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Clin Med III > Esophagus > Flashcards

Esophagus Flashcards

1
Q

why should you do an EGD with refractory GERD or GERD with concerning symptoms?

A

43% have Barrett’s Esophagitis and/or esophagitis

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2
Q

what is physiological reflux

A

degree of reflux that does not induce symptoms or esophageal mucosal abnormalities

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3
Q

pathophys of GERD

A

LES transiently relaxes allowing back flow of stomach contents

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4
Q

Montreal classification of GERD

A

condition that develops when the reflux of stomach contents cause troublesome symptoms or complications

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5
Q

what is hallmark symptom in GERD

A

heartburn (pyrosis)

usually post-prandial

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6
Q

what do we need to rule out if chest pain is present

A

cardiac cause

squeezing, substernal, radiates to back, neck, jaws, or arms – this is how chest pain can present

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7
Q

with what GERD system should you consider laryngoscopy?

A

hoarseness/laryngitis

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8
Q

what must we rule out of dysphagia is present

A

stricture

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9
Q

odynophagia versus dysphagia

A

painful swallowing versus difficulty swallowing

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10
Q

6 things that may worsen GERD

A

obesity

gravity

preg

tobacco/ETOHz

meds

foods

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11
Q

what medications decrease LES pressure and may increases GERD sxs

A

anticholinergics

TCAs

Ca++ channel blockers

nitrates

narcotics

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12
Q

what medications may injure the mucosa and increase GERD sxs?

A

bisphosphonates

iron supplements

NSAIDS/Aspirin

Potassium

Tetracycline

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13
Q

what part of the stomach does hiatal hernia effect

A

portion of the stomach enters above the diaphragm into the chest

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14
Q

most common type of hiatal hernia

A

sliding

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15
Q

other type of hiatal hernia (not most common)

A

paraesophageal hernia

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16
Q

which hernia may require surgical repair

A

paraesophageal

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17
Q

clinical presentation of hiatal hernia

A

usually asymptomatic and incidental finding

can cause GERD - heartburn, cough, hoarseness, CP
** tx similarly to GERD

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18
Q

hiatal hernia may be seen as a retrocardiac mass with or without what

A

air fluid level

without air fluid level - it is tough to dx based on xray alone

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19
Q

what dx test?

hiatal hernia and strictures are seen BUT mucosal inflammation are NOT seen

A

barium contrast esophagram

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20
Q

best diagnostic study to evaluate mucosal injruy

A

EGD - do it for Barrett’s esophagus

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21
Q

what dx test is used to observe bolus transit (complete or incomplete)

A

esophageal impedance testing

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22
Q

what dx test is used to QUANTIFY reflux and allows pt to log sxs

has a high sensitivity for detecting reflux

A

esophageal pH monitoring

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23
Q

what dx test?

measures the function of the LES and peristalsis

pressure and pattern of esophageal muscle contractions

A

esophageal manometry

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24
Q

can you used barium swallow for GERD

A

nope

does not show mucosal injury

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25
Q

does barium contrast show mucosal injury

A

no

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26
Q

two options for esophageal pH monitoring

A

transnasal catheter

wireless capsule option

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27
Q

if a pt comes in with typical GERD symptoms, infrequent medication use to tx symptoms, no chest pain, no dysphagia, do you need labs or dx?

A

NO

try tx first then if those don’t work or red flags happen, re-eval

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28
Q

7 (!!!) red flags on physical exam or in history that REQUIRE further workup

A

dysphagia (could be complication or could just be a symptom of GERD)

hematemesis/GI bleed

unexplained weight loss, fever, fatigue

anemia

inadequate response to tx

prior anti-reflux surgery

personal hx of cancer

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29
Q

3 broad options for GERD tx

A

lifestyle and dietary modifications

meds

anti-reflux surgery

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30
Q

what lifestyle mods can help tx GERD

A

adjustment of bed

no food or drink within 3 hours of bedtime

weight loss

selective elimination of dietary triggers

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31
Q

what 3 broad types of meds used to tx GERD

A

Antacids (TUMS)

H2 blockers (Zantac, Ranitidine)

PPI (Prilosex, Prevacid, Nexium)

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32
Q

step down or step up therapy needed??

less than 1-2 episodes/week

no evidence of erosive esophagitis

A

step up therapy: lifestyle meds, H2RAs, +/- antacids

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33
Q

step up or step down therapy needed?

