Gastroenterology
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| Esoph dx studies (4) | Barium esophagram (limited value); Upper endoscopy w/bx; Esophageal Manometry; Ambulatory esophageal pH monitoring
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| Heartburn (pyrosis) = | substernal burning, epigastric pain radiating to the neck
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| Transfer dysphagia etiologies (3) | Oropharyngeal. Neurologic Dysfunction (CVA, ALS). Zenker Diverticulum (most common)
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| Transport dysphagia = | Esophageal: food sticks
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| Odynophagia: Causes (2, but 4 answers in 2nd one) | Caustic (corrosive injury); infectious (CMV, Herpes, Candida, HIV)
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| GERD requires 3 factors: | Reflux (dysfn of anti-reflux mechanisms); reflux of caustic materials; sufficient duration of contact
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| Chest Pain can be due to: | GERD, diffuse esophageal spasm, nutcracker esophagus, achalasia
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| GERD s | Heartburn (30-60 min after meals, often when supine); Regurgitation; Sour brash; Dysphagia; Relief with antacids
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| Alarm sxs (5) | Dysphagia, weight loss, hematemesis, melena; Sx at age >50
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| Upper endoscopy: purpose: | document type/ extent of tissue damage in GERD; look for erythema, friability, stricture, Barrett’s
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| Barrett esophagus: pathophys | change of squamous epi cells to columnar epi; stomach creeping up into esophagus
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| Standard procedure for detecting pathologic acid reflux in the esophagus: | ambulatory pH monitoring
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| Manometry tests: | function of the esophageal mx contractions & esophageal sphincters; to ensure proper peristalsis, & proper sphincter fn prior to any surg/endoscopic correction for reflux
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| GERD complications | Barrett esophagus; stricture (scarred down)
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| GERD mgmt: | Lifestyle mods (wt loss, low fat diet, avoid food triggers), antacid trial; Rx (H2 antagonists, Reglan, PPI for severe); Surgical (fundo) if med tx fails
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| Indications for screening EGD for Barrett's | Sx > 10 years, age >50, white males
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| Barrett dx requires: | bx-proven presence of specialized intestinal metaplasia in the tubular esophagus
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| Metaplasia/Dysplasia/Car: poss interventions | Medical acid suppression tx; Anti-reflux surg; Endoscopic surveil; Endoscopic ablation tx; Esophagectomy
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| Infectious esophagitis: common agents: | Candida, CMV, HSV (ie, immunosuppressed pts: HIV, organ transplant, leuk/lymphoma)
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| Infectious esophagitis sx/sx: | Odynophagia, dysphagia, retrosternal CP; oral thrush common
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| Web = | a thin infolding of mucosa that narrows/constricts the lumen, typically in proximal esophagus
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| Plummer Vinson Syndrome | Symptomatic proximal webs in middle-aged women with evidence of Fe deficiency anemia; increased risk of cancer
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| Schatzki ring = | a web that occurs in the distal esophagus (at squamocolumnar mucosal junction)
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| Zenker diverticulum = | Outpouching in posterior wall at pharyngoesophageal junction; most common cause of transfer dysphagia; Men >60 yo
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| Zenker diverticulum sx | regurgitation, dysphagia, halitosis; ?palpable neck mass
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| Eosinophilic esophagitis | Rare/idiopathic; food allergies & asthma; food impaction, reflux, strictures; mucosal rings; >15 Intraepithelial Eos/hpf; concern for perf w/dilation
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| Eosinophilic esophagitis: mgmt | PPI; allergy testing & elimination diet; topical corticosteroids (fluticasone); systemic corticosteroids; +/- esoph dilatation
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| GI bleed 2/2 esophageal dz: | 1/3 of all pts with esophageal varices (2/2 portal HTN); Mallory Weiss tear; esophageal ulceration
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| Achalasia: Sx/Sx | Gradual, progressive dysphagia; regurgitation; substernal discomfort/fullness; anorexia
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| Achalasia: dx gold standard = | HRM: high-resolution manometry
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| Achalasia imaging modalities | CXR. Barium esophagography. Upper endoscopy
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| Achalasia: Mgmt | Endoscopic-guided Botox (relief in 2/3 of pts for 6-12 mos); Pharm (nifedipine); Fluoro-guided pneumatic dilation; botox; Myotomy (85% success rate)
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| Diffuse esophageal spasm: sx/sx | anterior nonexertional CP (unrelated to eating); simultaneous, nonperistaltic contractions of esophagus; usually self-limited
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| Diffuse esophageal spasm dx | Barium Esophagography: corkscrew or rosary-bead contraction below aortic arch; manometry: large amplitude intermittent simultaneous contractions
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| Most common connective tissue disorder involving the esophagus: | Scleroderma esophagus (atrophy & fibrosis of esophageal smooth mx)
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| Scleroderma esophagus: Dx findings: | Barium esophagography: patulous LES with free reflux; manometry: low amplitude/absent LES pressure; upper endoscopy detects Barrett or peptic stricture
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| Esophageal ca: presentation | Progressive solid food dysphagia, weight loss
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| Esophageal ca eval | CXR (mediastinal widening, lung or bony mets); barium esophagram (polypoid, infiltrative, or ulcerative lesion); EGD w/ bx (gold standard); Chest CT/EUS for staging
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| Esoph ca: tx | mainstay: surg resection (complete esophagectomy); unresectable: Rtx, Ctx, endoscopic stenting for palliation
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| GERD pathophysiology: | inappropriate relaxation of LES
