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Clin Med 2 > Esophageal and Stomach > Flashcards

Flashcards in Esophageal and Stomach Deck (83):
1

What is the esophagus

muscular tube that connects pharynx to stomach

2

Twi sphincters of the esophagus and what they do

UES : Prevents aspiration; voluntary
LES: Prevents reflux of gastric content; less voluntary

3

Two sphincters of the stomach

Pyloric (dital; connects stomach to duodenum) and LES (gateway between esophagus and stomach

4

Fxn stomach

- Movement and release of chemicals all controlled via the autonomic nervous system
- Digest, Absorb, Store

5

Patho dysmotility disorder

DYSFUNCTION OF COORDINATED PERSITALSIS/MOTILITY PATTERN OF THE ESOPHAGUS

6

Causes dysmotility disorder

• Achalasia
• Diffuse Esophageal Spasm
• Nutcracker esophagus
• Hypertensive LES
• Scleroderma esophagus

7

What is achalasia

Failure of the LES to relax--> obstruction and proximal dilation of the esophagus

8

What is Diffuse Esophageal Spasm

uncontrolled movement of the esophagus

9

What is nutcracker esophagus

Increase in pressure in the distal esophagus

10

Hypertensive LES

relaxing LES has increase in pressure

11

Scleroderma esophagus

Smooth muscle atrophy--> replaced by fibrosis--> lack of function and tone of LES

12

Clinical dysmotility disorder

dysphagia
- progressive solid to liquid
- regurg at night and supine
- long duration of sx
Chest pain
- sudden, squeezing in the retrosternal
exacerbated by food and stress

13

DX dysmotility disorder

Barium Esophagram- birdbeak or corkscrew
Esophageal Manometry

14

Tx dysmotility disorder

Lifestyle
- eat slow, not at bed time
CCB/Nitrates
Botulism injection into LES
Pneumatic dilation
Heller Myotomy

15

Patho Esophageal strictures

NARROWING OF THE LUMEN OF THE ESOPHAGUS

16

Causes Esophageal distal strictures

Peptic- GERD
Adenocarcinoma
Collagen vascular disease (scleroderma, lupus)

17

Causes Esophageal proximal/mid strictures

- caustic ingestion
- malignancy
-radiation
- esophagitis (infectious, pill)
- Eosinophilic esophagitis

18

What is Schatzki ring?

narrowing of the esophagus due to ring of tissue

19

Clinical Esophageal stricture

• Dysphagia*- slow onset, solid to liquid
• Odynophagia
• Heartburn
• Food impaction
• Chest pain
• Chronic cough, asthma

20

Clinical Schatzki ring

• Dysphagia*- intermittent, non-progressive, solids only
• Odynophagia
• Heartburn
• Food impaction
• Chest pain
• Chronic cough, asthma

21

Dx esophageal stricture

• Barium Esophagram
• Endoscopy- can see pathology in the lumen

22

Tx esophageal stricture

Lifestyle Modifications
o Weight loss
o Avoid exacerbate food and medications
o Small meals & eat slowly and deliberately
Rx
o PPI
o Intralesion steroid injection- If PPI and/or dilation fails; Only benign lesion
EGD w/ Esophageal dilation*

23

Patho Zenker Diverticulum

PROTRUSION OF PHARYNGEAL MUCOSA. CAUSING A PHARYNGOESOPHAGEAL DIVERTICULUM

Due to loss of elasticity in UES

24

Clinical Zenker Diverticulum

halitosis, regurgitation of undigested food, gurgling in throat

25

Dx Zenker Diverticulum

barium esophagram

26

Tx Zenker Diverticulum

myotomy

27

Patho Mallory Weiss Tear

Upper GI bleed d/t longitudinal mucosal lacerations @GIJ or gastric cardia typically d/t persistent retching/vomiting (sudden rise in esophageal pressure

28

Classic ptn for Mallory Weiss Tear

pregnancy; alcoholic males

29

Clincal Mallory Weiss Tear

Hematemesis 85%
o Vomit/retch then hematemesis classic- blood streaked vomit
Melena
Hematochezia
Syncope/Assoc GI hemorrhagic hypovolemia
Guaic stool positive

30

Gold standard Mallory Weiss Tear

EGD

31

Tx Mallory Weiss Tear

Stable patient- healing in 24-48hrs without intervention
• IVF PRN
• Anti-emetics
• Sulcrafate for 1-2wks
• PPI for 1-2wks
• D/c home
Unstable Patient
• H/H q6
o pRBC for hemodynamic support PRN
o HCT <30 w/ CAD and symptoms
• Correct coagulopathy (warfarin)
o Vitamin K/FFP/PCC
• EGD
• Admit

