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GI system Flashcards

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1
Q

What is achalasia?

A

Derangement of the myenteric motor plexus (coordinates motility)

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2
Q

S/s of achalasia

A
  • Dysphagia for BOTH solids and liquids
  • Regurgitation of food
  • Severe halitosis

-WEIGHT LOSS, cough

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3
Q

Similar between achalasia and GERD and different?

A

BOTH have regurgitation

GERD produces a sour taste but not achalasia

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4
Q

Tests for diagnosing achalasia

A
  • CXR lateral upright: absence of gastric bubble, bird beak sign and air-fluid levels in posterior mediastinum
  • Barium swallow- distal bird’s beak sign
  • Esophageal motility (aka manometry) study- nonperistaltic contractions, incomplete LES relaxation after swallowing, inc LES resting tone
  • SCOPE to rule out mass lesions or strictures, biopsy
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5
Q

Treatment

A
  • Nitrates or CCBs- relax the LES
  • Local botox
  • Surgery: esophagomyotomy with incision of the DISTAL tunica muscularis (DON’T completely divide the LES)
  • Endoscopic dilatation an option but less success and more complications (perf)
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6
Q

Complications of achalasia?

A

Risk of SCC is up to 10% in ppl w/ long-standing achalasia

-Reflux/aspiration can cause PNA, bronchiectasis, asthma

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7
Q

Diffuse esophageal spasm?

A

Myenteric plexus dysfunction.

Distal 2/3 of esophagus and is caused by uncoordinated large-amplitude contractions of smooth muscle

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8
Q

Secondary causes of DES?

A

Diabetes neuropathy, collagen vascular dz, reflux esophagitis, obstruction

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9
Q

S/s of esophageal spasm? Associated illnesses?

A
  • Dysphagia for both solids/liquids (like achalasia)
  • CHEST PAIN similar to MI! Acute onset, retrosternal, may be radiating to arms/jaw/back

INTESTINAL DISORDERS like IBS and spastic colon

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10
Q

Key about esophageal spasm vs. achalasia?

A

NO REGURGITATION IN DES.

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11
Q

Diagnosing DES?

A

Barium swallow- corkscrew appearance; may be TOTALLY NORMAL if it’s not catching the spasm at the time. LES normal diameter
-Esophageal manometry- swallow-induced LARGE uncoordinated contractions

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12
Q

DES treatment?

A

Nitrates or CCBs

NOT usually esophagomyotomy

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13
Q

Esophageal varicies s/s?

A
  • Bleeding stops spontaneously in 50% of cases

- Rebleeding risk is high

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14
Q

Treatment of unruptured esoph varicies?

A

Medical: drugs that decrease portal blood flow- vasopressin, octreotide, somatostatin.
Beta-blockers decrease portal pressure

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15
Q

Rx for ruptured esoph varicies?

A 
pRBCs, NS
NG suction
Endoscopic sclerotherapy
Endoscopic band ligation 
(these have 90% success)

Balloon tamponade can cause perf

TIPS/portocaval shunt, liver transplant

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16
Q

Ddx of esoph rupture?

A

Aortic dissection/MI
Spontaneous pneumothorax
Pancreatitis
Perforated peptic ulcer

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17
Q

How to diagnose esophageal rupture?

A

CXR: L-sided pleural effusion, mediastinal or subcutaneous emphysema

Esophagogram w/ water-soluble contrast (shows extravasation of contrast)

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18
Q

S/s esophageal cancer

A

GRADUAL dysphagia first solids then liquids (it takes 60% occlusion to have sx)
Wt loss, fatigability, weakness

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19
Q

Diagnosis?

A
  • Barium swallow showing mass
  • CXR w/ hilar LAD
  • EGD to look at mass/biopsy it
  • CT scan of thorax for spread
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20
Q

Treatment?

A

Usually caught after widespread/metastasis so <40% candidates for surgery; many post-op complications

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21
Q

Epiphrenic/pharyngoesophageal (Zenker’s) cause?

A

Elevated pressure
Both are FALSE

Zenker’s is the one most likely to be symptomatic

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22
Q

Treatment of Zenker’s?

A

Cervical esophagomyotomy with resection of diverticulum

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23
Q

Esophageal stricture s/s?

A

Small may be asx, otherwise progressive dysphagia

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24
Q

Esophageal stricture dx?