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| Drugs, etc that decrease LES tone -> GERD: | caffeine, nicotine, CCBs, nitrates, theophylline, sedatives
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| Optimal study to find pathologic reflux (esp in patients with normal endoscopy result) = | Ambulatory esophageal pH monitoring
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| infectious esophagitis workup = | EGD with biopsies
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| Endoscopic findings suggesting candidal esophagitis: | linear or diffuse yellow-white plaques
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| Endoscopic findings suggesting CMV vs HSV esophagitis: | CMV: single & multiple superficial ulcers; HSV: deep ulcers
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| CMV esophagitis tx = | IV ganciclovir (if not tolerated: IV foscarnet)
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| Common causes of pill esophagitis: | NSAIDs, iron, Abx, vitamin C, KCl, quinidine, zalcitabine, zidovudine, alendronate
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| Achalasia pathophysiology: | Progressive degeneration of ganglion cells in myenteric plexus in esophageal wall & loss of inhibitory (VIP- and nitric oxide-releasing & LES-dilating) neurons. Loss of esophageal smooth mx peristalsis in distal 2/3; increased tonus of LES
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| Diffuse esophageal spasm mgmt | Sx reduction. SL NTG, nitrates, CCBs may be effective; dilation w/Maloney bougies vs long myotomy if intractable
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| Scleroderma esophagus is often associated with this syndrome: | CREST syndrome
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| Scleroderma esophagus complications | severe erosive esophagitis; peptic stricture; Barrett metaplasia
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| Scleroderma esophagus mgmt: | H2 blocker, PPI, promotility agents; dilation if peptic stricture
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| esophageal varices tx | Tx underlying coagulopathy (if present); endoscopy +/- banding or sclerotherapy; balloon tamponade if big bleed; vasoconstrictive Rx (vasopressin / octreotide); Cipro IV
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| Scleroderma esophagus pathophysiology | Atrophy & fibrosis of esoph smooth mx -> low amplitude peristaltic waves -> aperistalsis. Decreased LES pressures -> free GE reflux & esophagitis
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| Zenker diverticulum mgmt: | Cricopharyngeal myotomy +/- diverticulectomy or excision
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| Esoph ca: SCC is associated with: | smoking and EtOH. AA > white. Most common type worldwide
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| Esophageal ca: adenocarcinoma is associated with: | GERD, increased BMI. White > AA. Barrett esophagus is precursor. Most common type in western world
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| Esophageal cancer is associated with mets to: | LNs, liver, lungs, bone, and brain
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| Corkscrew esophagus = | esophageal spasm
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| Bird's beak on imaging = | achalasia
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| Heartburn DDx | GERD, PUD/ gastritis, gallstones, pancreatitis
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| Achalasia definition | motor disorder in which the LES fails to relax, leading to a functional obstruction
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| 3 types of Achalasia | Type I (classic): minimal contractility in the esophageal body. Type II: intermittent panesophageal pressurization. Type III (spastic): premature or spastic distal esophageal contractions
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| Achalasia: findings on manometry | Complete absence of peristalsis, with simultaneous, low amplitude waves. Very tight LES. Lack of contractions in esophagus
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| Achalasia findings on CXR | Air-fluid level in enlarged, fluid-filled esophagus
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| Achalasia findings on barium esophagography | Bird's beak: smooth symmetric tapering; esophageal dilatation "sigmoid esophagus;" loss of peristalsis
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| Sx/sx of achalasia resemble those of which parasitic infestation? | Trypanosoma cruzi
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| GERD: pathophys, s/s | low LES/high intra abd pressure; burning epigastric pain, recurs despite food; cough, hoarse, dysphagia
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| GERD: dx tests, tx | EGD, barium (inc upper GI; sens < EGD), manometry; tx avoid trigger foods; H2 or PPI
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| Barrett esophagus physio | low stomach pH changes esoph squamous cells to adenomatous cells
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| esophageal dz: motility disorder vs mech obstruction | motility: prob swallowing solid/liquid; mech obstruction: prob swallowing solid
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| Choking, cyanosis, respiratory distress, increased secretions in 1st hours of life | Tracheoesophageal fistula
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| Alcoholic with massive hemoptysis | Esophageal varicies (Tx w/ octreotide)
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| Barrett esophagus: | pathophys change of squamous epi cells to columnar epi; stomach creeping up into esophagus
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| Plummer Vinson Syndrome | Symptomatic proximal webs in middle-aged women with evidence of Fe deficiency anemia ("sideropenic dysphagia"); increased risk of cancer
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| Schatzki ring = | a web that occurs in the DISTAL esophagus
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| Zenker diverticulum | Outpouching of upper esophagus; always involves posterior wall of pharynx; most common cause of transfer dysphagia; Men >60 yo
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| Achalasia definition | absence of esophageal smooth mx peristalsis w/ increased tonus of lower esophageal sphincter
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| Achalasia: S/S | Gradual, progressive dysphagia; regurgitation; substernal discomfort/fullness
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| Most common muscular abnormality in pts with GERD: | transient LES relaxations (TLESRs)
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| Schedule of EGD surveillance for pts with Barrett | Every 2 years. Increase frequency if bx shows low-grade dysplasia; consider resection if high-grade
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