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Clin Med- P > intro & Esophageal disorders > Flashcards

intro & Esophageal disorders Flashcards

1
Q

older pt with new swallowing/heartburn complaint.. think?

A

RED FLAG

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2
Q

who do you refer to for pharynx/swallowing problems?

A

ENT and/or speech pathology

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3
Q

are the sphincters of the esophagus true sphincters?

A

NO

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4
Q

cause of GERD

A

incompetent LES (lower esophageal sphincter) allowing gastric contents to reflux into esophagus

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5
Q

typical GERD sxs, atypical sxs (3), and 4 GERD red flags/ alarm symptoms

A

typical: postprandial HEARTBURN, increased with supine position and can be relieved with antacids. can have regurgitation into throat, lungs or mouth atypical: hoarseness, asp pneumo, wheezing odynophagia, dysphagia, weight loss, bleeding

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6
Q

how do you diagnose GERD?

A

CLINICAL gold standard: 24 hr ambulatory pH monitoring if symptoms are persistent, refractory to med trial or if there are alarm symptoms then do EGD

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7
Q

3 Goals for GERD txt

A

prevent reflux, lower acid secretion, prevent complications of esophagitis

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8
Q

txt for GERD

A

lifestyle modifications (diet, elevate bed with blocks, weight loss, stop smoking/alc) in combination with medications (antacid, PPI, H2 blocker) -<2 episodes per week = PRN antacids or H2 blockers - 2 or more episodes per week = PPI surgery (fundoplication) in medication-refractory pts

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9
Q

what is a Nissen fundoplication?

A

fold fundus of stomach and wrap around esophagus to prevent reflux (increase pressure)

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10
Q

GERD complications: 4

A

esophagitis, stricture (narrowing from acidic damage), barrett esophagus (MOST IMPORTANT), and adenocarcinoma

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11
Q

how can GERD cause asthma exacerbation?

A

microaspiration

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12
Q

antacids ____ but do not _____ acids.

A

neutralize but do not suppress

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13
Q

what are the antacids? antacids should be taken when?

A

BASIC components to neutralize acid: Mg++, Al++, Ca++ salts immediately after meals (when you have symptoms)

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14
Q

what do H2 blockers do for GERD?

A

block production of acid by gastric parietal cells

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15
Q

when are PPIs taken?

A

before you eat (this is when the enzyme works best)

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16
Q

one downside to PPIs?

A

inc risk for infection cause its taking away the acid that normally neutralizes bacteria that comes with food.

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17
Q

what is pH ambulatory monitoring and who is it good for?

A

Useful in Pts who have not benefited from a trial of anti-secretory meds or have refractory problems, or has a normal endoscopy and cont’d symptoms. **useful in GERD

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18
Q

how do you take PPIs? efficacy between PPIs? usual starting dose?

A

step-up and step-down approach, taken before meals, no difference in efficacy among the PPIs OTC omeprazole 20 mg qd is usual starting dose.

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19
Q

___ have good healing action for ulcers (GERD)

A

PPIs

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20
Q

txt for barrett’s

A

resection of that part of the esophagus (b/c does not get better with acid suppression, neoplastic change has already occurred)

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21
Q

what is a haital hernia? symptomatic?

A

protrusion of portion of the stomach through the haitus of the diaphragm into the thoracic cavity - usually asymptomatic

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22
Q

three types of esophageal motility disorders?

A

achalasia, diffuse esophageal spasm, and hypercontractile (jackhammer esophagus)

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23
Q

what is achalasia? CP for this?

A

*esophageal motality disorder* absence of peristalsis in lower 1/2 of esophagus (degeneration of auerbach’s plexus) and failure of LES to relax CP: leads to progressive dysphagia (both solids and liquids), regurg of undigested food, weight loss and halitosis (b/c food gets trapped)

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24
Q

how to Dx achalasia?

A

1). barium swallow (esophagram)- dilated tapering to “birds beak” appearance of esophagus (barium settles in trapped esophagus) 2). most accurate is manometry (shows increased LES pressure and loss of peristalsis)

25
Q

txt for achalasia?

A

Decrease LES pressure: botox, nitrates Surgery is more effective: balloon dilation of LES, esophagomyotomy (cuts in muscle)

26
Q

what is achalsia a risk factor for?

A

squamous cell carcinoma **EGD usually performed before initiating tx

27
Q

what diffuse esophageal spasm? common CP?

A

*esophageal motility disorder* severe non-peristaltic esophageal contractions CP: stabbing chest pain worse with hot or cold food (similar to angina but not exertional), dysphagia to both foods and liquids, “stuck in throat” sensation

28
Q

dx and txt for diffuse esophageal spasm

A

dx: esophagram “corkscrew esophagus” definitive dx: manometry (increased or premature contractions in distal esophagus) tx: CCB first-line, nitrates, TCAs

29
Q

what is hypercontractile esophagus?

A

“jackhammer/nutcracker esophagus” *esophageal motility disorder* increased pressure during peristalsis with NORMAL sequential contractions

30
Q

common CP and Dx for hypercontractile esophagus?

A

CP: dysphagia to both solids and liquids, chest pain similar to distal esophageal spasm Dx: manometry is definitive (increased pressure during peristalsis) **manometry is important in differentiating between this and diffuse esophageal spasm -EGD and esophagram is usually normal

31
Q

what is scleroderma (related to esophagus)?

A

subQ tissue becomes progressively calcified and stiffened. -peristalsis wave defect -reduced LES pressure

32
Q

tx for hypercontractile esophagus

A

lower the esophageal pressure with CCB, nitrates

33
Q

what % of patients with scleroderma have GI issues?

