Dysphagia, Odynophagia and Atypical Chest Pain Flashcards by Zach Visinoni

What is an iatrogenic cause of esophageal perforation?

What are some spontaneous causes of esophageal perforation? (3)

Trauma - NG tube, endoscopy, etc.

Retching/vomiting
History of alcohol abuse
Boerhaave’s - transmural rupture at the GEJ

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What is used to DX an esophageal perforation?

CXR with air in the mediastinum/subQ emphysema or CT chest w/ contrast

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What should be avoided diagnostically in a patient with an esophageal perforation? What is used instead?

Avoid barium swallow, as it will invade the mediastinum and cause inflammation.

Use Gastrografin (water-sol.) instead.

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What is the treatment for esophageal perforation? (4)

NPO
Parenteral ABX
Surgery
Endoscopic stenting

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What 3 findings may be found in a patient with Boerhaave’s or iatrogenic esophageal perforation?

SubQ emphysema: 30-60% of pts. Typically detected in the neck or precordial region.

Hamman’s sign: 12-50% of pts. A crunching, rasping sound synchronous with the heart beat.

Dyspnea: 30-60% of pts.

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What are the 2 most common places for PUD to occur?

What age group is more likely to develop PUD at either location?

Duodenal bulb (DU) and stomach (GU)

DU most common in pts. 30-55 y/o
GU in pts. 55-70 y/o

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What is the description given of the epigastric pain in a patient with PUD?

Gnawing, dull, aching or “hunger-like”

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What are signs of a GI bleed?

Coffee ground emesis, hematemesis, melena or hematochezia

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What is the PE like in a patient with uncomplicated PUD?

What might be elicited on exam?

Oftentimes normal.

Mild, localized epigastric tenderness to deep palpation. Possible hyperactive bowel sounds.

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What is the first step of DX PUD?

What else could be done?

EGD w/ BX (exclude malignancy in GU)

CXR/CT/MRI to eval. perforation, obstruction, etc.
NG lavage (if negative for blood, a bleeding DU cannot be excluded)

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What is the unique protocol to test for H. pylori?

How is H. pylori tested for? (5)

Must stop PPI for 14 days before fecal and breath tests.

Fecal Ag test
Detection of IgA Abs
Urea breath test
Upper endoscopy w/ gastric BX
Warthin-Starry's silver stain

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What is the overall treatment for H. pylori?

Suppress acid
D/C smoking
Treat H. pylori
D/C NSAIDs
Endoscopic intervention or surgery consult

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What are 2 major complications of PUD?

An ulcer along the posterior wall of the duodenum or stomach may perforate into structures like the pancreas, liver or biliary tree.
Bleeding, obstruction, perforation, etc. into the pancreas can cause pancreatitis.

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What occurs in nutcracker esophagus?

What is it associated with?

Hypertensive peristalsis

swallowing contractions are too powerful
greater amplitude and duration, but normal coordinated contraction (>180 mmHg)

Increased freq. of depression, anxiety and somatization

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What occurs with the LES in nutcracker esophagus vs. diffuse esophageal spasm?

Nutcracker: relaxes normally, but has elevated pressure at baseline

Diffuse esophageal spasm: LES function is normal

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What occurs in diffuse esophageal spasms?

What does it look like on barium XR?

Spastic contractions of the SM lead to uncoordinated peristalsis > “corkscrew esophagus”

“Rosary bead esophagus”

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What are primary vs. secondary causes of diffuse esophageal spasm?

Primary: idiopathic

Secondary: GERD, stress, DM, alcoholism, neuropathy, radiation, ischemia, etc. MANY things.

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What are the symptoms of both nutcracker esophagus and diffuse esophageal spasms?

Dysphagia to solids and liquids, which is intermittent and non-progressive

Atypical chest pain

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How is nutcracker esophagus vs. diffuse esophageal spasm DX?

