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158 Cards in this Set
- Front
- Back
|
When do you use PPI instead of endoscopy? |
Use a trial of proton pump inhibitor therapy rather than endoscopy for patients with suspected gastroesophageal reflux disease without alarm symptoms |
|
|
When do you repeat endoscopy for uncomplicated duodenal ulcers? |
Do not perform repeat endoscopy to confirm ulcer healing for uncomplicated duodenal ulcers unless the patient remains symptomatic despite treatment. |
|
|
What dose do you use for first line therapy for prophylaxis of NSAID related ulcers for patients with history or high risk of ulcer disease? |
For patients who have a history or high risk of ulcer disease, use standard-dose proton pump inhibitors as first-line therapy for prophylaxis of NSAID-related ulcers because they are as effective as high-dose proton pump inhibitors |
|
|
What stool studies do you do for patients with acute diarrhea? |
Do not routinely perform stool studies (fecal leukocytes, stool culture, ova and parasites, Clostridium difficile toxin assay) for patients with acute diarrhea, because the vast majority of patients will have a self-limited viral gastroenteritis that responds to supportive care |
|
|
When do you repeat colonoscopy for asymptomatic patients with low risk adenomas? |
Do not repeat colonoscopy within 5 years of an index colonoscopy in asymptomatic patients with low-risk adenomas (1 to 2 adenomas, <1 cm, tubular morphology, and low-grade dysplasia). |
|
|
What are low risk adenomas? (3) |
(1 to 2 adenomas, <1 cm, tubular morphology, and low-grade dysplasia). |
|
|
When do you repeat colonoscopy for hyperplastic polyps? |
Patients with a small number of hyperplastic polyps should be screened according to general population guidelines (every 10 years). |
|
|
What is the best serologic test for celiac disease? |
Tissue transglutaminase (tTG) IgA antibody, but the sensitivity (69%-93%) and specificity (96%-100%) vary significantly among laboratories |
|
|
What is the treatment for asymptomatic gallstones? |
Observation, not cholecystectomy, is recommended for adult patients with asymptomatic gallstones |
|
|
What are common symptoms of esophageal disorders? (5) |
Dysphagia, heartburn, acid regurgitation, chest pain, odynophagia, and globus sensation are common symptoms of esophageal disorders. |
|
|
What is the diagnostic test of choice for oropharyngeal dysphagia |
Videofluoroscopy. |
|
|
What is the diagnostic test of choice for esophageal dysphagia? |
Upper endoscopy |
|
|
What is management of functional oropharyngeal dysphagia? |
Dietary and postural measures to improve swallowing and reduce the risk of aspiration; consultation with a speech pathologist can be helpful in this regard. |
|
|
What are the causes of esophageal dysphagia? 2 categories (6/3) |
Structural: dysphagia lusoria (vascular dysphagia), epiphrenic/traction diverticulum, esophageal strictures, eosinophilic esophagitis, esophageal webs/rings, neoplasms; Motility disorders: achalasia, diffuse esophageal spasm scleroderma |
|
|
What is the most likely cause of progressive solid food dysphagia? |
Mechanical cause of obstruction |
|
|
What diagnosis is suggested by concomitant liquid and solid dysphagia? |
Motility disorder- achalasia |
|
|
Weight loss is concerning for what esophageal etiology? |
Malignancy |
|
|
What are the benefits of diagnostic test of choice for esophageal dysphagia? |
The diagnostic test of choice for esophageal dysphagia is upper endoscopy, which can be both diagnostic (allowing biopsy and visualization of the mucosa) and therapeutic (allowing dilation to be performed if indicated). |
|
|
When working up chest pain, what must be ruled out first? |
Cardiac causes must be ruled out before attributing chest pain to an esophageal cause. |
|
|
What is MCC of noncardiac chest pain and how do you treat it? |
MCC: untreated GERD; treat with empiric trial of PPI and if not working, upper endoscopy followed by ambulatory pH monitoring and/or esophageal manometry |
|
|
What are the causes of odynophagia? (2) |
Esophageal ulceration, which is usually caused by infectious esophagitis or pill-induced esophagitis. |
|
|
Best test for odynophagia? |
Upper endoscopy is the best test for odynophagia. |
|
|
What is cause of globus sensation? What is unlikely to be related to it? |
