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Gastrointestinal > MDT Upper GI > Flashcards

MDT Upper GI Flashcards

1
Q

What is Gastroesophageal Reflux Disease?

A

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

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2
Q

What sphincter plays a vital role in frequency and severity of GERD

A
  • Lower esophageal sphincter
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3
Q

General pathophysiology of GERD?

A
  • Pain associated with GERD is secondary to stimulation and activation of mucosal chemoreceptors
  • Spicy, acidic, and salty foods exacerbate
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4
Q

Symptoms of GERD?

A
  • Heartburn 30-60 minutes after meals
  • Pt’s report relief from antacids or baking soda
  • Dysphagia (in 1/3 of Pt’s)
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5
Q

“Atypical” or “extraesophageal” manifestations of GERD?

A
  • Asthma
  • Chronic cough
  • Chronis laryngitis
  • Sore throat
  • non-cardiac chest pain
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6
Q

Complications of GERD?

A
  • Barret Esophagus

- Peptic Stricture

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7
Q

What is Barret Esophagus?

A

Squamous epithelium of the esophagus is replaced by metaplastic columnar epithelium containing goblet and columnar cells
- most serious complication Barret Esophagus is esophageal adenocarcinoma

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8
Q

What is Peptic Stricture?

A
  • Occurs within 5% Pt’s

- Manifested by the gradual development of solid food dysphagia progressive over months to years

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9
Q

Rad for GERD?

A

Endoscopy in complicated Pt’s

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10
Q

Treatment for mild GERD?

A
  • Lifestyle modification (smaller meals, discontinue acidic foods)
  • Weight loss
  • Antacids (Ranitidine, Famotidine)
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11
Q

Treatment for troublesome symptoms of GERD?

A
  • Protein Pump Inhibitors
  • Omeprazole (Prilosec)
  • Esomeprazole (Nexium)
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12
Q

When to refer for GERD?

A
  • Do not resolve with maximum empiric management with 3 months of twice-daily PPI therapy
  • Significant dysphagia
  • Barret’s or stricture
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13
Q

What is reflux esophagitis?

A

Subset of patients with GERD who have endoscopic evidence of esophageal inflammation

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14
Q

What is infectious esophagitis?

A

Esophagitis and thrush often occur together in immunosuppressed patients and presence of thrush may help determine the cause of esophageal symptoms
*absence of thrush does not preclude diagnosis of candida esophagitis

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15
Q

Medications that cause direct esophageal mucosal injury?

A
  • Tetracycline, Doxy, Clindamycin
  • Anti-inflammatory medications
  • Biphosphates
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16
Q

Signs and symptoms of medication-induced esophagitis

A
  • Retrosternal chest pain or heartburn
  • Odynophagia
  • Dysphagia
  • Rarely, may have hematemesis, abdominal pain, and weight loss
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17
Q

Candida Esophagitis symptoms?

A

Hallmark: Odynophagia (pain on swallowing)

  • Localize pain to discrete retrosternal area
  • Diagnosis made when white mucosal plaque-like lesions are noted on endoscopy
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18
Q

Labs for esophagitis?

A

If infection considered:

  • CBC
  • Specimen culture
  • Swab for candida
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19
Q

Rad for esophagitis?

A

Consider endoscopy

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20
Q

Treatment of pill-induced esophagitis?`

A

Stop taking offending medication

Take with water

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21
Q

Treatment of candida esophagitis ?

A

Evaluate for immunocompromised conditions: HIV, Cancer, Diabetes

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22
Q

Complications of esophagitis?

A
  • Peptic stricture
  • Esophageal Spams
  • Mallory-Weiss tear
  • Boerhaave
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23
Q

What are some causes of Esophageal Stricture?

A
  • Likely caused as a result to esophageal irritation from chronic GERD
  • Other causes (roughly 25%)
  • External beam radiation
  • Esophageal sclerotherapy
  • Caustic ingestions
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24
Q

Why do esophageal strictures form?

A

To reduce the volume of reflux in the esophagus to reduce the symptoms of GERD

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25
Q

Signs/Symptoms of esophageal stricture?

