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45 Cards in this Set
- Front
- Back
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EGU/upper endoscopy
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-passing an endocope with a light and video camera on one end through the mouth to examine the esophagus, stomach and duodenum
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BRAVO/Esophageal pH testing
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-capsule is passed through your mouth and suctioned to the wall of your esophagus
-the capsule transmits data every 12 sec to a pager that is worn for 48hrs |
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Manometry
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-procedure to measure the tone within the esophagus and also the esophageal sphincter
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muscular anatomy of the esophagus
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-upper third is striated muscle
-middle third is a combination of striated and smooth muscle -lower third - smooth m |
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Nerve innervation of esophagus
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1. Parasym: motor innervation
2. Sympath: regulates blood vessel constriction, esophageal sphincters contractions, relaxation of the muscular wall, and increases in glandular and peristaltic activity -peristalsis - vagus n -spinal afferent act as nociceptors |
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layers of the esophagus
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-mucosa
-lamina propria -muscularis mucosae -submucosa -muscularis externa |
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upper esophageal sphincter anatomy
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-prevent esophageal air insufflation
-Prevent esophagopharyngeal & laryngeal reflux -contracted at rest |
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lower esophageal sphincter
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-Composed of thickened circular smooth muscle
The Z-line marks the boundary between the esophageal squamos epithelium and the gastric columnar epithelium. The phrenoesophageal ligament helps fix the LES within the diaphragm Is contracted at rest |
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types of peristalsis
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Primary peristalsis- a reflex associated with swallowing, involves all phases of the swallowing reflex including the oral phase, pharyngeal peristalsis, UES relaxation, esophageal peristalsis, and LES relaxation.
Secondary peristalsis- restricted to the esophagus, not accompanied by pharyngeal contraction or UES relaxation Tertiary Contractions- not normally seen, nonperistaltic |
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odynophagia
globus pyrosis |
-pain with swallowing
-nonpainful sensation of a lump/foreign body in throat -heartburn |
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dyspepsia
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one or more of the following: postprandial fullness
Early satiety and/or epigastric pain or burning |
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Oropharyngeal dysphagia
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-disease arising from the cranial nerves or skeletal muscle
-Arise from disorders that affect the function of the oropharynx, larynx, and upper esophageal sphincte, such as: poor dentition, decrease in salivary, neurologic disorders, disruption of the oropharyngeal mucosa, neuromuscular discoordination, zenkers diverticulum |
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Zenker's diverticulum
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-outpouching of the mucosa through killan's triangle
-above the UES, at midpoint of esophagus, or just above the LES. -older adults -can retain contents -sx:dysphagia, gurgling in throat, regurgitations -tx: surgical or endoscopic resection |
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Esophageal dysphagia
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-arises within the body of the esophagus, the lower esophageal sphincter, or cardia, and is most commonly due to mechanical causes (obstruction) or a motility disturbance.
-If related to solids only-likely caused by obstruction: stricture, ring, or lesion. -If related to liquids and solids like due to motor dysfunction like esophageal spasm or achalasia. |
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Esophageal rings/webs
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-web: thin mucosal fold that protrudes into the lumen; related to bullous conditions, iron def, graft vs. host dz
-ring: related to damage from GERD -cause solid food dysphagia -tx: EGD with dilatation, PPI ->50% recoccur w/in 5 yrs |
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Esophagitis
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-inflamm/irritation of esophagus
-causes: GERD,meds, chemical ingestion, radiation, infx -sx: pyrosis/dyspepsia, dysphagia, odynophagia -rx: identify cause, reverse if possible, protect mucosa |
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Squmous cell cancer risks
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1. familial
2. smoking 3. alcohol 4.foods containin N-nitroso liked pickled foods and mets 5. Betel nut chewing 6. Zinc def 7. HPV |
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adenocarcinoma risks
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1. GERD
2. smoking 3. obesity 4. H. pylori infx 5. foods containing N-nitroso |
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Esophageal spasm
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-sx: dyspepsia, dysphagia. chest pain
-dx with manometry -mgmt: Calcium Channel Blockers diltiazem tid before meals, tricyclic antidepressants like imipramine , nitro 0.3mg 4-5 min before meals |
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Achalasia
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-loss of peristalsis in the distal esophagus and failure of LES relaxation
-sx:dysphagia to solids >liquids, difficulty belching, wt loss, regurgitation, chest pain -increases risk of developing squamoua cell cancer |
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Achalsais tx
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Dilatation of LES-temporary relief, can increase reflux symptoms afterward
Surgical myotomy-70% have improvement still at 10 years, increase GERD symptoms along with risk of Barretts and squamos cell CA Botox of LES-inhibits release of acetylhcoline and relaxes LES, mild to moderate improvement, no long term studies regarding efficacy or safety. |
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GERD
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-sx: heartburn, "agita", bloating, early satiety, N/V
-caused by acid from the stomach entering esophagus from: transient lower esophageal sphincter, hypotensive lower esophageal sphincter, anatomic disruption of gastroesophageal junction -esophageal acid clearance is altered -esophageal emptying is impaired |
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Hiatal hernia