Unrelated to meals, GERD or swallowing. Related to emotional distress |
|
|
What disease presents with dysphagia to solids and liquids, aspiration, or chest pain? |
Esophageal motility disorders |
|
|
What is achalasia? |
Failure of esophageal peristalsis and failure of the lower esophageal sphincter to relax with swallowing. LES is tonically contracted. |
|
|
What is primary test for achalasia? |
Barium radiography (barium swallow) is the primary screening test for achalasia. |
|
|
What is the first line therapy for achalasia? |
Surgical release of the lower esophageal sphincter by laparoscopic myotomy is first-line therapy for achalasia. |
|
|
How do you classify hypertonic esophageal disorders? |
Esophageal manometry |
|
|
What is barium swallow test used for? |
Achalasia |
|
|
Symptoms of achalasia? |
Dysphagia, chest pain, regurgitation of fermented retained food, and weight loss. |
|
|
What do you see on barium swallow for achalasia? |
Bird's beak appearance distal and to and fro movement of barium from loss of peristalsis |
|
|
What do you need to confirm achalasia? |
Manometry |
|
|
When do you use upper endoscopy in achalasia? |
To exclude mechanical obstruction in region of the lower sphincter |
|
|
What do you call achalasia caused by a malignant lesion? |
Pseudoachalasia |
|
|
What is pseudoachalasia? |
obstruction caused by malignant lesion |
|
|
Treatment goal of Achalasia |
Lower resting pressures at lower esophageal sphincter |
|
|
1st line treatment for achalasia |
Surgical release of the lower esophageal sphincter by laparoscopic myotomy |
|
|
What must be done with 1st line treatment for achalasia to prevent complication? |
Nissen fundoplication to reduce risk of secondary GERD' |
|
|
Other options to treat achalasia, risks and benefits (3) |
1. Endoscopic pneumatic balloon dilatation - 5% esophageal perforation; 2. Botulinum toxin - lasts 6-9 months; 3. nitrates/CCB with inconsistent results |
|
|
Presentation of diffuse esophageal spasm |
dysphagia and chest pain |
|
|
Definition of Diffuse esophageal spasm |
intermittent high amplitude > 30 mmHg, simultaneous, nonperistaltic contractions in response to swallowing |
|
|
How do you diagnose Diffuse esophageal spasm? |
diagnosis made clinically; barium swallow with corkscrew esophagus, manometry following exclusion of other disorders (cardiac disease, GERD) |
|
|
What is long term complication of diffuse esophageal spasm? |
May progress to achalasia |
|
|
what is difference between nutcracker esophagus and diffuse esophageal spasm? |
DES: intermittent high amplitude > 30 mmHg; Nutcracker - distal esophageal pressures during peristalsis of > 220 mmHg |
|
|
Treatment for diffuse esophageal spasm |
1st line: CCB |
|
|
Manometry of hypotonic motility disorders |
low amplitude contractions with a substantial portion of nonperistaltic contractions = ineffective esophageal motility |
|
|
MC associated condition with hypotonic motility disorders |
GERD |
|
|
Causes of hypotonic motility disorders (2) |
1. Medications (narcotics) 2. systemic disease (scleroderma) |
|
|
Difference bewteen scleroderma esophagus and achlasia on manometry |
scleroderma: hypotensive LES; achalasia: hypertensive LES |
|
|
Complication of scleroderma esophagus |
GERD and complications associated with it |
|
|
Why is fundoplication not an option for hypotonic motility disorders? |
Esophageal aperistalsis causes severe dysphagia after fundoplication |
|
|
Hypotonic motility disorders - presentation |
dysphagia, slower transit times, increased risk for pill induced erosions |
|
|
MCC of infectious esophagitis (3) |
candida, HSV, CMV |
|
|
MCC of infectious esophagitis in immunocompetent patients |
Candida |
|
|
Difference in presentation between CMV and HSV esophagitis |
CMV: isolated esophageal ulcers; HSV: multiple superficial ulcers |
|
|
Risk factor for infectious esophagitis asides from immunosuppression |
Inhaled steroids |
|
|
How do you diagnose infectious esophagitis? |
Brushing for candida, biospies from ulcer BASE for CMV or EDGES for HSV |
|
|
Treatment for Candida esophagitis |
Antifungal |
|
|
Treatment for HSV esophagitis |
acyclovir |
|
|
Treatment for CMV esophagitis |
Ganciclovir |
|
|
Causes of pill induced esophagitis (6) |
tetracycline, iron sulfate, bisphosphonates, potassium, NSAIDs, or quinidine. |
