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GI 2 > Approach to GI Patient Atypical Chest pain & Odynophagia McGowan > Flashcards

Approach to GI Patient Atypical Chest pain & Odynophagia McGowan Flashcards

1
Q

What are the life threatening GI causes of chest pain?

A
  • Boerhaave Syndrome
  • Iatrogenic Esophageal Perforation
  • Peptic Ulcer Disease (PUD)
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2
Q

What are the life threatening non-GI causes of chest pain?

A
  • Myocardial infarction
  • Pulmonary Embolism
  • Aortic Dissection
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3
Q

What are the non life threatening GI causes of atypical chest pain?

A
  • GERD
  • Hiatal Hernia
    • Esophageal Dysmotility
  • Nutcracker Esophagus
  • Diffuse Esophageal Spasm (DES)
  • Eosinophilic Esophagitis
  • Esophageal Impaction
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4
Q

What are the iatrogenic and spontaneous causes of esophageal perforation?

A

Iatrogenic:

  • Trauma such as nasogastric tube or endoscopy

Spontaneous:

  • Forceful vomiting
  • Hx of EtOH abuse
  • Boerhaave’s
    • transmural rupture at gastroesophageal junction
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5
Q

What does a HPI and PE look like for a patient with Esophageal perforation?

A

HPI:

  • Patient is in distress
  • Pleuritic/retrosternal chest pain

PE:

  • Subcutaneous emphysema
    • air in tissue usually in neck or precordial area
  • Hamman’s Sign: auscultation: crunching rasping sound heard simultaneously with the heart beat. Particularly over precordium during systole and in left lateral decubitus position
  • Dyspnea
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6
Q

How do you diagnose and treat Esophageal perforation?

A

Diagnose:

  • CXR or CT of chesst
  • Looking for pneumomediastinum or subcutaneous emphysema

Tx:

  • stabilize
  • NPO
  • Parenteral abx
  • Surgery
  • Endoscoping stenting
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7
Q

What causes PUD?

A
  • H. pylori
  • NSAIDS
  • Zollinger Ellison syndrome

exacerbated by stress/anxiety, coffee, alcohol

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8
Q

What will the HPI and PE of a person with PUD look like?

A

HPI:

  • gnawing, dull aching or “hunger like” epigastric pain
  • atypical chest pain
  • symptomatic periods with pain free intervals
  • Coffee ground emesis, hematemesis, melena, or hematochezia

PE:

  • Often normal in uncomplicated PUD
  • Milkd, localized epigastric tenderness to deep palpation
  • Hyperactive bowel sounds
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9
Q

Complications of PUD?

A
  • Bleeding due to erosion into left gastric artery or gastroduodenal artery
  • Obstruction from edema
  • Perforation presenting as referred shoulder pain, pneumoperitoneum
  • Gastric adenocarcinoma or MALT lymphoma
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10
Q

What tools are used to diagnose PUD? What are we excluding?

A

Diagnose:

  • EGD with biopsy
    • exclude malignancy in GU
  • BUN/Creatine
    • UGIB has increased BUN
  • Hbg/Hct look for anemia
  • Barium XR
  • Nasogastric lavage considered
    • if fluid is negative for blood it doesn’t exclude active bleeding from duodenal ulcer
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11
Q

What are the alarm features of reflux esophagitis secondary to GERD? What further follow up is needed with these sx?

A
  • constant &/or severe pain
  • Dysphagia/odynophagia
  • unexplained weight loss
  • Persistent vomiting
  • Palpable mass or adenopathy
  • Hematemesis
  • MElena
  • Anemia

Need Endoscopy, radiographic Abd imaging and surgical eval

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12
Q

What is the etiology of Reflux esophagitis secondary to GERD? What are the risk factors?

A
  • Motility DO: ineffective esophageal motility
  • Lower esophageal sphincter allowing stomach acid to reflux

Risks:

  • increased abdomen girth/obesity
  • Pregnancy
  • Hiatal hernia
  • Zollinger Ellison syndrome
  • Scleroderma
  • Fat rich diet/caffiene/alcohol/smoking
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13
Q

Complications of GERD?