Nutcracker: manometry, video fluoroscopy
Diffuse: manometry, EGD. barium swallow

Nitrates, Ca++ antagonists and mental health consult

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When should an EGD be done in GERD?

If there are alarm features, like weight loss, vomiting, severe pain, etc.

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Which hiatal hernia is associated with increased risk for GERD?

Sliding hiatal hernia

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Which patients are at an increased risk for sliding hiatal hernia?

Obese pts., pregnancy, etc.

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What occurs in paraesophageal hernia?

What can it lead to? (3)

Herniation into the mediastinum including a visceral structure other than the gastric cardia (usually the colon)

“Upside down stomach”
Gastric volvulus
Strangulation of the stomach

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How are hiatal hernias diagnosed?

What is the treatment?

Barium XR

None if ASX, surgery if SX

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Globus pharyngeus =

The sensation of a lump lodged in the throat, with swallowing unaffected

What diagnostics should be considered in the following causes of dysphagia/odynophagia: Oropharyngeal Esophageal Motor cause

Oropharyngeal - video fluoroscopy of swallowing Esophageal - barium swallow or esophagogastroscopy w/ BX Motor cause - barium swallow or manometry

Where does food "stick" in oropharyngeal dysphagia? Patients may have... If it occurs with solid only, what are likely causes?

Level of the suprasternal notch NG regurg or aspiration Structural causes - cancer or congenital/acquired webs

Esophageal webs mainly cause what kind of dysphagia? Where does it occur within the esophagus? It can be congenital or acquired. What are 2 acquired causes? What are the symptoms like?

Mainly esophageal dysphagia, but if proximal, it can be oropharyngeal Proximal or mid esophagus Eosinophilic esophagitis or Plummer Vinson syndrome SX are intermittent and not progressive

What is used to DX esophageal webs? What is the treatment?

Barium swallow Dilation (bougie dilator) Can give PPI if there is associated reflux

Plummer-Vinson syndrome is most common in which patients? What are some features of it?

Middle-aged women ``` Esophageal webs (symptomatic and proximal), angular chelitis, glossitis, Koilonychia (spoon nails) Iron-deficiency anemia (weakness and fatigue) ```

Who is more likely to have a Zenker diverticulum? What occurs to the UES? Where does it occur mostly?

Older males Loss of elasticity of the UES Killian's triangle (near cricopharyngeus m.)

How is a Zenker diverticulum DX? What is the treatment?

Video esophagography Surgery - upper myotomy or surgical diverticulectomy

What kind of dysphagia is associated with Sjogren's? What are some other SX?

Oropharyngeal dysphagia Dryness everywhere, candida, dental caries, parotid enlargement

What is a strong association with Sjogren's? What patients are most likely to develop it? What is the DX and TX?

B cell non-Hodgkin lymphoma F>M, mid 50s, post-menopausal DX: lip BX, serology TX: supportive

Where does food "stick" in esophageal dysphagia? Patients may have...

Mid to lower sternal area May have regurg, aspiration or odynophagia

Which antibodies are seen in diffuse vs. limited Scleroderma? What ANA pattern is seen?

Diffuse - topoisomerase I Abs (Scl-70) Limited - Anti-centromere Abs Speckled or centromere

Diffuse scleroderma has involvement of... There is early and progressive involvement of... How aggressive is it?

Diffuse involvement including the proximal extremities and trunk Internal organ involvement Very aggressive - worse prognosis

Limited scleroderma includes which symptoms?

CREST syndrome - calcinosis, Raynaud's, esophageal dysmotility, sclerodactyly, telangiectasia Better prognosis

Which patients are at a higher risk for Scleroderma? What are the 3 hallmarks?

30-60 y/o; F>M Atrophy of the esophageal SM Fibrosis of the skin and viscera, leading to aperistaltic esophagus (thickening and hardening of the tissue) Microangiopathy

2 major complications of GERD include:

Esophageal stricture | Barrett's esophagus

Esophageal stricture causes what? Where are they most commonly located? What type is most common?