|
|
How to diagnose eosinophilic esophagitis |
endoscopic biopsy after GERD excluded |
|
|
Treatment of eosinophilic esophagitis |
Swallowed aerosolized corticosteroids |
|
|
How to diagnose pill induced esophagitis |
Medication review and confirm with endoscopy |
|
|
Treatment for pill induced esophagitis |
Temporary cessation of medication or taking it with large bolus of water and avoid recumbent posture |
|
|
Presentation of eosinophilic esophagitis |
solid food dysphagia and food impaction |
|
|
Epidemiology of eosinophilic esophagitis |
asthma, seasonal allergies, male |
|
|
Diagnostic criteria for eosinophilic esophagitis |
> 15 eosinophils/hpf on esophageal endoscopic biospy and by exclusion of GERD with ambulatory pH monitoring or lack of response with empiric trial of PPI |
|
|
What happens if treatment for eosinophilic esophagitis does not work? |
systemic corticosteroids or food elimination diet, and/or esophageal dilation |
|
|
How to diagnost GERD |
Clinically - with heartburn or regurgitation |
|
|
How to treat GERD without alarm symptoms |
PPI empirically |
|
|
If empiric PPI does not work for GERD without alarm symptoms, what do you do? |
Endoscopy to assess for alternative diagnoses |
|
|
H2 blockers vs. PPI |
Proton pump inhibitors have been shown to be superior to H2 blockers or placebo in relieving symptoms of gastroesophageal reflux disease and healing esophagitis. |
|
|
MC SE for PPI |
headache, diarrhea, abd pain, and constipation |
|
|
How to treat SE associated with PPI |
Switch to different PPI |
|
|
what are alarm symptoms with GERD? (4) |
Alarm symptoms = dysphagia, anemia, weight loss, and vomiting |
|
|
Complications of GERD (5) |
esophagitis, bleeding, stricture, Barrett esophagus, adenocarcinoma |
|
|
Difference between Mild and severe GERD |
Mild: excessive number of transiet LES relaxations; Severe: reduced resting LES pressures |
|
|
GERD is exacerbated by 5 mechanisms and why |
Xerostomia - ↓ salivary secretions; Scleroderma - ↓LES sphincter pressure Gastroparesis: delays clearance of gastric contents Drugs: nicotine by ↑ LES relaxations Obesity: ↑ frequency of transient LES sphincter relaxations by ↑ intragastric pressure and gastroesophageal pressure gradient and by hiatal hernia formation |
|
|
When do you use PPI instead of endoscopy? |
Use a trial of proton pump inhibitor therapy rather than endoscopy for patients with suspected gastroesophageal reflux disease without alarm symptoms |
|
|
When do you repeat endoscopy for uncomplicated duodenal ulcers? |
Do not perform repeat endoscopy to confirm ulcer healing for uncomplicated duodenal ulcers unless the patient remains symptomatic despite treatment. |
|
|
What dose do you use for first line therapy for prophylaxis of NSAID related ulcers for patients with history or high risk of ulcer disease? |
For patients who have a history or high risk of ulcer disease, use standard-dose proton pump inhibitors as first-line therapy for prophylaxis of NSAID-related ulcers because they are as effective as high-dose proton pump inhibitors |
|
|
What stool studies do you do for patients with acute diarrhea? |
Do not routinely perform stool studies (fecal leukocytes, stool culture, ova and parasites, Clostridium difficile toxin assay) for patients with acute diarrhea, because the vast majority of patients will have a self-limited viral gastroenteritis that responds to supportive care |
|
|
When do you repeat colonoscopy for asymptomatic patients with low risk adenomas? |
Do not repeat colonoscopy within 5 years of an index colonoscopy in asymptomatic patients with low-risk adenomas (1 to 2 adenomas, <1 cm, tubular morphology, and low-grade dysplasia). |
|
|
What are low risk adenomas? (3) |
(1 to 2 adenomas, <1 cm, tubular morphology, and low-grade dysplasia). |
|
|
When do you repeat colonoscopy for hyperplastic polyps? |
Patients with a small number of hyperplastic polyps should be screened according to general population guidelines (every 10 years). |
|
|
What is the best serologic test for celiac disease? |
Tissue transglutaminase (tTG) IgA antibody, but the sensitivity (69%-93%) and specificity (96%-100%) vary significantly among laboratories |
|
|
What is the treatment for asymptomatic gallstones? |
