Esophageal D/os; Peptic Ulcer Disease

Front 1

The trachea is (anterior, posterior) to the esophagus.

Back 1

anterior

Front 2

A tumor from the esophagus can spread to the trachea and cause the development of a _______

Back 2

tracheo-esophageal fistula.

Front 3

Blood supply of esophagus and implciations

Back 3

It steals arterial branches from the inferior thyroid artery, aorta, etc. Therefore, esophageal surgery is very difficult since many blood vessel anomalies can be present.

Front 4

What are the 3 functional/physiological phases of swallowing?

Back 4

1) Preparatory phase - conscious effort to ingest food and reflexes in the oral cavity that help prepare bolus to be swallowed
2) Transfer phase - reflex activities in oral and pharyngeal phases
3) Transport phase - transport of food bolus thru LES and stomach

Front 5

What are the 3 anatomical phases of swallowing?

Back 5

1) Oral
2) Pharyngeal
3) Esophageal

Front 6

Where is voluntary/striated muscle located re the esophagus?

Back 6

In the upper 1/3.

Front 7

What innervates the voluntary/striated muscle of the esophagus?

Back 7

The upper 1/3 of esophague is innervated by lower motor neurons that are <b>all excitatory</b> by release ACh at motor end plates.

Carried by cranial nerves, including Vagus.

Front 8

Where is involuntary/smooth muscle located re the esophagus?

Back 8

Lower 2/3 and Lower Esophageal Sphincter

Front 9

What innervates the involuntary/smooth muscle of the esophagus?

Back 9

Autonomic innervations that consist of extrinsic preganglionic fibers that are carried in teh vagus nerves and intramural postganglionic neurons that are part of the myenteric plexus.

There is <b> excitatory pathway (ACh) and inhibitory pathway (VIP/NO) </b>

Front 10

What do the excitatory autonomic neurons innervating esophageal smooth muscle release?

Back 10

ACh, just like the voluntary muscle.

Front 11

What do the inhibitory autonomic neurons innervating esophageal smooth muscle release?

Back 11

Vasoactive intestinal peptide (VIP) and NO

Front 12

Where is the upper esophageal sphincter located?

Back 12

The UES is between pharynx and cervical esophagus.

Made of back of thyroid/cricoid cartilage, hyoid bone, and three muscles: cricopharyngeus, thyropharyngeus, and cranial cervical esophagus.

Front 13

Between what muscles is there a zone of sparse musculature through which a zenker's diverticulum might emerge?

Back 13

The thyropharyngeus and cricopharnygeus, which are oriented in different directions.

Front 14

Major anti-reflux barrier

Back 14

Lower esophageal sphincter (LES)

Front 15

Deglutition : defn

Back 15

act/process of swallowing

Front 16

Neural mechanism of primary peristalsis

Back 16

Premotor neurons in solitary tract send projections to dorsal motor nucleus of vagus, which inhibits the LES and excites others sequentially.

Front 17

Neural mechanism of secondary peristalsis

Back 17

Local intramural reflex that's elicited by distension of the esophagus.

Clears esophagus of food residues.

Front 18

What is the transient LES relaxation? (TLESR)

Back 18

It's inappropriate relaxation of the LES without the peristaltic stimuli. May be part of belch reflex, implicated as important mech for GERD.

Front 19

What are some important Extra-esophageal symptoms of esophageal diseases?

Back 19

Asthma

Halitosis

Cough

Apnea

Hemoptysis

Hoarseness

Dental erosions

Front 20

Odynophagia: defn

Back 20

pain with swallowing.

Can be achy or stabbing with radiation.

Front 21

Pyrosis: defn

Back 21

"heartburn"

Burning discomfort behind breastbone, beginning inferiorly and radiation up to neck

Front 22

What is water brash?

Back 22

Sudden appearance in mouth of slightly sour or salty fluid secreted from salivary glands in response to intraesophageal acid

Front 23

Physiology of heartburn

Back 23

Not well understood. Same symptom can be elicited with distension of esophagus, reflex of bile salts, and others.

Front 24

Globus sensation: defn

Back 24

Feeling of tightness or lump in thoat. NOT related to swallowing.

Front 25

Hiatal hernia: defn

Back 25

herniation of gastroesophageal junction and/or stomach thru diaphragmatic hiatus. Different types.

Front 26

What is the strongest predcitor of the severity of esophagitis?

Back 26

Size of hiatal hernia

Front 27

Barrett's esophagus: defn

Back 27

metaplastic columnar epithelium replaces the normal squamous epithelium of the distal esophagus.

Front 28

Complications of Barrrett's esophagus

Back 28

Higher risk for esophageal adenocarcinoma

Front 29

4 GERD management options

Back 29

1) Lifestyle mods

2) Acid neutralization (antacids)

3) proton pump inhibitors

4) anti-reflux surgery

Front 30

What is eosinophilis esophagitis?

Back 30

Symptoms of esophageal dysfunction in association with histologic evidence of eosinophilic infiltration of esophageal mucosa

Front 31

T/F eosinophilic esophagitis is associated with atopy

Back 31

T.