32

Patho Boerhaave Syndrome

Transmural perforation of the esophagus

33

What is the most lethal perforation of the GI tract

Boerhaave Syndrome

34

Clinical Boerhaave Syndrome

- repeated episodes of retching and vomiting
- severe chest pain lower thorax and upper abdomen radiating to the back or left shoulder.
- Swallowing aggravates the pain
- Shortness of breath
- Mackler triad
- Neck pain, upper chest pain, epigastric pain
- rales (pleural effusion)

35

Dx Boerhaave Syndrome

Chest radiography- unilateral effusion
Esophagraphy- confirm dx

36

Tx Boerhaave Syndrome

IVF resuscitation
Broad Spectrum Antibiotics
Prompt Surgical Intervention (mainstay tx)- Left thoracotomy

37

Causes pre-hepatic esophageal varicies

- portal /splenic vein thrombosis
- portal vein stenosis

38

Causes intra-hepatic esophageal varicies

cirrhosis- alcohol or chronic hepatitis

39

Causes post-hepatic esophageal varicies

budd-chiari
extrinsic tumor compression
R. HF
IVC thrombosis

40

Clinical esophageal varicies

- Hematemesis
- melena
- hematochezia
- Pale, hypotensive, lightheaded, syncope, orthostatic, tachycardic
- Liver disease/Cirrhosis signs : jaundice, pruritus, ascites, encephalopathy/MS changes, muscle cramps, anorexia, spontaneous bleeding/easy bruising, abdominal pain, nausea/vomiting

41

Dx esophageal varicies

EGD- Every 2-3yrs to monitor enlargement
Capsule endoscopy
Ultrasound*- Screen for portal HTN
CT/MRI- When ultrasound inconclusive

42

Tx esophageal bleed

- 2 large bore IV access/Central access
- pRBC txn (target 25-30)
- Octreotide 50mcg/hr
- Desmopression 1-2 mg q 4 hours
- Endoscopy *- Varix ligation (banding)
- Band ligation*
Last resort
TIPS (transjugular intrahepatic portosystemic shunt)
Angiotherapy
Balloon tube tamponade

43

Patho esophagitis

INFLAMMATION, IRRITATION OR SWELLING OF THE ESOPHAGUS

44

Cause esophagitis

• Reflux Esophagitis (GERD)
• Infectious-HSV, Candida, CMV
• Allergic/Eosinophilic
• Pill-Esophagitis
• Radiation induced
• System Illness


45

Clinical esophagitis

- retrosternal pain
- heart burn
- odynophagia
- dysphagia
- water bursh
- globus densation
- food impaction
- laryngitis
- chronic cough
- hematemesis
- abdominal pain
- weight loss

46

MC site for pill induced esophagitis

aortic arch

47

Dx pill induced esophagitis

Clinical and EGD

48

Tx pill induced esophagitis

stop agent
take pill with 8oz water
stay upright for over 30 min after taking pill
eat in 30 min of pill
take antacids, sulcrafate, lidocaine, PPI

49

Cause pill induced esophagitis

aspirin
NSAID
tetracyclines
doxycyclines
clindamycin
bisphosphonates
**decrease pH to 3

50

Infectious esophagitis due to

Candida
HSV
CMV

51

Clinical Candida esophagitis

odynophagia
Immunocompromised ptn
Thrush

52

Dx Candida esophagitis

Clinical; EGD

53

Tx Candida esophagitis

Fluconazole

54

Isolated Eosinophilia Esophagitis has a history of

atopy, asthma, food or medicine allergies

55

Isolated Eosinophilia Esophagitis mainly occurs in

Men 20-30

56

Isolated Eosinophilia Esophagitis associated with

achalasia, GERD, crohns, connective tissue dx.