Observation, not cholecystectomy, is recommended for adult patients with asymptomatic gallstones |
|
|
What are common symptoms of esophageal disorders? (5) |
Dysphagia, heartburn, acid regurgitation, chest pain, odynophagia, and globus sensation are common symptoms of esophageal disorders. |
|
|
What is the diagnostic test of choice for oropharyngeal dysphagia |
Videofluoroscopy. |
|
|
What is the diagnostic test of choice for esophageal dysphagia? |
Upper endoscopy |
|
|
What is oropharyngeal or transfer dysphagia? |
Difficulty in the initial phase of swallowing, in which the bolus is formed in the mouth and is transferred from the mouth through the pharynx to the esophagus. |
|
|
What is management of functional oropharyngeal dysphagia? |
Dietary and postural measures to improve swallowing and reduce the risk of aspiration; consultation with a speech pathologist can be helpful in this regard. |
|
|
What are the causes of esophageal dysphagia? 2 categories (6/3) |
Structural: dysphagia lusoria (vascular dysphagia), epiphrenic/traction diverticulum, esophageal strictures, eosinophilic esophagitis, esophageal webs/rings, neoplasms; Motility disorders: achalasia, diffuse esophageal spasm scleroderma |
|
|
What is the most likely cause of progressive solid food dysphagia? |
Mechanical cause of obstruction |
|
|
What diagnosis is suggested by concomitant liquid and solid dysphagia? |
Motility disorder- achalasia |
|
|
Chest pain is often a sign of what GI etiology |
Achalasia/ diffuse esophageal spasm |
|
|
Weight loss is concerning for what esophageal etiology? |
Malignancy |
|
|
What are the benefits of diagnostic test of choice for esophageal dysphagia? |
The diagnostic test of choice for esophageal dysphagia is upper endoscopy, which can be both diagnostic (allowing biopsy and visualization of the mucosa) and therapeutic (allowing dilation to be performed if indicated). |
|
|
When working up chest pain, what must be ruled out first? |
Cardiac causes must be ruled out before attributing chest pain to an esophageal cause. |
|
|
What is MCC of noncardiac chest pain and how do you treat it? |
MCC: untreated GERD; treat with empiric trial of PPI and if not working, upper endoscopy followed by ambulatory pH monitoring and/or esophageal manometry |
|
|
What are the causes of odynophagia? (2) |
Esophageal ulceration, which is usually caused by infectious esophagitis or pill-induced esophagitis. |
|
|
Best test for odynophagia? |
Upper endoscopy is the best test for odynophagia. |
|
|
What is cause of globus sensation? What is unlikely to be related to it? |
Unrelated to meals, GERD or swallowing. Related to emotional distress |
|
|
What disease presents with dysphagia to solids and liquids, aspiration, or chest pain? |
Esophageal motility disorders |
|
|
What is achalasia? |
Failure of esophageal peristalsis and failure of the lower esophageal sphincter to relax with swallowing. LES is tonically contracted. |
|
|
What is primary test for achalasia? |
Barium radiography (barium swallow) is the primary screening test for achalasia. |
|
|
What is the first line therapy for achalasia? |
Surgical release of the lower esophageal sphincter by laparoscopic myotomy is first-line therapy for achalasia. |
|
|
How do you classify hypertonic esophageal disorders? |
Esophageal manometry |
|
|
What is barium swallow test used for? |
Achalasia |
|
|
Symptoms of achalasia? |
Dysphagia, chest pain, regurgitation of fermented retained food, and weight loss. |
|
|
What do you see on barium swallow for achalasia? |
Bird's beak appearance distal and to and fro movement of barium from loss of peristalsis |
|
|
What do you need to confirm achalasia? |
Manometry |
|
|
When do you use upper endoscopy in achalasia? |
To exclude mechanical obstruction in region of the lower sphincter |
|
|
What do you call achalasia caused by a malignant lesion? |
Pseudoachalasia |
|
|
What is pseudoachalasia? |
obstruction caused by malignant lesion |
|
|
Treatment goal of Achalasia |
Lower resting pressures at lower esophageal sphincter |
|
|
1st line treatment for achalasia |
Surgical release of the lower esophageal sphincter by laparoscopic myotomy |
|
|
What must be done with 1st line treatment for achalasia to prevent complication? |
Nissen fundoplication to reduce risk of secondary GERD' |
|
|
Other options to treat achalasia, risks and benefits (3) |