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-a condition in which a portion of the stomach protrudes upward into the chest, through an opening in the diaphragm
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GERD-hx
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1. ulcer-like complaints: burning, epigastric hunger pain with food
2. Dysmotility-like complaints: chest pain/pressure, N, bloating 3. Unspecific dyspepsia-vague epigastric discomfort or burning, not necessarily related to meals, increased with lying down, c/o bloating, burping, sour taste in mouth, possible hiccups |
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GERD-PE
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-usually nml except for epigastric tenderness
-evaluate with the Carnett test: increased local tenderness during muscle tensing |
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GERD-diagnostic strategies
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1. trial of PPI or H2 blockers
2. noninvasive testing for H.pylori infx 3. Endoscopy 4. upper GI series (May demonstrate active ulcers and reflux when occurring, limited by technique and interpretation) |
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Gastric malgnancy-Alarms
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Unintended weight loss
Persistent vomiting Progressive dysphagia Odynophagia Anemia Hematemesis Palpable abdominal mass or lymphadenopathy Unexplained iron deficiency anemia Family history of upper gastrointestinal cancer Previous gastric surgery Jaundice |
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EGD
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-Gold standard for dx of PUD, GERD, and malignancy
-Diagnostic yield of EGD for dyspepsia increases with age |
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mgmt of GERD
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1. elevate head of bed
2. avoid exacerbating foods, acidic beverages, mint, caffeine, alcohol 3. avoid tight fitting garments 4. stop smoking 5. chew gum or inc salivation 6. PPI (prazoles) or H2 blocker (cimetidine, famotidine) 7. Metocloprimide:Increase LES tone, enhance gastric emptying, and improve peristalsis; used in refractory GERd; many SE |
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problems with long term acid suppresion
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Atrophic Gastritis
Enteric Infections Vitamin B12 Malabsorption Decreased Calcium absorption and Osteopenia/porosis |
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Barrett's esophagus
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-abnormal, intestinal-type epithelium called specialized intestinal metaplasia replaces the normal stratified squamous epithelium of the distal esophagus
-develops as a consequence of chronic GERD -predisposes to adenocarcinoma tx: esophagectomy, ablation, palliative (chemo, radiation) |
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Peptic ulcer disease
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-Defects in the gastrointestinal mucosa that extend through the muscularis mucosae
-causes: H. pylori and NSAIDs also...infx, drugs, hormonal or mediator induced, vascular |
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gastric and duodenal ulcers
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-gastric- more likely to be NSAID related; higher rate of cancer
-duodenal- morel likely H.pylori related |
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presentation of PUD
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-asymptomatic
-upper or lower GI bleed -dyspepsia: burning, epigastric hunger pain with food, antacid and antisecretory agent relief -anorexia, wt loss, early satiety -classic of duodenal ulcer: pain 2-5 hrs after meals -gastric ulcer-more severe pain occuring soon after meals -dx: EGD |
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Complications of PUD
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1. bleeding
2. perforation 3. penetration 4. obstruction |
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perforation
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-ulcer erodes through all layers of the stomach or duodenum
-NSAID use -sudden onset of severe diffuse abd pain and possibly altered VS/signs of shock |
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Penetration
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-Penetration of the ulcer through the superficial layers of stomach wall without free perforation and leakage of luminal contents into the peritoneal cavity
-Pain with meals, and loss of food and antacid relief |
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CLO test
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-A tissue sample is inoculated into a medium containing urea and phenol red, a dye that turns pink in a pH of 6.0 or greater. The pH will rise above 6.0 when H. pylori, the Campylobacter-like organism, metabolizes urea to ammonia by way of its urease activity
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Urea breath test
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-For the test, patients swallow a capsule containing urea made from an isotope of carbon
-If H. pylori is present in the stomach, the urea is broken up into nitrogen and carbon -The carbon dioxide is absorbed across the lining of the stomach and into the blood. It then is excreted from the lungs in the breath. Samples of exhaled breath are collected, and the isotopic carbon in the exhaled carbon dioxide is measured. |
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treatment of H.pylori
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-Standard dose PPI twice daily (or esomeprazole once daily) plus clarithromycin 500 mg twice daily, and amoxicillin 1000 mg twice daily for 10-14 days*
-metronidazole if allergic to PCN -bismuth, metronidazole, tetracycline, rantidine |
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treatment of PUD not related to H.pylori
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1. antisecretory med: H2 blockers, PPIs
2. Sucralfate 3. Misoprostol |
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treatment of refractory ulcers
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-most respond to oral therapies
-Must differentiate between continued symptoms and continued disease -surgery last resort: vagotomy,gastric resection, vagotomy with antrectomy -r/o hypersecretory cause and tx |
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Gastrectomy complications
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1. post vagatomy dirrhea
2. dumping-post prandial discomfort, nausea, vommitting, diarrhea, cramps, diaphoresis, palpitations 3. alkaline reflux 4. early satiety |
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NSAID induced PUD
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-Risk increased with: prior h/o ulcer, length of use, increased age, cotherapy, and ? Dose/strength
-Most subtle change is disruption of mucosal barrier -More sever problems include: edema, erythema, subepithelial hemorrhage, erosions, and ulcers |
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prevention of NSAID induced PUD
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1. misoprostol
2. PPIs |
