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GI Board Review. Elizabeth Paine, MD Division of Digestive Diseases The University of Mississippi Medical Center. Esophagus. Proximal 1/3 esophagus- striated muscles under CNS control Distal 2/3 esophagus- smooth muscle under vagal and myenteric nervous system control

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GI Board Review


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    1. GI Board Review Elizabeth Paine, MD Division of Digestive Diseases The University of Mississippi Medical Center

    2. Esophagus • Proximal 1/3 esophagus- striated muscles under CNS control • Distal 2/3 esophagus- smooth muscle under vagal and myenteric nervous system control • UES and LES are normally in a contracted state • Initiation of swallow relaxes both of the sphincters

    3. Question 70 year old female with PMH of Parkinson’s disease, HTN, DM presents with dysphagia and occasional choking while eating for past several weeks. She notices dysphagia as soon as she initiates a swallow. CXR is normal. Which modality is the most sensitive in the diagnosis of this patient’s dysphagia? A. Esophageal manometry B. Modified barium swallow C. EGD D. Chest CT

    4. Dysphagia • Oropharyngeal Dysphagia - Structural disorders - Neurological disorders (Stroke, ALS, myasthenia gravis, Parkinson’s, myotonic dystrophy) • Esophageal Dysphagia

    5. Esophageal Dysphagia Solids Only: Solids and Liquids:

    6. Schatzki’s Ring • 45yo M with longstanding GERD presenting with 6 months of intermittent solid food dysphagia

    7. Odynophagia • Ulcerative Esophagitis - Due to infection or pill - Viral (HSV,CMV) - Candida - most common • Pill-Induced Esophagitis - Tetracyclines, FeSO4, Bisphosphonates, NSAIDs, Quinidine, Potassium

    8. Question • 55 y/o man presents with progressive dysphagia for both solids and liquids, intermittent regurgitation of food, and wt loss of 30 lbs over the course of 1 year. Symptoms not relieved with PPI. Barium esophagram shows a dilated esophagus with an air/fluid level and tapered narrowing of the distal esophagus. What is the most likely diagnosis? A. Esophageal cancer B. Esophageal stricture C. Achalasia D. Esophageal ring

    9. Achalasia • Failure of the LES to relax with swallowing • Progressive dysphagia for solids and liquids and regurgitation • Barium esophagram with esophageal dilation with classic “bird’s beak” appearance distally • Esophageal manometry shows lack of relaxation of the LES with swallowing and aperistalsis of the esophageal body

    10. Achalasia treatment • Laparoscopic Heller myotomy • Pneumatic dilation • Botox injection just proximal to LES • Nitrates/CCB offer temporary relief

    11. Pseudoachalasia • If obstruction at LES is caused by a malignant lesion, the disorder is designated “pseudoachalasia” • Mimics manometric findings of achalasia • EGD is recommended in all suspected cases of achalasia

    12. GERD • Most common cause of non-cardiac chest pain • Inappropriate LES relaxation • Empiric PPI - first dx/tx • Refractory GERD needs EGD, pH monitoring and/or esomanometry • Indications for EGD • Failure of treatment • Age > 50 • Symptoms > 5 years • Alarm symptoms - Wt Loss - Dysphagia - Anemia

    13. GERD Treatments • Life style modifications • PPI • H2 Blockers • Fundoplication

    14. Risks of PPI • Enteric infections (C. difficile) • Pneumonia • Hip fractures (Osteoporosis) • B12 deficiency

    15. Dyspepsia • Definition • Alarm signs - Age >55 years with new-onset symptoms - Family history of gastric cancer - Unintentional wt. loss - GI bleeding - Dysphagia/Odynophagia - Gastric outlet obstruction signs/symptoms

    16. Dyspepsia

    17. Question 59 y/o white male with h/o GERD for the last 5-6 years. Symptoms have gotten worse lately. OTC tums don’t help much. Recent cardiac work up was negative. Denies N/Vor weight loss. Also has HTN, DM, and Obesity. He is a smoker. Meds include HCTZ , Metformin. Other than BMI of 32 rest of PE is normal. Which of the following is the most appropriate management of this patient? • Ambulatory esophageal pH monitoring • Barium swallow study • EGD • H2 Blockers

