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Ahmed GI Sadness 1 > Dysphagia, Odynophagia, Atypical Chest Pain > Flashcards

Dysphagia, Odynophagia, Atypical Chest Pain Flashcards

1
Q

Close to one third of pts with chest pain have what as the source?

A

esophagus

Atypical chest pain = not angina

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2
Q

What part of hx and PE can be used to distinguish CV vs. GI chest pain source?

A

none - they cannot make a distinction

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3
Q

What are potentially life threatening GI causes of chest pain?

A

a. Boerhaave Syndrome/Iatrogenic esophageal perforation
b. Peptic ulcer disease

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4
Q

What is Boerhaave Syndrome?

A
  • transmural tear of the distal esophagus induced by a sudden increase in pressure
  • classic triad*: vomiting, abdominal or chest pain, and subcutaneous emphysema

*absent in many patients

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5
Q

What are iatrogenic causes of esophageal perforation? spontaneous?

A

a. trauma: nasogastric tube, endoscopy…
b. forceful retching/vomiting, hx of alcohol use, Boerhaave’s

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6
Q

How do you dx an esophageal rupture?

A
  1. CXR - air in mediastinum/subQ emphysema

or

  1. CT chest with contrast (gastrografin contrast - do not use barium bc it can cause inflammation of mediastinum)
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7
Q

How do you treat an esophageal rupture?

A

a. NPO
b. Parenteral ABs
c. Surgery
d. Endoscopic stenting

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8
Q

What is Hamman’s sign?

A
  • crunching, rasping sound
  • synchronous with heartbeat
  • heard over precordium mainly during systole
  • best heard in left lateral decubitus position
  • often associated with muffled heart sounds
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9
Q

PUD ulcers extend through what layer?

A

muscularis mucosae

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10
Q

What age group typically gets PUD?

A

most commonly:

30-55 - duodenal ulcer

55-70 - gastric ulcer

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11
Q

What are the key sx of PUD?

A
  • gnawing, dull, aching, hunger like pain
  • periodicity (sx for weeks; fine for months)
  • signs of GI bleeds
  • mild, localized epigastric tenderness to deep palpation may be present on PE
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12
Q

How do you dx PUD?

A
  • EGD with biopsy, CXR, nasogastric lavage, CBC
  • Detection of H. Pylori
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13
Q

What is a key step in H. Pylori detection?

A
  • Stop PPIs 14 days before fecal and breath tests
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14
Q

What does it mean if fluid is negative for blood in nasogastric lavage?

A

you still cannot rule out active bleeding from a DU

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15
Q

What is unique about GU tx?

A

need to exclude malignancy

*DUs are almost never malignant

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16
Q

For tx of DU/GU, dietary restriction is …?

A

unnecessary

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17
Q

Compare and Contrast: Nutcracker Esophagus and Diffuse Esophageal Spasm

a. Define/etiology/association
b. LES
c. Sx
d. Dysphagia
e. Dx/Tx

A
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18
Q

What is a serious complication of GERD?

A

laryngopharyngeal reflux

esophagitis

stricture

Barrett’s esophagus –> Adenocarcinoma

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19
Q

With GERD, when should you do an EGD?

A

When alarm features are present

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20
Q

What is a sliding hiatal hernia?

A
  • due to increased intraabdominal pressure
  • abdominal obesity, pregnancy, hereditary
  • propensity of affected individuals to have GERD
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21
Q

What is a paraesophageal hernia?

A
  • Herniation into the mediastinum includes a visceral structure other than the gastric cardia (most commonly the colon)
  • Can lead to: “upside down stomach,” gastric volvulus, strangulation of the stomach
  • on PE, can hear bowel sounds in lung fields
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22
Q

How do we dx and tx hiatal hernias?

A

a. Dx: barium x-ray
b. asx: nothing; sx: surgery

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23
Q

If a pt cannot swallow liquids (including their own saliva), think:

A

Foreign bodies/food impaction

risk factors: schatzki ring, peptic stricture, webs, esophagitis, achalasia, cancer

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24
Q

The sensation of a lump lodged in the throat, but with swallowing unaffected, is called?

A

Globus Pharyngeus

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25
Q

Flow chart: Approach to pt with Dysphagia

A
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26
Q

With oropharyngeal dysphagia, where does food stick?

A

level of suprasternal notch

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27
Q

When can an esophogeal web cause oropharyngeal dysphagia?