2+ episodes of reflux/week + sxs impair quality of life

A

step down therapy:

PPI daily for 8 weeks + lifestyle mods

gradually decrease therapy unless maintenance PPI tx is needed

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34
Q

what meds am i describing

do not prevent GERD

neutralizes gastric pH

short lived

A

antacids (TUMS)

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35
Q

what med am i describing?

block action of histamine at gastric parietal cells

decrease secretion of stomach acid

A

ranitidine (Zantac), Famotidine (Pepcid)

H2 blockers/antagonists

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36
Q

what med am i describing?

reduce amount of acid produced by glands in stomach

MUST take 30 min before 1st meal of the day

A

PPI - Omeprazole, Lansoprazole, Esomeprazole, Pantoprazole

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37
Q

what medication puts pt at risk for increased risk of infection

A

PPIs

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38
Q

why do PPIs increase infection risk

A

acidic environment is protective; decreasing acid can increase risk of C.Diff without antibiotic use + other infections

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39
Q

what GERD med is associated with risk of malabsorption (spec of magnesium)

A

PPIs

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40
Q

what should you have checked with PPIs

A

Mg level

B12

bone density

41
Q

how long should this pt stay on medication for GERD?

pt does not have severe erosive esophagitis and Barrett’s esophagus

A

lowest possible dose and shortest duration appropiate

DC completely in pts without symptoms

42
Q

how long should this pt stay on meds to tx GERD?

severe esophagitis or Barrett’s esopagus?

A

requires maintenance and suppression with PPI; they will have recurrent symptoms and complications if they discharge meds

43
Q

when do you consider surgical management of GERD

A

failed optimal medical management

GERD complication (esophagitis, Barret’s)

noncompliance

44
Q

what is Nissen Fundoplication

A

surgical tx of GERD

passage of gastric fundus behindt he esophagus to encircle to the distal esophagus

can be laparoscopic or open

45
Q

if a pt is on H2 blocker and symptoms aren’t gone, what do you do

A

switch to PPI

46
Q

if pt is on PPI and still having symptoms, what do you do?

A

BID dosing with close follow-up

OR

ENDOSCOPY – do this first if warning signs have developed

47
Q

most common cause of esophagitis

A

GERD

48
Q

what happens in esophagitis

A

gastric acid, pepsin, and bile irritate the squamous epithelium which leads to irritation, inflammation, erosion, ulceration

49
Q

5 kinds of esophagitis

A

reflux esophagitis (most common)

infectious esophagitis

pill esophagitis

eosinophillic esophagitis

radiation esophagitis

50
Q

signs/sxs of esophagitis

A

similar to GERD

51
Q

complicatiosn of esophagitis

A

bleeding, stricture, Barrett’s

52
Q

Barrett’s esophagus;

____ in distal esophagus replaced with ___

A

squamous epithelium is replaced with columbar epithelium

53
Q

Barrett’s predisposes pt to what

A

adenocarcinoma of esophagus

54
Q

what predisposes pt to adenocarcinoma

A

Barrett’s Esophagus

55
Q

Barrett’s: more common in males or females

A

males

56
Q

avg age of onset for Barretts

A

55

57
Q

5 steps in progression of Barrett’s to adenocarcinoma

A

GERD –> Barrett’s –> Low grade dysplasia –> high grade dysplasia –> adenocarcinoma

58
Q

tx of Barrett’s

A

indefinite use of PPIs (aggressive to precent cancer)

can do QD dosing first before BID

59
Q

what must be done to monitor progression of Barrett’s

A

EGD - detects evidence of dysplasia

60
Q

surgical tx of Barrett’s esophagus

A

endoscopic resection or endoscopic ablation

61
Q

what surgical procedure?

remove segment of Barrett mucosa; therapeutic and provides info on depth of involvement

A

endoscopic resection

62
Q

what surgical procedure?

thermal or photochemical energy to destroy Barrett mucosa

A

endoscopic ablation

63
Q

2 types of esophageal cancer

A

squamous cell

adenocarcinoma

64
Q

more common in African American males

incidence is decreasing

risk factors of smoking, ETOH abuse

what type of cancer

A

squamous cell carcinoma

65
Q

more common in Caucasian males

incidence is increasing among white males

prevention and early detection is key

Barrett’s esophagus is a risk factor

A

adenocarcinoma

66
Q

what if a patient has progressive dysphagia (had problems swallowing meat, the pasta, to fluids), what do you need to do?

A

ENDOSCOPY MUST BE DONE +/- barium contrast esophagram

67
Q

what other worrisome symptoms may occur with progressive dysphagia?