1. Endoscopic pneumatic balloon dilatation - 5% esophageal perforation; 2. Botulinum toxin - lasts 6-9 months; 3. nitrates/CCB with inconsistent results |
|
|
Presentation of diffuse esophageal spasm |
dysphagia and chest pain |
|
|
Definition of Diffuse esophageal spasm |
intermittent high amplitude > 30 mmHg, simultaneous, nonperistaltic contractions in response to swallowing |
|
|
How do you diagnose Diffuse esophageal spasm? |
diagnosis made clinically; barium swallow with corkscrew esophagus, manometry following exclusion of other disorders (cardiac disease, GERD) |
|
|
What is long term complication of diffuse esophageal spasm? |
May progress to achalasia |
|
|
what is difference between nutcracker esophagus and diffuse esophageal spasm? |
DES: intermittent high amplitude > 30 mmHg; Nutcracker - distal esophageal pressures during peristalsis of > 220 mmHg |
|
|
Treatment for diffuse esophageal spasm |
1st line: CCB |
|
|
Manometry of hypotonic motility disorders |
low amplitude contractions with a substantial portion of nonperistaltic contractions = ineffective esophageal motility |
|
|
MC associated condition with hypotonic motility disorders |
GERD |
|
|
Causes of hypotonic motility disorders (2) |
1. Medications (narcotics) 2. systemic disease (scleroderma) |
|
|
Difference bewteen scleroderma esophagus and achlasia on manometry |
scleroderma: hypotensive LES; achalasia: hypertensive LES |
|
|
Complication of scleroderma esophagus |
GERD and complications associated with it |
|
|
Why is fundoplication not an option for hypotonic motility disorders? |
Esophageal aperistalsis causes severe dysphagia after fundoplication |
|
|
MCC of infectious esophagitis (3) |
candida, HSV, CMV |
|
|
MCC of infectious esophagitis in immunocompetent patients |
Candida |
|
|
Difference in presentation between CMV and HSV esophagitis |
CMV: isolated esophageal ulcers; HSV: multiple superficial ulcers |
|
|
Risk factor for infectious esophagitis asides from immunosuppression |
Inhaled steroids |
|
|
How do you diagnose infectious esophagitis? |
Brushing for candida, biospies from ulcer BASE for CMV or EDGES for HSV |
|
|
Treatment for Candida esophagitis |
Antifungal |
|
|
Treatment for HSV esophagitis |
acyclovir |
|
|
Treatment for CMV esophagitis |
Ganciclovir |
|
|
Causes of pill induced esophagitis (6) |
tetracycline, iron sulfate, bisphosphonates, potassium, NSAIDs, or quinidine. |
|
|
How to diagnose eosinophilic esophagitis |
endoscopic biopsy after GERD excluded |
|
|
Treatment of eosinophilic esophagitis |
Swallowed aerosolized corticosteroids |
|
|
How to diagnose pill induced esophagitis |
Medication review and confirm with endoscopy |
|
|
Treatment for pill induced esophagitis |
Temporary cessation of medication or taking it with large bolus of water and avoid recumbent posture |
|
|
Presentation of eosinophilic esophagitis |
solid food dysphagia and food impaction |
|
|
Epidemiology for eosinophilic esophagitis |
asthma, seasonal allergies, male |
|
|
Diagnostic criteria for eosinophilic esophagitis |
> 15 eosinophils/hpf on esophageal endoscopic biospy and by exclusion of GERD with ambulatory pH monitoring or lack of response with empiric trial of PPI |
|
|
What happens if treatment for eosinophilic esophagitis does not work? |
systemic corticosteroids or food elimination diet, and/or esophageal dilation |
|
|
How to diagnost GERD |
Clinically - with heartburn or regurgitation |
|
|
How to treat GERD without alarm symptoms |
PPI empirically |
|
|
If empiric PPI does not work for GERD without alarm symptoms, what do you do? |
Endoscopy to assess for alternative diagnoses |
|
|
H2 blockers vs. PPI |
Proton pump inhibitors have been shown to be superior to H2 blockers or placebo in relieving symptoms of gastroesophageal reflux disease and healing esophagitis. |
|
|
MC SE for PPI |
headache, diarrhea, abd pain, and constipation |
|
|
How to treat SE associated with PPI |
Switch to different PPI |
|
|
what are alarm symptoms with GERD? (4) |
Alarm symptoms = dysphagia, anemia, weight loss, and vomiting |
|
|
Complications of GERD (5) |
esophagitis, bleeding, stricture, Barrett esophagus, adenocarcinoma |
|
|
Difference between Mild and severe GERD |
Mild: excessive number of transiet LES relaxations; Severe: reduced resting LES pressures |