A

SCOPE bc it MUST BE EVALUATED for malignancy

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25
Stricture rx?
Dilators passed thru stricture
26
What drugs can cause PUD? Why?
NSAIDs, acetazolamide, alpha blockers, alcohol They inhibit bicarb secretion into the mucous gel
27
Which drugs reduce gel thickness?
NSAIDs, steroids PGE increases it
28
Complications of PUD?
Bleeding 20% Perforation 7% Gastric outlet obstruction from scarring and edema
29
52 yo lady pw 3 months of early satiety, wt loss, and non-bilious vomiting
Gastric outlet obstruction
30
What does an anterior perforation of duodenal ulcer look like?
Free air under the diaphragm 70%
31
Posterior perf od duodenal ulcer?
Pain radiating to back Pancreatitis GI bleed
32
Duodenal ulcer causes
- H pylori (being colonized doesn't mean you'll get an ulcer...only 10-20% of ppl do) - NSAIDs/steroids - Zollinger-Ellison (2/3 are malignant ulcers; diarrhea common)
33
Duodenal ulcer sx?
Burning epigastic pain when stomach empty; food relieves within 30min N/V Nighttime awakening (Weirdly assoc with blood type O)
34
Dx duodenal ulcer?
Give treatment and see if it resolves; no need for biopsy H. pylori- endsocopy w/ bx, serology H. pylori IgG, urease breath test Zollinger-Ellison- Serum gastrin level >1000pg/mL SECRETIN STIM TEST--> paradoxical rise in serum gastrin
35
Rx of duodenal ulcers?
DC NSAIDS, steroids, smoking cessation PPIs better than H2 blockers H PYLORI ERADICATION: PPI, clarithromycin, amoxicillin/mtz for 14 days
36
Surgical rx of duodenal ulcers?
HIGHLY SELECTIVE VAGOTOMY Cut middle of nn, spare the most distal branches; lowest rate of dumping after but highest recurrence which depends on the site of the ulcer. PREPYLORIC ulcers highest recurrence. Rarely needed! Only if refractory to 12 wks medical rx, or hemorrhage, obstruction, perf
37
Surgical complications for rx of PUD?
- Dumping syndrome - Afferent loop syndrome - Postvagotomy diarrhea - Duodenal stump leak - Efferent loop obstruction - Marginal ulcer (ulcers that develop at the margins of a gastrojejunostomy) - Chronic gastroparesis - Postgastrectomy stump cancer
38
Gastric ulcer? RFs?
Decreased protection against acid | Smoking
39
What do they all need?
Biopsy bc 3% are malignant Dx with endoscopy
40
Types for gastric ulcers and their treatments?
I- Lesser curvature II- Gastic and duodenal ulcer These get antrectomy III- Prepyloric ulcer= highly selective vagotomy IV- ULCER IN CARDIA Subtotal gastrectomy then Roux-en-Y esophagogastrojejunostomy
41
Dumping syndrome
From unregulated movement of gastric contents from stomach to intestine Rx: avoid excessive water intake or high sugar food. Severe- octreotide
42
What is Billroth II used for? What is it?
Refractory PUD and gastric adenocarcionma CBD gets sewn to duodenum then gastrojejunostomy BILLROTH II=GASTROJEJUNOSTOMY
43
What is afferent loop syndrome? Rx?
Obstruction of afferent limb (the duodenum pouch to the stomach) of Billroth II Mostly present within 1st wk post-op Vomiting relieves postprandial RUQ pain/nausea Steatorrhea Rx: surgical revision Endoscopic balloon dilatation
44
Gastritis s/s?
Burning/gnawing pain | Pain worse w/ food and relieved by antacids
45
Gastritis dx?
Endoscopy
46
Gastritis rx?
Stop NSAIDs, triple therapy, stop smoking/EtOH, H2 blockers
47
Gastric outlet obstruction causes? Dx? Rx?
Obstructing duodenal or gastric ulcers! Tumor in head of pancreas or stomach Endoscopy or barium swallow x-ray Endoscopic balloon dilatation Surgical resection: 7 days NG decompression and antisecretory rx then truncal vagotomy+pyloroplasty
48
What's a good drug for upper GI hemorrhage?
Somatostatin- inhibits gastric, intestinal, and biliary motility and dec visceral blood flow
49
How often is a laparotomy needed for a UGI bleed?
5% Undersew the vessel on either side of the bleeding vessel Gastric ulcers are 3x more likely to rebleed than duodenal
50
Types of gastric bypass?
Vertical banded gastroplasty Signal to hypothalamus that you're full when proximal pouch is distended Roux-en-Y gastric bypass- More complications but greater weight loss
51
Best diagnostic test for gastric cancer?
Upper GI endoscopy (bc you biopsy duh)
52
S/s of gastric cancer?
Adenocarcinoma is 95% Krukenberg's tumor- mets to ovaries Blumer's shelf- mets to pelvic cul-de-sac felt on DRE Virchow's node- L supraclavicular Sister mary joseph's- mets to umbilical LNs
53
Gastric lymphoma
Men more, 5% of gastric cancers HIV 5x risk
54
Treatment of low vs high grade MALT? Poor prognosis?
Men more, low grade- H pylori rx High grade- Radiation/chemo Lesser curvature involvement bad
55
Why do you need to do a biopsy to definitively diagnose MALT?
Bc you can't distinguish from adenocarcinoma by simple inspection
56
Carney triad?
Gastric leiomyosarcoma Pulm chondromas Extra-adrenal paraganglioma Seen in women <40
57
How many neoplasms of stomach are malignant? benign?
90% malignant | 10% benign
58
MC benign tumors of stomach? When do you NEED to biopsy them
Adenomatous polyps Biopsy >5mm to check for cancer
59
Menetrier's disease
BENIGN! Can look like cancer on barium study but do monitor closely bc increased risk of cancer Autoimmune w/ hypertrophic gastritis that causes PROTEIN-LOSING ENTEROPATHY Definitive dx: Endoscopy w/ DEEP MUCOSAL BIOPSY (barium swallow shows thickened rugae) Rx: Anticholinergics, H2 blockers, HIGH PROTEIN DIET, severe may need gastrectomy
60
Dieulafoy's lesion?
Mucosal end artery that doesn't branch like it should. Causes pressure necrosis, erodes into stomach, and ruptures Massive/recurrent painless hematemesis Dx: Upper GI endoscopy Rx: Endoscopic sclerosing therapy or electrocoag Wedge resection
61
Gastric volvulus cause?
Paraesophageal hernia usually Can't vomit, NG tube can't pass, intermittent severe epigastric pain/distention Dx: Upper GI contrast study Rx: Gastropexy (tack stomach to anterior abdominal wall), fix the hernia

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