Esophageal dysphagia GEJ Peptic secondary to GERD, but possibly from eosinophilic esophagitis

What is the onset and progression of esophageal strictures? What happens to GERD SX?

Gradual onset and progressive, with improving GERD SX as it progresses (stricture acts as a barrier to reflux).

What diagnostics should be done in esophageal strictures?

Barium swallow *EGD w/ BX is mandatory to differentiate peptic strictures from stricture from esophageal carcinoma

What is the treatment for an esophageal stricture? (2) What if it is a refractory stricture?

Dilation at time of EGD Long-term PPI use Steroid injection if refractory stricture

Patients with the greatest risk for Barrett's esophagus are:

Obese white males over 50 who smoke

What will be seen on BX in a patient with Barrett's? How often do they need surveillance endoscopies? What is the treatment? (2)

Goblet and columnar cells Every 3-5 years PPI, or endoscopic ablation for patients with high-grade dysplasia or intramucosal adenocarcinoma

SCC of the esophagus is most common in which patients? What are some risk factors? Where does it occur in the esophagus? What is used for DX? What is the treatment?

M>F; AA>Caucasions Smoking/EtOH Chemical or thermal injuries Esophageal disorders 50% in mid esophagus EGD w/ BX Esophagectomy

Adenocarcinoma of the esophagus is most common in which patients? Where does it occur in the esophagus? What is the precursor lesion? What is used for DX? TX?

M>F; Caucasion>AA Distal 1/3 of esophagus Barrett's > dysplasia > adenocarcinoma EGD w/ BX Endoscopic ablation

What is an association with a Schatzki ring? What are the SX like? How old are patients with it? DX? TX?

Hiatal hernia Intermittent and non-progressive >40 y/o Barium swallow Dilation, can use PPI also

What is Steakhouse Syndrome?

AKA Schatzki ring - large poorly chewed food bolus is the instigator - food may pass on its own with drinking extra fluid

What kind of dysphagia occurs in achalasia? It is a ____ disorder. Is it progressive? What is the problem? (2)

Esophageal dysphagia Motor disorder and is progressive (worsening) Loss of peristalsis (distal 2/3) and failure of deglutitive LES relaxation Denervation of the esophagus due to loss of NO-producing inhibitory neurons of the myenteric plexus

What is the primary vs. secondary cause of achalasia?

Primary - idiopathic, loss of ganglion cells in myenteric plexus Secondary - Chagas disease

What is a unique sign in secondary achalasia?

Painless swelling around the eye - Romana sign

What is the treatment for achalasia? What suggests a DX? What test confirms the DX?

Reduce LES pressure - nitrates, CCB, botox Ballooning Surgery Suggests: "bird's beak" on barium esophagogram Confrims: Esophageal manometry - complete absence of normal peristalsis and incomplete LES relaxation w/ swallowing

3 classic findings on manometry in achalasia

Incomplete LES relaxation Increased LES tone/elevated esophageal resting pressure Loss of peristalsis

4 major types of esophagitis

Pill Infectious (candida/HSV/CMV) Eosinophilic Caustic - accident or suicide attempt

Patients with eosinophilic esophagitis present with what >50% of the time? What is another common history? Who gets it most?

Allergies or atopic condition History of food bolus impaction M>F

What is a major concerning complication of eosinophilic esophagitis? How is it diagnosed?

Esophageal perforation EGD - multiple esophageal rings creating a corrugated appearance. "Feline esophagus".

What are the symptoms of eosinophilic esophagitis in adults vs. kids?

Adults: dysphagia, pyrosis, poor med response, regurg of food, eosinophilia Kids: vomiting, feeding problems, dysphagia, failure to thrive, eosinophilia

What is a common presentation in a patient with a food bolus obstruction?

Hypersalivation

Dysphagia, Odynophagia and Atypical Chest Pain Flashcards

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