Front 32

T/F There are normally a small amount of eosinophils in the esophagus.

Back 32

F. Unlike the rest of the Gi tract, the esophagus normally doesn't contain eosinophils

Front 33

Tx for eosinophilic esophagitis

Back 33

fluticasone (swallowed instead of inhaled)

Front 34

What is achalasia cardia?

Back 34

Insufficient lower esophageal sphincter relaxation and loss of esophageal peristalsis.

Poor esophageal emptying of barium, dilation esophagus

Front 35

Goal for achalasia tx

Back 35

Relief of sx and improved esophageal emptying.

Front 36

What is achalasia tx?

Back 36

pneumatic dilation and surgical myotomy

Also injection of LES with botulinum, or tx with CCBs or nitrates

Front 37

What is Zenker's diverticulum?

Back 37

Outpouching of mucosa thru Killians triangle, area of muscular weakness between oblique fibers of inferior pharyngeal constrictor and transverse fibers of cricopharyngeus

Front 38

area of muscular weakness between oblique fibers of inferior pharyngeal constrictor and transverse fibers of cricopharyngeus thru which a Zenker's diverticulum can occur

Back 38

Killian's triangle

Front 39

sx of Zenker's diverticulum

Back 39

Dysphagia, foul breath, gurgling in throat, pulmoanry aspiration

Front 40

Typical Zenker's diverticulum patient

Back 40

male 6-8th decade

Front 41

chronic abdominal pain and altered bowel habits in absence of organic cause

Back 41

irritable bowel syndrome

Front 42

What are the Rome III diagnostic criteria for irritable bowel syndrome?

Back 42

Recurrent abdominal pain or discomfort at least 3 days/month in last 3 months associated with 2 or more of the following

1) Improvement with defecation

2) Onset associated with a change in frequency of stool

3) Onset associated with a change in the form (appearance) of stool

Front 43

hematochezia: defn

Back 43

passage of fresh blood per anus, usually in or with stools (contrast with melena).

Front 44

What are IBS "alarm" features for which to consider an alternative dx?

Back 44

1) hematochezia

2) Weight loss >10 lbs

3) Family hx of colon cancer

4) recurring fever

5) Anemia

6) Chronic severe diarrhea

Front 45

borborygmus: defn

Back 45

stomach growling, rumbling, gurgling

Front 46

Most common type of hiatal hernia (95%)

Back 46

Sliding

Front 47

Which esophageal cancer:
almost always in upper and middle third of esophagus (smoking, alcohol, achalasia)

Back 47

squamous cell

Front 48

Which esophageal cancer:
almost always in lower third of esophagus

Back 48

adenocarcinoma

Front 49

What is considered to be the gold standard for the diagnosis of GERD?

Back 49

Nothing. All of the methods (upper endoscopy, impedance testing, barium esophagram) have their problems.

Front 50

Converts pepsinogen --> pepsin (pepsin is the proteolytic enzyme)

Back 50

Gastric acid

Front 51

The proton pump inhibitors end in what?

Back 51

-azole

Front 52

What does gastric acid facilitate absorption of?

Back 52

iron, B12, calcium

Front 53

2 functional areas of stomach

Back 53

oxyntic(parietal) areas - secrete acid - 80%

pyloric gland areas - secrete gastrin - 20%

Front 54

The cardia, fundus, and body are the ______ area, while the antrum is the _____ area.

Back 54

oxyntic ; pyloric gland

Front 55

Where are the pepsinogen-secreting chief cells found in the stomach?

Back 55

At the base of the oxyntic gland

Front 56

In the oxyntic gland, Somatostatin cells are structurally and functionally coupled to the parietal and histamine-containing Enterochromaffin-like cells (ECL)s and inhibit the secretion of __ and ___

Back 56

acid and histamine

Front 57

In the pyloric gland, Somatostatin cells are structurally and functionally coupled to ____ cells and inhibit secretion of _______.

Back 57

G cells; gastrin

Front 58

two main complexes of the enteric nervous system

Back 58

1) Myenteric plexus

2) Submucosal plexus

Front 59

What does the myenteric plexus innervate and do?

Back 59

Innervates circular and longitudinal muscle layers, regulates motility.

Front 60

What does the submucosal plexus innervate and do?

Back 60

innervates the mucosa, regulates secretion.

Front 61

The efferent fibers of the vagus are (pre, post) ganglionic, release ______.

Back 61

pre; ACh

Front 62

How does H pylori stimulate gastrin and acid secretion?

Back 62

It inhibits antral somatostatin secretion, thus stimulating gastrin and acid secretion.

Front 63

Release of acid into stomach lumen (stimulates, inhibits) somatostatin secretion

Back 63

stimulates

Front 64

The H/K/ATPase reabsorbs ___ in exchange for ____

Back 64

K; H

Front 65

What is the structure of the H/K/ATPase?