A
  • Barrets esophagus
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14
Q

Etiology of a hiatal hernia?

A
  • Herniation of stomach into mediastinum through esophageal hiatus of diaphragm
  • Can be sliding
    • Result of increased intraabdominal pressure from abdominal obesity pregnancy and heredity
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15
Q

Hiatal hernia presents with pain in what region?

A

Atypical cause of chest pain

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16
Q

How do you diagnose and treat a hiatal hernia?

A
  • Barium swallow XR
  • surgical repair if having symptoms
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17
Q

What is the cause of the esophageal dysmoltility disorder nutceracker esophagus?

A
  • Hypertesive peristalsis
  • swallowing contractions are too powerful- they are increased in ampitude and duration
  • Lower esophageal sphinter relaxes normal, but has elevated pressure at the baseline
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18
Q

What will a HPI and PE look like for a person with Nutcracker esophagus?

A

HPI and PE

  • Atypical chests pain
  • Dysphagia to solids and liquids
  • Intermittent not progressive
  • Assoc with increased frequency of depression, anxiety, and somatization
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19
Q

How do you diagnose and treat nutcracker esophagus?

A
  • EDG
  • Nitrates such as isosorbide dinatrate
  • Calcium antagonists such as nifedipine
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20
Q

What is the etiology of the esophageal dysmotility disorder Diffuse Esophageal Spasm (DES)?

A
  • Multiple spastic contractions of the esophagus’s circular muscles
  • Functional imbalance between excitatory and inhibitory post ganglionic paths
  • Disrupts peristalsis
    • long duration and recurrent uncoordinated esophageal contractions
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21
Q

What will HPI and PE look like for patient with DES?

A

same as nutcracker esophagus

HPI and PE

  • Atypical chests pain
  • Dysphagia to solids and liquids
  • Intermittent not progressive
  • Assoc with increased frequency of depression, anxiety, and somatization
22
Q

How do you diagnose and treat DES?

A
  • Manometry- goldstandard uncoordinated peristalsis
  • EGD used to exclude mechanical and inflammatory lesions
  • Barium swallow XR
    • ​Corckscrew esophagus or rosary bead esophagus
23
Q

How to treat DES?

A
  • Nitrates such as isosorbide dinatrate
  • Calcium antagonists such as nifedipine
24
Q

Eosinophilic esophagitis (EOE) etiology and who does it affect more?

A
  • Males>females
  • Unknown etiology
25
Q

Complicatiosn of EOE?

A
  • Food impaction
  • Esophageal perforation
  • Narrow caliber esophagus
  • Esophageal stricture
26
Q

Treatment of EOE?

A
  • PPI
  • Swallow inhaled glucocorticoids
  • Allergist referral
  • Empiric elimination of common food allergens
  • Esophageal dilation is effect at relieving dysphagia
    • _​_risk of deep esophageal mural laceration or perforation
27
Q

In adults with EOE, what will a HPI and PMH look like ?

A
  • Dysphagia
  • Pyrosis
  • Regurgitation of undigested food

PMH:

  • Allergies or atopic conditions in >50% patients
  • Hx of food bolus impaction
28
Q

In kids with EOE, what will a HPI and PMH look like ?

A
  • Vomit
  • Difficulty feeding
  • Dysphagia
  • Failure to thrive

PMH:

same as adults

  • Allergies or atopic conditions
  • Hx of food bolus impaction
29
Q

What is the diagnostic feature of EOE on EGD and CBC?

A
  • multiple circular esophgeal rings creating a corrugated appearance
    • ​”feline esophagus”
    • looks like trachea
  • CBC shows eosinophillia
30
Q

What can cause esophageal impaction?

A
  • Eosinophilic Esophagitis
  • Achalasia
  • Cancer
  • Peptic stricture
  • Schatzki ring
  • Accidental swallowing foreign body
31
Q

what does HPI for esophageal impaction look like?