A
  • Localized substernal chest pain
  • Heartburn
  • Dysphagia (cardinal feature)
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26
Q

Rad for esophageal stricture?

A
  • Endoscopy

- Barium study

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27
Q

Treatment for mild and severe esophageal stricture?

A
  • Mild: treat for GERD
  • Severe: consider MEDEVAC for potential surgery
  • Refer all Pt’s to Gastroenterology for Dilation and evaluation
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28
Q

What is esophageal spasm?

A

Idiopathic motility disorder which causes loss of peristalsis in the distal two-thirds of the esophagus and impaired relaxation of the LES

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29
Q

Signs and symptoms of esophageal spasm?

A
  • Gradual onset of dysphagia with solid foods and some liquids
  • Can be present for months
  • Substernal discomfort/chest pain
  • Regurgitation is common
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30
Q

Rad for Esophageal Spasm?

A
  • CXR
  • Barium Esophagography
  • Edoscopy
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31
Q

Treatment of Esophageal Spasm?

A
  • PPI for GERD
  • Symptom reduction
  • Smaller bites of food
  • Invasive procedures (endoscopic injection of botulinum toxin)
32
Q

Where are Peptic Ulcers located?

A

Stomach and Duodenum

33
Q

How does a peptic ulcer occur?

A

When the balance between the aggressive factors and the defense mechanisms is disrupted

34
Q

What is the diagnostic procedure of choice for peptic ulcer?

A

Upper endoscopy with gastric biopsy for H pylori

35
Q

What is a peptic ulcer?

A

A break in the gastric or duodenal mucosa that arises when normal mucosal defense factors are impaired or are overwhelmed by aggressive luminal factors such as acid or pepsin

36
Q

Where are peptic ulcers five times more common?

A

In the duodenum

37
Q

Duodenal ulcers most commonly occur in what age group?

A

30-55

38
Q

Gastric ulcers most commonly occur in what age group?

A

55-70

39
Q

What are the 3 major causes of peptic ulcer disease?

A
  • NSAIDS
  • Chronic H pylori infection
  • Acid hypersecretory states
40
Q

The risk of NSAID complications is greater for peptic ulcers:

A
  • Within the first 3 months of therapy
  • Have a history of ulcer disease
  • Take NSAIDS in combination with aspirin, corticosteroids, or anticoagulants
41
Q

Symptoms of Peptic Ulcer?

A
  • Hallmark: Dyspepsia ( epigastric pain)
  • Nausea
  • Anorexia
  • Physical exam often normal in uncomplicated, may have localized epigastric tenderness
42
Q

Rad for peptic ulcer?

A

Upper endoscopy procedure of choice for the diagnosis of duodenal and gastric ulcers

43
Q

Treatment for peptic ulcer?

A
  • Eat balanced meals at regular intervals
  • Discourage smoking
  • NSAID causing: PPI 4-6 weeks
  • H pylori causing: 10-14 days PPI (continue for 4-6 wks), antibiotic
44
Q

Disposition for peptic ulcer?

A
  • Retain on board unless any red flags or not responsive to PPI
45
Q

What is the anatomical landmark that separates upper and lower GI

A

Ligament of Treitz

46
Q

What is occult GI bleeding?

A

No visible evidence of blood loss. Only present on fecal occult test or iron deficiency anemia

47
Q

What is the most common cause of lower GI bleeding?

A

Colon carcinoma

- often occult, but not always

48
Q

What is overt GI bleeding?

A

Blood loss visible to clinician or Pt

49
Q

What is Hematemesis?

A

Vomiting of blood

50
Q

A “coffee-ground” black color of blood in hematemesis indicates a bleed from what location?

A

At or distal to the stomach

51
Q

A bright redin color of blood in hematemesis indicates a bleed from what location?

A

At or proximal to the LES

52
Q

A melena (dark black, “tar-like”) color of blood in hematemesis indicates a bleed from what location?

A

Upper GI bleed

53
Q

What is hematochezia and what type of bleed does it indicate?