57

Dx Isolated Eosinophilia Esophagitis

Esophageal PH
EGD
PPI trial

58

Tx Isolated Eosinophilia Esophagitis

Elimination and elemental diets
PPI
Topical Glucocorticoid- Fluticasone 440-880mcg BID
Esophageal dilatation to tx strictures

59

Def GERD

CONDITION THAT DEVELOPS WHEN REFLUX OF STOMACH CONTENTS CAUSE TROUBLESOME SYMPTOMS OR COMPLICATIONS OF THE ESOPHAGUS

60

Patho GERD

Transient lower esophageal sphincter relaxation; hypotensive lower esophageal sphincter; anatomic disruption of the GE junction

61

RF GERD

• Obesity
• Pregnancy
• +/- Foods (coffee, alcohol, chocolate, fatty meals)
• +/- Tobacco/nicotine
• Zollinger-Ellison Syndrome

62

Clinical GERD

- retrosternal pain
- heart burn
- odynophagia
- dysphagia
WATER BRUSH
- globus densation
- food impaction
LARYNGITIS
- chronic cough
- hematemesis
- abdominal pain
- weight loss

63

MC complication of GERD

esophagitis
Barrets esophagus

64

DX GERD

Clinical; EGD

65

GERD classification

Grade I – erythema
Grade II – Linear non-confluent 
erosions
Grade III – Circular confluent erosions
Grade IV – Stricture or Barrett Esophagus

Symptom
Mild symptoms or Intermittent <2 episodes/week
Severe or Frequent > 2 episodes/wk and severe

66

Tx GERD

Lifestyle modifications
o Lose weight
o Avoid exacerbating foods
o Avoid large meals
o Eat 3 hours before lying down
o Elevate head of the bed
Meds
o Antacids- symptomatic
o H2RA- mild
o PPI- severe
Surgery- Nissen Fundoplication

67

GERD endoscopy screening

Patients > 50 yo age

Patients with chronic GERD symptoms >5 years
- identify Barret’s esophagus, to prevent transition to adenocarcinoma

68

GERD Surgery indications

• Desire to discontinue medical treatment
• Medication non-compliance
• Presence large hiatal hernia
• Esophagitis refractory to treatment
• Persistent symptoms

69

Patho gastritis

INFLAMMATION OF THE LINING OF THE STOMACH ASSOCIATED WITH MUCOSAL INJURY

70

Erosive v. non-erosive

Erosive- bleeding, ulceration
Non-erosive= inflammation

71

Cause gastritis

Infection - H.Pylori
Medications – NSAID #1
Alcohol
Smoking
Autoimmune: Crohn’s
Radiation therapy
Allergic/Eosinophilia

72

Complication gastritis

PUD
MALT lymphoma
Pernicious anemia

73

Clinical gastritis

- Epigastric pain
- Burning sensation
- Gnawing Sensation
- Nausea +/- vomiting
- +/- Hematemesis (BR or coffee ground)

74

Dx gastritis

Clinical Diagnosis
H. Pylori Testing- Breath, Stool, Serum
UGI series- Thick folds, inflammatory nodules, erosion
EGD

75

Tx gastritis

- H. Pylori – Triple therapy (PPI +Amoxicillin + Clarithromycin)
- D/c offending agent
- Antacids (Alka-Seltzer, Maalox, Mylanta, Rolaids)
- H2RA: cimetidine (Tagamet), famotidine (Pepcid), e.g
- PPI: omeprazole (Prilosec), lansoprazole (Prevacid), pantaprazole (Protonix

76

Patho PUD

DEFECT IN GASTRIC OR DUODENAL MUCOSA THROUGH THE MUSCULARIS MUSCOSA INTO DEEPER LAYERS OF THE WALL

77

RF PUD

H. Pylori-Produce urease
NSAIDs
Age
Hypersecretory states (rare)
Genetic Factors
Acute physiologic stress- burns, cushing dz

78

Complication PUD

GI bleed, perforation, obstuction

79

Clinical PUD

- Asymptomatic
- Epigastric pain
o Gastric – while eating
o Duodenal – hours after eating or middle of the night
- Early satiety
- Nausea +/- vomiting
- Belching, bloating, distention
- Chest pain/heartburn
- GI bleed– hematemesis, melena
- Guaic + stools
- Perforation – sudden onset of pain +/- peritoneal signs

80

Dx PUD

H. Pylori Testing Options
o EGD Biopsy w/ Rapid urease testing
o Urea breath test- best in patient with active GI bleed
Endoscopy +/- biopsy- Gold standard

81

Tx PUD

- Consider PPI – Non H.Pylori and Non-NSAID ulcer
- Advise discontinue of tobacco, minimize alcohol, avoid spicy foods

82

Consider long term PPI PUD

o Recurrent PUD
o Refractory PUD
o Continued NSAID or ASA therapy
o >50 yo age

83

Tx active bleed PUD

- IVF, Blood transfusion
- High dose IV PPI (Protonix)bolus and drip
- Endoscopic Intervention
o Epinephrine injection
o Hemoclips
o Thermal coagulation
- Surgery