A

90%

34
Q

txt for scleroderma?

A

depends on symptoms (txt with reflux or motility medications)

35
Q

5 types of esophagitis

A

GERD- MC cause Infectious- Candida (MC), CMV, HS *usually immunosuppressed pts Eosinophilic- children with atrophic triad with allergies Pill-induced esophagitis Caustic esophagitis: due to acidic or basic substance

36
Q

early/mild esophagitis vs erosive/severe

A

early: reddened severe: has gone into submucosa

37
Q

pill-induced esophagitis: what is it and what pills usually cause it?

A

caused by delayed transit time in esophagus bisphosphonates, ASA, NSAIDS, Ferrus Sulfate, Tetracyclines*** (alendronate/fosamax)

38
Q

caustic esophagitis examples of substances

A

strong alkali and acids (drano, lye, bleach) *alkali injury generally worse than acid -can lead to death, strictures, etc.

39
Q

txt for caustic esophagitis

A

Supportive: IV fluids and H2 blockers, pain meds (DON’T try to neutralize, just flush out)

40
Q

eosinophilic esophagitis: what is it and how does it present?

A

allergy in esophagus - almost always present with dysphagia/regurg/food impaction with GERD-like complaints

41
Q

txt: eosinophilia esophogitis

A

remove allergic agents and some need topical steroids

42
Q

only test of cure for eosinophilia esoph. is what?

A

re-biopsy, so we often just txt symptoms

43
Q

symptoms for infectious esoph.

A

dysphagia and odynophagia (very painful)

44
Q

txt for infectous esoph.

A

txt underlying condition, appropriate anti-infectives (usually antifungals)

45
Q

how to diagnose esophagitis?

A

EGD

46
Q

what is barretts esophagus?

A

longterm acid exposure predisposes for adenocarcinoma -metaplastic columnar epithelial cells replace squamous epithelium -not a Cancer but neoplastic changes that inc. the risk for cancer

47
Q

esophageal rings: what are they? MC location? etiology? Sx? Dx? Txt?

A

circular diaphragm of tissue that protrudes into esophageal lumen -location: lower esophagus (SC junction) -etiology: varied (reflux, hiatal hernia, etc) -Sx: MOST AS, if sxs then EPISODIC dysphagia esp to solids (bolus of foods may get stuck) -Dx: barium esophagram (more sensitive)- circumferential ridge above diaphragm hiatus -txt: if sxs then dilation and txt underlying cause **control reflux to prevent worsening

48
Q

esophageal webs are more ___ while rings are more ____

A

webs: mucosal rings: muscular

49
Q

what is esophageal web?

A

non circumferential thin membrane in mid-upper esophagus CP: Many are AS, dysphagia especially to solids Dx: barium esophagram test of choice Tx: dilation of area if severe sxs (PPI therapy after dilation may decrease risk of recurrence)

50
Q

esophageal diverticula (aka ____)

A

Zenker’s : caused by motility d/o of upper esophagus; relaxation/contraction problems, causes high pressures that result in diverticuli (pouches/herniation in muscular wall of pharynx)

51
Q

symptoms of esophageal diverticula? txt?

A

regurg and really FOUL breath txt: excision

52
Q

two types of esophageal cancer, where is each found in esophagus, and risk factors

A

adenocarcinoma: MC in US, found in distal esophagus *RFs: Barrett’s esophagus, smoking, obese squamous cell: MC worldwide, found in upper third *RFs: smoking and alcohol

53
Q

esophageal cancer: presentation and Dx

A

CP: PROGRESSIVE dysphagia (solid to eventual liquids too) and late odynophagia, weight loss, anorexia, iron deficiency **advanced disease upon presentation Dx: EGD with biopsy **endoscopic US preferred method for locoregional staging

54
Q

txt for esophageal cancer

A

early detection and prevention major surgery for resection, maybe radiation/chemo, palliative stenting for dysphagia

55
Q

what is mallory-weiss syndrome? what is it due to? common CP? how to dx?

A

longitudinal mucosal lacerations at the gastro-esophageal junction or gastric cardia PP: sudden rise in intraabdominal pressure (i.e. persistent retching or vomiting) CP: Hematemesis associated with persistent retching and vomiting, often following an alcoholic binge Dx: EGD is test of choice

56
Q

mallor weiss syndrome tx: Majority of patients heal _______ with only minor blood loss, but ~__% may have more serious sequelae (active vs non active bleeding)

A

heal spontaneously 10% shock, need for transfusion not active: SUPPORTIVE (PPIs for 1-2 weeks to promote acid suppression, anti nausea med, transfuse if Hb <8) active bleed: transfuse, hemoclips/band ligation, balloon tamponade

57
Q

what are esophageal varices? what is the most common cause?

A

dilation of esophago-gastric venous plexus (from elevated portal HTN) Cause: cirrhosis

58
Q

presentation of esophageal varices?

A

usually an acute rupture with active bleeding (hematemesis) *may develop signs of shock/hypovolemia

59
Q

how to diagnose and tx esophageal varices?

A

dx: EGD to diagnose and treat (esp acutely) tx: 1). acute variceal bleed: stabilize the patient (IVs, fluids), octreotide, endoscopic intervention (variceal ligation) or surgical intervention (TIPS) if endoscopy is unsuccessful, ABX proph (rocephin) 2). chronic: improving the liver (dec alc, tx hepatitis) and BB to prevent rebleeding (propranolol)

Clin Med- P (124 decks)

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