A

if it is proximal

*typically causes esophageal dysphagia

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28
Q

What is the problem in esophageal dysphagia?

A
  • structural problem: thin, diaphragm like membranes of squamous mucosa
  • congenital or acquired
  • acquired: eosinophilic esophagitis, Plummer Vision Syndrome
  • sx are intermittent (not progressive)
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29
Q

What is Plummer Vinson Syndrome?

A
  • rare disease characterized by:

angular chelitis

glossitis

symptomatic proximal esophageal webs

koilonychia

iron-deficiency anemia (weakness and fatigue)

  • consider middle aged women
30
Q

What are the sx of a Zenker’s Diverticulum?

A
  • Halitosis
  • Spontaneous regurgitation
  • Nocturnal Choking
  • Gurgling in the throat
  • Protrusion in the neck
  • Voice changes
  • Weight loss
  • Aspiration (–> pneumonia/lung abscess)
31
Q

What is the problem in Zenker’s?

A
  • False diverticula involving herniation of the mucosa and submucosa through the muscular layer of the esophagus posteriorly between the cricopharyngeus muscle and the inferior pharyngeal constrictor muscles (at pharyngoesophageal junction)
  • Loss of elasticity of UES
  • Occurs in Killian’s triangle
32
Q

How do you dx Zenker’s?

A
  • video esophagography or Barium swallow

*due before EGD due to risk of perforation

33
Q

What are the sx of Sjogren’s?

A
  • Dry eyes, dry mouth –> oropharyngeal dysphagia
  • Vaginal dryness, tracheo-bronchial dryness
  • Increased incidence of oral infection (candida)
  • Dental caries
  • Parotid/major salivary gland enlargement
  • Keratoconjunctivitis sicca (foreign body sensation)

*Strong association with B cell non-Hodgkin lymphoma

34
Q

How do you dx Sjogren’s? tx?

A
  • dx: lip biopsy, serology
  • Tx: supportive

* F>M, mid 50s, post-menopausal

35
Q

Describe Diffuse Scleroderma

A
  • Topoisomerase I antibodies (Scle-70)
  • involves proximal extremities and trunk
  • early and progressive internal organ involvment
  • worse prognosis
36
Q

Describe Limited Scleroderma

A
  • anti-centromere ABs
  • fingers, toes, face, distal extremities
  • Raynaud’s commonly precedes other sx
  • CREST Syndrome
    • Calcinosis cutis
    • Raynaud’s (20)
    • Esophageal dysmotility !!!
    • Sclerodactyly
    • Telangiectasia
  • Good prognosis
37
Q

What is the hallmark of Scleroderma?

A
  • atrophy of esophageal smooth m.
  • fibrosis of skin and visceral organs —> aperistalic esophagus
  • microangiopathy
  • progressive
38
Q

What are causes of esophagitis due to truly refractory reflux?

A
  • Gastrinoma with gastric acid hypersecretion (Zollinger-Ellison Syndrome)
  • Pill-induced esophagitis
  • Resistance to PPIs
  • Medical noncompliance
39
Q

What is the most common cause of reflux esophagitis?

A

GERD

40
Q

For esophageal strictures, are sx progressive or intermittent? What is unique about heartburn/reflux?

A

a. progressive
b. lessens/improves because stricture acts as a barrier

41
Q

What is mandatory in all cases of esophageal stricture dx? tx?

A

a. EGD - differentiates b/t peptic stricture from stricture by esophageal carcinoma

*barium swallow might be helpful

b. dilation at time of EGD, long term PPIs, endoscopic steroid injection

*operative management is rarely used

42
Q

What is the tissue switch in Barrett’s Esophagus?

A

normal stratified squamous mucosa of distal esophagus —> specialized intestinal (metaplastic) columnar metaplasia

*risk factors: GERD, truncal obesity ==> obese WMs >50 who smoke

pathoma: NKSS –> nonciliated columnar with goblet cells

43
Q

What are the risk factors for adenocarcinoma?

A
  • chronic GERD
  • male
  • white
  • obese
  • hiatal hernia
  • age 50+
44
Q

What do we see on biopsy of Barrett’s Esophagus?

A

goblet and columnar cells

45
Q

What are tx options for Barrett’s Esophagus?

A
  1. PPI
  2. Endoscopic ablation
  3. Surgical resection has high risk of morbidity and mortality —> NOT recommended
46
Q

What do you know about Squamous Cell Carcinoma of the Esophagus?

