GI #4 Flashcards by Tyler Cichowski

Infectious esophagitis MC occurs in those with _______, but can occur in healthy individuals as well

Immunocompromised states (HIV, post-transplant, malignancy, chemotherapy)

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MCC of infectious esophagitis

Candida

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Clinical manifestations of infectious esophagitis (triad of symptoms)

Odynophagia
Dysphagia
Retrosternal chest pain

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On endoscopy for Candida infectious esophagitis, what is expected to be seen?

-linear yellow-white plaques

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First-line treatment for Candida infectious esophagitis

PO Fluconazole

- 2nd line options: Voriconazole, Caspofungin

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On endoscopy for CMV infectious esophagitis, what is expected to be seen?

-Large, superficial shallow ulcers

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What is the first-line treatment for CMV infectious esophagitis?

Ganciclovir

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What is expected to be seen on endoscopy for HSV esophagitis?

small, deep ulcers

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What is the first-line treatment for HSV esophagitis?

Acyclovir

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Eosinophilic esophagitis is MC seen in…

Children and associated with atopic disease (asthma, eczema, etc.)

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Symptoms of eosinophilic esophagitis

Dysphagia (solids), Odynophagia, Reflux or feeding problems in kids

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What is seen on endoscopy for eosinophilic esophagitis?

-Normal or multiple corrugated rings, white exudates

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Management for eosinophilic esophagitis

Remove foods that incite allergic response
PPIs may be needed in some
Inhaled topical corticosteroids WITHOUT a spacer to allow penetration

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What medications MC cause pill-induced esophagitis?

NSAIDs
Bisphosphonates
BB, CCB
Iron Pills
Vitamin C

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How do you manage pill-induced esophagitis?

Take pills with at least 4 ounces of water

- Avoid laying down 30-60 minutes after pill ingestion

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What is caustic (corrosive) esophagitis from?

-Ingestion of corrosive substances: alkali (drain cleaner, bleach) or acids

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Management of caustic (corrosive) esophagitis

Supportive
Pain medications
IVF

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MC type of hiatal hernia

Sliding (Type I): GE junction slides into mediastinum (increases reflux)

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MC type of hiatal hernia

Sliding (Type I): GE junction slides into mediastinum (increases reflux)Wh

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A paraesophageal hiatal hernia (rolling hernia), occurs when

the fundus of the stomach protrudes through diaphragm with the GE junction remaining in anatomic location

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Symptoms of a hiatal hernia

Postprandial fullness (prolonged persistence of food in stomach)
May be asymptomatic
May have intermittent epigastric pain
Nausea, vomiting

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Treatment for sliding hernia

-Management of GERD + PPI + Weight loss

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Treatment for paraesophageal hernia

-Surgical repair if complications (volvulus, strangulation, bleeding)

What is an esophageal atresia?

Complete absence or closure of a portion of the esophagus (associated with tracheoesophageal fistula, polyhydramnios)

Symptoms of esophageal atresia

-Presents immediately after birth with excessive oral secretions that lead to choking, drooling, inability to feed, respiratory distress, and coughing

How to diagnose esophageal atresia?

- Inability to pass NG tube further than 10-15 cm (coiling in esophagus) - Fluoroscopy: water-soluble contrast may help visualize it

How to treat esophageal atresia

-Surgical ligation of fistula

GERD is due to an

Incompetent lower esophageal sphincter

What is the pathophysiology of GERD

-Transient relaxation of LES (incompetency) --> gastric acid reflux --> esophageal mucosal injury

Typical Symptoms of GERD

- Heartburn (Pyrosis): increased with supine position - Sour taste in mouth - Cough - Sore Throat - Regurgitation

Alarm Symptoms of GERD

- Dysphagia - Odynophagia - Weight loss - Bleeding

4 main complications from GERD may present with alarm symptoms

- Esophagitis - Stricture - Barrett's Esophagus - Esophageal Adenocarcinoma

Although GERD is a clinical diagnosis based on history if presenting with classic, typical symptoms, what is the GOLD standard if confirmation is needed?

-24-hour ambulatory pH monitoring

What does an esophageal manometry show if the patient has GERD?

Decreased LES pressure

If the patient has persistent symptoms or alarm symptoms, what diagnostic should be done?

Endoscopy

Management for early or Stage 1 GERD

-Lifestyle modifications: elevate head of bed, avoid laying down for 3 hours after eating, smoking cessation, decreased alcohol intake, avoid chocolate/peppermint/caffeine/spicy foods, weight loss

Management for Stage 2 GERD ( < 2 episodes per week)

Antacids and H2 receptor antagonists

Management for Stage 3 GERD ( 2 or more episodes per week)

PPI

If the GERD is medication-refractory, what is the treatment?

Nissen fundoplication

Name some H2 receptor antagonists

- Famotidine (Pepcid) - Cemetidine (Tagamet) - Nizatidine

Name some PPI

- Omeprazole - Pantoprazole - Rabeprazole

Mechanism of action of PPI

-block gastric acid secretion by irreversibly binding to and inhibiting the hydrogen-potassium ATPase pump that resides on the luminal surface of the parietal cell membrane

What is Barrett's Esophagus?

-Esophageal squamous epithelium replaced by precancerous metaplastic columnar cells from cardia of stomach (complication of long-standing GERD)

How to diagnose Barrett's Esophagus

-Upper endoscopy with biopsy

Recommendations for treatment based on findings of upper endoscopy with Barrett's Esophagus...

- Barrett's Esophagus only (metaplasia): PPI and rescope every 3-5 years - Low-grade dysplasia: PPI and rescope every 6-12 months - High-grade dysplasia: Ablation with endoscopy, radio frequency ablation

What type of esophageal neoplasms is the MC in the US?

Adenocarcinoma

Adenocarcinoma of the esophagus is common in ______ and is MC in what area of the esophagus?

Caucasian males -Distal esophagus, esophagogastric junction

What type of esophageal neoplasm is the MCC worldwide?

Squamous cell

Squamous cell esophageal cancer is MC in _____ and is most common in what area of the esophagus

- African-Americans | - Mid to upper third of esophagus

Risk factors for Adenocarcinoma of the esophagus

- Barrett's Esophagus - Smoking - High body mass index

Risk factors for Squamous Cell Carcinoma of the Esophagus

- Smoking - Alcohol - Poor Nutritional status - Drinking beverages at high temperatures - HPV infection - Achlasia

What are two protective factors for esophageal neoplasms?

-Aspirin or NSAIDs

What are some symptoms of esophageal neoplasms?

- Progressive dysphagia (solid food progressing to fluids) - Odynophagia - Weight loss, anorexia - Iron deficiency anemia (chronic blood loss) - Hoarseness (recurrent laryngeal nerve) - Horner's Syndrome

What is the diagnostic study of choice for Esophageal neoplasms?

-Upper endoscopy with biopsy

What is the preferred method for pretreatment staging for esophageal neoplasms?

Endoscopic US

Treatment for esophageal neoplasms

- Esophageal resection with chemotherapy | - Palliative stenting to improve dysphagia