A

weight loss, odynophagia, malnutrition, anorexia

68
Q

esophageal cancer prognosis

A

not good - regardless of histology, 50-80% of pts present with incurable, unresectable, or metastatic disease

THIS IS WHY WE NEED EARLIER DETECTION WITH ENDOSCOPY

69
Q

Goal for majority of esophageal cancer pts?

A

palliative tx - chemo, radiation, surgery dep on disease stage

70
Q

what type of esophagitis?

immunocompromised (like with DM) and has asthma which require inhaled steroids for tx + 2 rounds of antibiotics for pneumonia

A

infectious esophagitis caused by candida - fungal overgrowth

71
Q

if pt has +PPD, night sweats, and cough - what type of esophagitis should we suspect

A

tuberculosis esophagitis

72
Q

if pt has a hard time swallowing pills, what type of esophagitis?

A

pill esophagitis

73
Q

if pt has systemic sclerosis, what kind of esophagitis

A

esophagitis with systemic illness due to poor acid cleaning that leads to epithelial damage

74
Q

if pt has asthma, rhinitis, food allergy, and chronic eczema, what kind of esophagitis

A

eosinophilic esophagitis

75
Q

what kind of inflammation with eosinophilic esophagitis

A

eosinophil-predominant inflammation

76
Q

other symptoms assoc with eosinophilic esophagitis

A

dysphagia

food impaction

CP

refractory heartburn

upper abdominal pain

77
Q

strong connection with other allergic disease - food allergy, rhinitis, asthma, atopic dermatitis

A

eosinophilic esophagitis

78
Q

tx of eosinophilic esophagitis

A

DIET - avoid allergens, acid suppression through PPIs, topical corticosteroids that are SWALLOWED, not inhaled

may or may not due esophageal dilation but risky

79
Q

what kind of disorders should you consider if pt presents with dysphagia, noncardiac chest pain, and refractory GERD sys

A

esophageal motility disorders

80
Q

2 disorders of esophageal peristalsis

A

hypercontractile (Jackhammer)

achalasia

81
Q

what dx test is needed to dx hypercontractile (jackhammer) esophagus

A

manometry

82
Q

if pt says they have angina but typically occurs with meals… what are you looking at

A

esophageal motility disorders

83
Q

tx of hypercontractile (jackhammer) esopagus

A

calcium channel blockers (diltiazem) or TCA (imipramine) +/- botox

84
Q

IF on manometry, aperistalsis occurs - NO esophageal contraction in the distal two-thirds of the esophagus and incomplete LES relaxation, what kind of dx are you thinking

A

achalasia

85
Q

birds beak is seen on what dx test with achalasia

A

barium esophagram

86
Q

what will barium esophagram show with achalasia

A

birds beak

aperistalsis

poor emptying of barium

esophageal dilation

87
Q

progressive degeneration of esophageal neurons leading to failure of relaxation of LES and no peristalsis

what dx?

A

achalasia

88
Q

symptoms: dyspagia, regurgitation, difficulty belching, chest pain, heart brun

gradual onset

A

achalasia

89
Q

what tests must be done if you suspect achalasia?

A

EGD - rule out malignancy

Manometry - required for dx (looking for defect in LES relaxation and aperistalsis in distal 2/3 esophagus)

Barium swallow - dilation of esophagus and BIRD’S BEAK

90
Q

what should you consider when pt is unresponsive to trial PPIs (4 weeks) with dysphagia to solids and liquids + regurg

A

achalasia

91
Q

tx of achalasia (WHAT not MEDS or HOW)

A

disruption of LES muscle fibers

biochemical reduction in LES pressure

92
Q

How do you disrupt the LES muscle fibers in achalasia tx?

A

pneumatic dilation

heller myotomy (incision into muscles of the LES)

93
Q

What do you use to reduce biochemicals in LES pressure in tx of achalasia?

A

botox, nitrates, Ca2+ channel blockers

94
Q

mucosal laceration in distal esophagus and proximal stomach

A

mallory weiss tear

95
Q

usually assoc with repetitive vomtiing, retching, excessive alcohol consumption, hiatal hernia (which increases abdominal pressure)

what dx

A

mallory weiss tear

96
Q

dx of mallory weiss tear

A

endoscopy (or clinical exam IF problem has already resolved)

97
Q

tx of mallory weiss tear

A

stabilize pt

control bleeding (if it hasn’t stopped)

tx with PPI

98
Q

how do you control bleeding in mallory weiss tear

A

epi or electrocauterization

Clin Med III (6 decks)

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