A
  • Bright red blood in stool

- Likely lower GI bleed

54
Q

What are the two most common presentations of Upper GI bleed

A
  • Hematemesis
  • Melena
  • May present with hematochezia
55
Q

Rads for GI Bleeding?

A
  • Upper endoscopy
  • CT angiogram and nuclear scintigraphy
  • X-ray and conventional CT scan has little value
56
Q

Labs for GI Bleeding?

A
  • Labs are of little value, can be helpful identifying severity and aggravating factors
  • CBC, PT, PTT, INR
57
Q

Can Nasogastric Tubes be helpful in diagnosing GI Bleeds?

A

Yes, should be inserted in Pt with suspected active upper GI bleed
- Aspiration of red blood or “coffee grounds” confirms upper GI source of bleed

58
Q

Assessing NG Tube in upper GI Bleed?

A
  • Systolic BP <100 identifies a patient who has sustained severe blood loss (30-40% blood volume)
  • HR >100 bpm with systolic BP >100 indicative of moderate blood loss
    (15-29%)
    -
59
Q

What type of intravascular blood volume replacement should be used in severe blood loss associated with upper GI bleeds?

A

Fresh Whole Blood

60
Q

Pharmacotherapy for upper GI Bleeds?

A
  • IV PPI (Omeprazole/Pantoprazole)

- IF tolerating PO, PPI orally can be good for long term care

61
Q

Disposition for upper GI Bleeds?

A
  • MEDADVICE minimum

- MEDEVAC depending on presentation and response to Tx

62
Q

Common causes of lower GI bleeding?

A
  • Diverticulosis/Diverticulitis
  • IBD
  • Anorectal disease
  • Hemorroids
  • Fissures
63
Q

What stool color suggests a colonic source in lower GI bleeds?

A

Bright red blood

64
Q

What stool color suggests a lesion on right colon or small intestine in lower GI bleeds?

A

Maroon stools

65
Q

What stool color suggests a source proximal to the ligament of Treitz in lower GI bleeds?

A

Black tarry stools (melena)

66
Q

Management of lower GI bleed?

A
  • Initial stabilization
  • Blood replacement
  • Triage
  • Treating underlying cause is goal of therapy
  • Will likely need colonoscopy
67
Q

What are two conditions that may result in upper GI bleed?

A
  • Mallory-Weiss syndrome

- Boerhaave syndrome

68
Q

What is Mallory-Weiss Syndrome?

A

Characterized by a non-penetrating vertical mucosal tear/laceration at the gastroesophageal junction

69
Q

Pertinent information regarding Mallory-Weiss Syndrome?

A
  • Caused by sudden increase in intraabdominal pressure (vomiting/retching/lifting)
  • Heavy alcohol use
  • Bleeding more severe when associated with portal hypertension and esophageal varices
70
Q

What is Boerhaave’s syndrome?

A

More severe laceration of the anterior esophagus associated with a full perforation of the esophagus into the mediastinum

71
Q

Pt presentation for Mallory-Weiss?

A
  • Heavy alcohol user
  • S/S upper GI bleed
  • Hematemesis with or without retching
  • History of retching/vomiting/straining
  • Possible hypovolemia
72
Q

Pt presentation for Boerhaave’s syndrome?

A
  • Hartman’s sign (crunching sound heard on mediastinum)

- Possible crepitus with palpation on test

73
Q

Diagnosing Mallory-Weiss or Boerhaave’s?

A
  • CBC to rule out anemia
  • Upper endoscopy
  • CXR
  • Normal in mallory-weiss
  • Mediastinal air may be present in boerhaave’s
74
Q

Treatment for Mallory-Weiss?

A
  • Most Pt’s stop bleeding spontaneously and require no therapy
  • NPO
  • IV PPI
  • IV/IM antiemetic
  • Surgical intervention
75
Q

Treatment for Boerhaave’s?

A
  • NPO
  • IV PPI
  • IV/IM antiemetic
  • IV ertapenem
  • Surgical intervention
76
Q

Disposition for Mallory-Weiss or Boerhaave’s?

A

MEDEVAC

Gastrointestinal (6 decks)

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