Back 65

Heterodimer, consisting of an &alpha; catalytic portion and a &beta; subunit.

Front 66

How do the -azoles interact with the H/K/ATPase?

Back 66

They inhibit the activity of the &alpha; subunit

Front 67

What causes the H/K/ATPase to become active?

Back 67

Stimulation causes it to be translocated to the membrane

Front 68

What types of things increase gastrin release?

Back 68

Presence of proteins, amino acids, amines.

Distension.

Neutralization of the lumen (antisecretory drugs), atrophy.

Massive small bowel resection.

H pylori

Front 69

What are indications for measurement of gastric acid secretion in humans?

Back 69

Recurrent ulcer, especially after acid-reducing surgery, to r/o ZES and to test completeness of vagotomy.

Front 70

Defn of peptic ulcer disease

Back 70

Benign ulcerative lesion of the stomach and/or duodenum extending thru muscularis mucosa

Front 71

T/F Gastric acid is central to the pathogenesis of the peptic ulcer diseases

Back 71

T

Front 72

Clinical features of peptic ulcer disease

Back 72

1) Abdominal pain

2) Nausea/vomiting - unusual unless there's an obstruction

3) Complications of bleeding, obstruction, perforation, pancreatitis

Front 73

tx for peptic ulcer disease

Back 73

Antisecretory drugs: H2 blockers or PPIs

Eliminate inciting factor (H pylori) or NSAIDS. If not eliminated, then it will recur.

Surgery (highly selective vagotomy or antrectomy)

Front 74

What type of bacteria is H pylori?

Back 74

Spiral shaped gram-negative with flagella

Front 75

How to dx H pylori?

Back 75

Histologic stains

Rapid urease test (H pylori has urease and metabolizes urea to NH3 and CO2)

Urea breath test

Serology

Culture

Front 76

What are the two enzymes that nonselective NSAIDs inhibit?

Back 76

COX1 (constitutive) and COX2 (induced by inflammatory stimuli)

Front 77

Which COX provides GI cytoprotection as well as platelet activity?

Back 77

COX1

Front 78

T/F There is direct AND indirect damage done to gastric mucosa by aspirin and ibuprofen

Back 78

T

Front 79

What is the indirect damage done to the gastric mucosa by NSAIDs?

Back 79

Decreased mucosal blood flow

Decrease mucus secretion

Decrease bicarb secretion

Increase acid secretion

Leukocyte adherence to vasculature

Increase TNF&alpha;

Front 80

Side effects / toxicity of NSAIDs

Back 80

1) Ulcers (pain, bleeding, perforation, obstruction)
2) Elevated transaminases
3) Inhibition of platelet aggregation
4) Kidney: fluid retention, hyperkalemia, ARF, HBP

Front 81

How is the NSAID-induced ulcer prevented?

Back 81

Discontinue or change the NSAID

Misoprostol

H2R Antagonists - high dose

PPIs

use a COX2 selective NSAID (there is concern for CV problems)

Front 82

Zollinger-Ellison Syndrome: Defn

Back 82

Gastrin secreting tumor causing gastric acid hypersecretion

Front 83

Where are the gastrinomas located?

Back 83

>95% in pancreas and duodenum

Front 84

20% of Zollinger-Ellison syndrome patients hve what disease?

Back 84

MEN1: multiple endocrine neoplasia type 1

Front 85

Symptoms of Zollinger-Ellison syndrome

Back 85

Pain, Diarrhea, Dysphagia/heartburn

Front 86

Tx of Zollinger-Ellison

Back 86

Control acid hypersecretion (PPIs)

Localie and remove tumor.

If no liver metastases then evaluate whether patient has MEN1

Front 87

_____ cell releases somatostatin which inhibits the ECL cell from releasing histamine and the parietal cell from releasing H+

Back 87

D

Front 88

What are the effects of the vagus' release of ACh onto the D cell?

Back 88

They INHIBIT the D cell (inhibits the release of somatostatin (which promotes release of gastrin))

Front 89

What are the effects of the vagus' release of ACh onto the G cell?

Back 89

Stimulates G cell

Front 90

What are the effects of the vagus' release of ACh onto the parietal cell?

Back 90

stimulates release of H+

Front 91

When is the best time to take PPIs?

Back 91

Before meals

Front 92

What are potential side effects of PPIs?

Back 92

"addiction" - rebound acid hypersecretion

Drug-drug interactions

Increased susceptibility to C. difficile infections

Osteoporosis/fracture

Hypomagnesemia

Front 93

What is the mechanism behind the physiological addiction to PPIs?

Back 93

Normally H+ inhibits the release of gastrin by stimulating SST. However, when there is less H+, there is MORE GASTRIN. It takes awhile for this effect to balance out.

Front 94

An ulcer is A TRANSMUCOSAL hole that occurs in the esophagus, stomach,
duodenum, or intestine due to a combination of ____ and _____.

Back 94

ACID and PEPSIN

Front 95

Best diagnostic tests for H pylori

Back 95

Urea breath test

Rapid urease test