A
  • Hypersalivation: inablity to swallow liquids including own saliva
  • Severe chest pain
  • Dysphagia
  • Odynophagia
  • Sensation of choking
  • Neck/throat pain
  • retching and emesis
32
Q

How do you diagnose and treat an impacted esophagus?

A
  • Diagnose with an emergent EGD
  • Tx endoscopically by removing the bolus/object, or push it though lower esophgeal sphincter
  • Surgery
  • Possibility it passes spontaneously
33
Q

Complications of an impacted esophagus?

A
  • Perforation
  • Ulceration
34
Q

What are the three types of esophagitis that can cause Odynophagia and atypical chest pain?

A
  1. Pill Induced Esophagitis
  2. Infectious Esophagitis
  3. Caustic Esophagitis
35
Q

Etiology of pill induced esophagitis?

A
  • Most common medications:
    • NSAIDS
    • potassium chloride
    • Abx
    • Bisphosphonates for osteoperosis
    • Iron
  • Most likely to occur if pills are swallowed without water or while supine
36
Q

HPI of patient with pill induced esophagitis?

A
  • Severe retrosternal chest pain
  • Odynophagia
  • Dysphagia
  • may occur several hours after taking a pill
  • May occur suddently and last days
  • elderly patients may have little pain and present with dysphagia
37
Q

Complications of pill induced esophagitis?

A
  • Severe esophagitis with stricture
  • Hemorrhage
  • Perforation
38
Q

Etiology of infectious esophagitis?

A
  • Candidia albicans
  • HSV
  • CMV
  • HIV
39
Q

HPI of infectious esophagitis?

A
  • Odynophagia
  • Fever (?)
  • Dysphagia
  • Substernal chest pain
  • sometimes asx
40
Q

How do you diagnose CMV, HSV, and Candida infectious esophagitis?

A

CMV:

  • EGD: shows one to several large shallow superficial ulcerations
  • biopsy has inclusion bodies

HSV:

  • EGD: shows multiple small deep ulceration
  • oral ulcers may be present as well

Candida:

  • EGD: diffuse linear yellow-white plaques adherent to mucosa
41
Q

How do you treat infectious esophagitis due to CMV?

A

Gancyclovir

42
Q

How do you treat infectious esophagitis due to HSV

A

Oral or IV acyclovir

43
Q

How do you treat infectious esophagitis due to candida?

A

Systemic therapy such as fluconazole

44
Q

how do you prevent and manage pill induced esophagitis?

A
  • Manage by stopping the medication or switching to liquid/parenteral form
  • Healing will occur quickly when offending agent is eliminated
  • Consider adding a PPI

Prevent by taking pills with a 4-8 oz galss of water and stay sitting upright for 30 minutes

45
Q

what is the etiology of caustic esophagitis?

A
  • Ingestine of liquid or crysalline alkali such as drain cleaners or acid
  • usually accidental in children
  • Deliberate with intentions of suicide
46
Q

HPI with caustic esophagitis?

A
  • odynophagia
  • Severe burning
  • Varying degrees of chest pain
  • oral burns and drooling
  • hematemesis
  • Oropharyngeal lesions
47
Q

How do you diagnose caustic esophagitis?

A
  • Laryngoscopy
  • Chest and abdominal radiographs to look for pneumonitis or free air
  • assess circulatory status
48
Q

What do you do to treat patient with caustic esophagitis?

A
  • Stabilize them
  • Hospitalized in ICU
  • Monitor for signs of deterioration in which emergency surgery is called for
  • EGD is performed within 12-24 hrs to assess injury extent
  • Laryngoscopy for patiets in respiratory distress to asses for a Tracheostomy
49
Q

What should NOT be done for a patient with caustic esophagitis?

A
  • Nasogastric lavage
  • Oralantidotes
  • Oral corticosteriords
  • Oral abx

basically anything oral shouldn’t be done

50
Q

Complications of Caustic esophagitis?

A
  • Perforation
  • Bleeding
  • Esophageal tracheal fistulas
  • Long term:
    • Esophageal strictures

GI 2 (19 decks)

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