A
47
Q

What do you know about adenocarcinoma of the esophagus?

A
48
Q

What is the problem with an esophageal ring (schatzki)?

A
  • structural problem: smooth, circumferential, thin mucosal structures, distal
  • Intermittent sx, not progressive

*associated with hiatal hernia

49
Q

What is another name for esophageal ring?

A

“Steakhouse Syndrome”

= typically instigated by large, poorly chewed food bolus

50
Q

How do we get rid of a food bolus?

A
  • may pass on own with drinking extra liquids after regurgitation
  • if impacted —> extracted endoscopically
51
Q

How do we dx and tx esophageal rings?

A
  1. Dx: barium swallow (esophagogram)
  2. Tx: dilation (bougie dilator) or small endoscopic electrosurgical incision; PPIs for heartburn
52
Q

What is the problem in Achalasia?

A
  • propulsion problem
  • Loss of peristalsis (distal 2/3) and failure of deglutitive LES relaxation
  • denervation of the esophagus resulting primarily from loss of nitric oxide-producing inhibitory neurons (ganglion cells) in the myenteric plexus
53
Q

What are the two types of Achalasia?

A
  1. Primary (Idiopathic)
    1. loss of ganglion cells within the esophageal myenteric plexus
  2. Secondary causes (Chagas’ disease or other)
    1. Chagas’ disease (think Mexico, SE US…)
    2. Other secondary causes: lymphoma, carcinoma, chronic idiopathic intestinal pseudoobstruction, ischemia, neurotropic viruses, drugs, toxins, radiation therapy, postvagotomy
54
Q

What is Chaga’s Disease?

A
  • esophageal dysfunction that is indistinguishable from primary, idiopathic achalasia
  • should be considered in patients from endemic regions
  • reduviid bug that transmits the protozoan, Trypanosoma cruzi
  • chronic phase of the disease develops years after infection, and results from destruction of autonomic ganglion cells throughout the body including the heart, gut, urinary tract, and respiratory tract
55
Q

What causes “pseudoachalasia”?

A

Primary or metastatic tumors that invade the gastroesophageal junction

56
Q

What is Romana sign and when do we see it? Bird’s peak?

A

a. painless periorbital swelling; Achalasia
b. narrowing of distal esophagus; Achalasia

57
Q

Why is esophageal manometry useful in achalasia?

A

confirms diagnosis - complete absence of normal peristalsis and incomplete LES relaxation with swallowing

58
Q

Dx?

A

bird beak esophagus - Achalasia

59
Q

What are the manometry findings in achalasia?

A
60
Q

How do you distinguish between schatzki or web?

A

schatzki = distal

web = mid to proximal

61
Q

What pills most commonly cause pill induced esophagitis?

A
  1. NSAIDs
  2. potassium chloride pills
  3. alendronate, risedronate (both for osteoporosis)
  4. iron
  5. antibiotics

*most likely to occur if pills are swallowed without water or while supine

62
Q

What sx imply pill induced esophagitis?

A
  • severe retrosternal chest pain
  • odynophagia
  • dysphagia

*begin several hours after taking a pill; can occur suddenly and persist for days

63
Q

Dx, complications, tx, and prevention of pill induced esophagitis

A
64
Q

What organisms most commonly cause infectious esophagitis?

A
  • Candida albicans
  • herpes simplex
  • CMV
65
Q

What are the sx of infectious esophagitis?

A

odynophagia

dysphagia

substernal chest pain

66
Q

what are the risk factors of infectious esophagitis?

A
67
Q

what is the significance of eotaxin 3?

A

eosinophil chemokine implicated in etiology of eosiniphilic esophagitis

68
Q

what is a way to distinguish GERD from eosiniphilic esophagitis?

A

eosiniphilic esophagitis will have more eosinophils

69
Q

eosiniphilic esophagitis: adults vs. children

A
70
Q

Caustic Esophageal Injury: RFs, Sx, Dx, Complications, Tx

A
71
Q

what are the risk factors for foreign bodies/food impaction?

A
  • Schatzki ring
  • peptic stricture
  • webs
  • esophagitis (Eosinophilic!)
  • achalasia
  • cancer
72
Q

What are sx of a foreign body/food impaction?

A

severe chest pain

chest pressure

dysphagia

odynophagia

sensation of choking

neck or throat pain

Ahmed GI Sadness 1 (25 decks)

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