week 4- esophagus Flashcards
• What hx Q’s should you ask for GI cc?
o OPQRST for pain, psychological stress, diet, thorough PMHx, SHx, ROS
• What are alarm sxs with GI cc (require further eval)?
a. appetite (anorexia)
b. blood in stool/urine (gross or occult)
c. changes in skin (jaundice)
d. dysphagia
e. edema
f. fever
g. gaunt (weight loss)
h. heavy (Abdominal mass, organomegaly)
i. irrupt (N/V)
j. jolt (pain awakens pt)
• what is general PE for GI cc?
o general observations, signs of distress, orientation, nourished appearance?
o vitals, weight/BMI, pulse ox
o skin: rash or erythema? jaundice? pallor?
o Extremities: nail clubbing, contractures, liver flap?
• What HEENT PE should you look at with GI cc? Chest?
o eyes: jaundice in sclera, conjunctival pallor?
o mouth: lesions?
o LN: upper cervical and Virchow’s node
• How do you perform chest exam for GI cc?
o inspect for spider nevi, purpura, gynecomastia
o ausc heart and lungs
• how do you perform abdominal exam for GI cc?
o Inspection: lesions, masses, distention (7 Fs), scars, vessels, peristalsis
o Ausc: bowel sounds, bruits
o Percussion: mixed resonant/dull (norm), Hyper-resonance/tympany (gas), dull (solid organs, feces, fluid, tumors, shifts w ascites). Determine liver span in cm at MCL
o Palpation: 4 quad, superficial and deep, tenderness, mass, guarding. Liver, spleen, kidneys (tenderness, organomegaly, masses, enlarged AA)
o Special tests: Murphy’s sign (GB); McBurney’s (appendicitis), Rovsing’s sign, Psoas sign, Obturator sign
Digital rectal exam w occult blood
o Pelvic exam in women, male genitalia exam
• What are some general tests done for GI cc?
o UA
o Serum/Liver: LFT: ALP, AST, ALT, LDH, GGT, 5’ Nucleotidase, PT, INR, bili, albumin
o CMP: Bilirubin, total protein, albumin
o Serum imunoglobulins, anti-mitochondrial antibodies, α-fetoprotein
o General: ESR, CBC
o Pancreas: Amylase and lipase
• What tests and procedures are specific to upper GI cc (dependent on clinical findings)?
o acid tests: ambulatory pH monitoring, gastric analysis o endoscopy, Anoscopy, Sigmoidoscopy o laparoscopy o manometry o nuclear scans o x-ray, other contrast imaging o nasogastric, Intestinal Intubation o abdominal paracentesis o electrogastrography, electrical impedance test
• what is the first stage of digestion? Saliva?
o Smell food → saliva
o Saliva: water, 0.5% electrolytes, mucus, glycoproteins, enzymes, antibacterial (sIgA, lysozyme)
o moisten, lubricate food, form bolus, pass easily from mouth to esophagus
• what are some problems of the mouth?
o Mb involve the tongue, teeth, gingival or mucous membranes, local musculature, local nervous system, local exocrine glands (salivary)
o mb indicate local dz or systemic illness (dehydration, nutritional def, etc)
• what are the esophageal and swallowing dos?
o Dysphagia: oropharyngeal, esophageal o Cricopharyngeal incoordination o Obstructive dos: lower esophageal rings, esophageal webs, dysphagia lusoria o Motility dos: achalasia, symptomatic diffuse esophageal spasm o Esophageal diverticula o GERD o Hiatal hernia o Infectious esophageal dos: Mallory-weiss syndrome o Esophageal rupture o Tumors o esophageal varices o foreign bodies
• what is globus sensation?
o Feeling lump in throat
o Unrelated to swallowing (not dysphagia)
• What is oropharyngeal dysphagia? Ssx?
o difficulty emptying material from oropharynx to E
o ssx: hard to initiate swallowing, food stuck in throat, nasal regurgitation, cough/ choke w swallow, drool, unexplained wt loss, recurrent pneumonia, change in voice
• what are some causes of oropharyngeal dysphagia?
o Neurologic: stroke, PD, MS, motor neuron dos (ALS, progressive bulbar palsy), bulbar poliomyelitis
o Mulcular: myasthenia gravis, dermatomyositis, MD, cricopharyngeal incoordination
• What is esophageal dysphagia? Ssx?
o Hard to pass food down E
o Ssx: sensation of food stuck throat/chest, regurg, drool, wt loss, recurrent pneumonia
• What are some causes of esophageal dysphagia?
o Motility dos: achalasia, DES, systemic sclerosis, eosinophilic E-it is
o Mechanical obstruction: peptic stricture, E CA, lower E rings, caustic ingestion, extrinsic compression (big LA, AA, aberrant subclavian artery, substernal thyroid, cervical bony exostosis, thoracic tumor)
• What PE is done for E dysphagia?
o nutritional status (include weight)
o Complete neuro: resting tremor, cranial nerves, ms strength, observe gait, test balance
o Skin: rashes, thickening
o Muscles: wasting, fasiculations, tenderness
o Neck: thyromegaly, masses
• What are some helpful findings and possible cause for dysphagia?
o Tremor, ataxia, balance disturbance: PD
o Focal easy fatigability (esp facial mm): Motor neuron dz, myopathy
o Rapidly progressive, constant dysphagia, no neuro finding: E obstruction, prob CA
o GERD sxs: Peptic stricture
o Intermittent dysphagia: LE rig, DES
o Slow progression (mos-yrs) of dysphagia to solids and liquids, mb nocturnal regurgitation: achalasia
o Neck mass, thyromegaly: Extrinsic compression
o Dusky, erythematous rash, muscle tenderness: dermatomyositis
o Raynaud’s, arthralgias, skin tightening/contractures of fingers: Systemic sclerosis
o Cough, dyspnea, lung congestion: Pulmonary aspiration
• What is the work-up for dysphagia?
o endoscopy to r/o CA
o Barium swallow (w solid bolus): May show obstruction, if negative or suggestive of motility do then order motility study
• What are red flags for dysphagia?
o Sxs of complete obstruction (drool, can’t swallow anything)
o → weight loss
o New focal neuro deficit, esp objective weakness
• What is cricopharyngeal incoordination? Etio, ssx, complications, tx?
o = upper E sphincter → Zenker’s diverticulum
o Etio: neuromuscular dos
o Ssx: choking, swallowing air, regurg fluid into nose, dysphagia w solids
o Comp: Repeated aspiration of material from diverticulum → chronic lung dz
o Tx: surgical section of the muscle
• What are lower E rings? Ssx? Work up?
o aka Schatski’s Ring
o 2-4mm mucosal stricture, prob congenital → ring-like narrowing of distal E at SCJ
o Ssx: intermittent dysphagia for solids, esp. meat and dry bread; can begin at any age, usu after 25
o Work-up : Barium swallow
• What are esophageal webs? Etio, ssx, work up, px?
o Seen in Plummer-Vinson Syndrome; Paterson Kelly Syndrome; Sideropenic Dysphagia
o thin mucosal membrane across lumen, usu in upper E
o Etio: rarely develop w severe untx IDA (Plummer-Vinson Syndrome)
o Ssx: Dysphagia for solids
o Work-up: barium swallow
o Px: usu resolve w tx anemia, can easily rupture during esophagoscopy. May increase risk for SCC of E
• What is dysphagia lusoria? Work up?
o Dt compression of E dt congenital abnormalities, usu dt aberrant R subclavian a
o Work-up: Barium swallow (extrinsic compression)
o Arteriography for absolute diagnosis
