dis: Requires stool sample
What are the indications for stress ulcer prophylaxis?
Mechanical ventilation
Burns
Head trauma
Coagulopathy
What is peptic ulcer disease (PUD)?
The term peptic ulcer disease (PUD) refers to both duodenal ulcer and gastric ulcer disease.
The name is a misnomer based on the mistaken belief that they were caused by the protein-digesting enzyme pepsin.
What are the 2 most common etiologies of peptic ulcer disease (PUD)?
PUD is most commonly caused by Helicobacter pylori. NSAIDs are the second most common cause.
NSAIDs inhibit prostaglandins and prostaglandins produce the mucus.
What is the relationship between peptic ulcer disease (PUD) and eating?
Duodenal ulcer (DU) disease is more often improved with eating, whereas gastric ulcer (GU) disease is more often worsened by eating. Hence, GU is associated with weight loss.
What are the chances of a Pt having gastric cancer in a Pt with a Gastric ulcer (GU) or Duodenal ulcer (DU)?
Cancer is present in 4% of those with GU but in none of those with DU.
What the best initial therapy for peptic ulcer disease (PUD)?
a PPI combined with clarithromycin and
amoxicillin.
Which drugs can be used in peptic ulcer disease (PUD) if the Pt does not respond to the Tx?
Metronidazole and Tetracycline can be used as alternate antibiotics. Adding Bismuth to a change of antibiotics may aid in resolution of treatment-resistant ulcers.
After how long and how can we test if the therapy has cured H. pylori in peptic ulcer disease (PUD)?
30-60days post-therapy.
Retest with stool antigen or breath test
A 56-year-old woman comes to the clinic because her symptoms of epigastric pain from an endoscopically confirmed duodenal ulcer that has not responded to several weeks of a PPI, clarithromycin, and amoxicillin.
What is the most appropriate next step in the management of this patient?
a. Refer for surgery.
b. Switch the PPI to ranitidine.
c. Abdominal CT scan.
d. Capsule endoscopy.
e. Urea breath testing.
f. Vagotomy.
g. Add sucralfate.
*E.
If there is no response to DU therapy with PPIs, clarithromycin, and amoxicillin, the first thought should be antibiotic resistance of the organism. Persistent H. pylori infection can be detected with several methods such as urea breath testing, stool antigen detection, or a repeat endoscopy for biopsy. It would be very hard to choose between these, and that is why they are not all given as choices in this question
Capsule endoscopy cannot detect H. pylori. Vagotomy and surgery were done more frequently in the past before we knew that H. pylori was the cause of most ulcers and we did not routinely eradicate it. H2 blockers and sucralfate add nothing to a PPI and have less efficacy, not more
What is the most common cause of epigastric pain?
Non-Ulcer Dyspepsia (NUD)
How is the age of the patient important when considering the next best step in a Pt you suspect to have Non-Ulcer Dyspepsia (NUD)?
If the patient is under 45 years old, treat empirically with antisecretory therapy such as PPIs and scope only if symptoms do not resolve.
For those over 55, endoscopy is definitely indicated to exclude cancer.
If “Alarm” symptoms are present (dysphagia, weight loss, anemia), scope
What features of the ulcers would make a Gastrinoma (Zollinger-Ellison Syndrome) the most likely diagnosis?
A patient with ulcers that are: Large (>1–2 cm) Recurrent after Helicobacter eradication Distal in the duodenum Multiple
Why are Gastronomas often associated with diarrhea?
Acid Inactivates lipase.
How is a Gastrinoma (Zollinger-Ellison Syndrome) Dx?
After endoscopy confirms the presence of an ulcer, the most accurate diagnostic test is:
High gastrin levels despite antisecretory therapy (PPIs or H2 blockers) with high gastric acidity.
Or, Persistent high gastrin levels despite injecting secretin
What in the chemical metabolic profile will make multiple endocrine neoplasia from
hyperparathyroidism the most likely diagnosis?
Hypercalcemia