    18. Barrett’s Esophagus • Normal squamous epithelium of the distal esophagus is replaced by columnar epithelium • Obese/white/male/smoker with GERD • Pre-malignant condition • Increased risk of esophageal adenocarcinoma • Long segment BE > 3 cm • Histologically diagnosed by detection of specialized intestinal metaplasia and goblet cells

    19. Barrett’s Esophagus

    20. Management of Barrett’s esophagus (AGA guidelines 2011)

    21. Esophageal Squamous Cell Cancer • More common in men, especially black men • Risk factors: Smoking, alcohol, nitrosamine exposure, corrosive injury to esophagus, achalasia, HPV • Clinical presentation: Dysphagia, weight loss, GI bleed, anorexia • Dx: Endoscopy. Mass usually involves upper esophagus • Rx: Surgery/Chemo/Radiation

    22. Question 39y/o male with PMH of seasonal allergies for past several years presented with c/o chest discomfort after he ate pork chops for lunch 2-3 hrs ago. He can’t swallow anything and feels food stuck in his chest. He has had 2 such episodes in the past. Physical examination is unremarkable. EGD is as shown. Histologic examination of the mucosa shows intense inflammation of the lamina propria with more than 15 eosinophils per HPF. No strictures are seen. What is the diagnosis? A. Achalasia B. Severe GERD C. Eosinophilic esophagitis D. Schatzki’s ring

    23. Eosinophilic Esophagitis • Young adults with dysphagiaand food impaction and with h/o other allergic disorders • Endoscopic Dx : - Mucosal longitudinal furrowing - Circumferential rings • Pathology shows > 15-20 Eos/HPF • TX : PPI and swallowed fluticasone

    24. H.Pylori Diagnosis • Stool Antigen Test • Urea Breath test • Serum antibody test • Endoscopic histology (gold standard)

    25. Treatment of H.pylori • Triple Therapy PPI BID+ Amox 1 Gm + Clarithromycin 500mg BID X 10-14 days • With PCN Allergy PPI BID + Metronidazole 500mg BID + Clarithromycin 500 mg BID X 10-14 Days • Quadruple Therapy PPI BID+ Bismuth 525 mg QID + Metronidazole 500 mg BID + Tetracycline 500 mg QID X 10-14 days

    26. Peptic Ulcer Disease Causes • H.Pylori • NSAIDS • ZE Syndrome • Malignancy • Crohn’s disease • Viral infections

    27. Peptic Ulcer Disease Complications • Bleeding (most common) (Risk factors: Age and NSAIDS) • Perforation • Gastric outlet obstruction • Anemia

    28. Management of PUD • Stop NSAIDS • Eradicate HP if present • PPI BID x 8 weeks • Follow up EGD in 8 weeks for gastric ulcers • Surgery for those refractory to medical therapy

    29. Zollinger-Ellison Syndrome • Involves gastrinoma causing ulcers and diarrhea • Gastrinomas are frequently in the duodenum or pancreas • Can be associated with MEN 1 • Initial tests are 3 fasting serum gastrin levels off PPI on different days • Additional testing includes secretin stimulation test, octreotide scan, CT/MRI to localize gastrinoma, EUS

    30. Upper GI Bleeding Causes • Non-Variceal: Gastric and DU UlcersEsophagitis/Gastritis Mallory-Weiss tear Malignancy GAVE (watermelon stomach) Hemobilia AVMs (Age, CRI, AV, OWR) Dieulafoy lesion HemosuccuspancreaticusAortoenteric fistula • Variceal

    31. Question 57 year old male presents with c/o weakness and melena for 3 days. No significant abdominal pain. He is orthostatic on exam. Stool is heme positive. NG suction with coffee-grounds material. HCT 30. What is the next step in management? • EGD • UGI series • Angiography • Insert large-bore IV’s and T/C match for blood • EGD/Colon exam

    32. Management of UGI Bleed • Fluid resuscitation • Blood transfusion • 2 large bore IV’s or Central Line Placement • PPI infusion initially • Octreotide infusion (Variceal Bleed) • EGD Epinephrine inj + Coag and/or clips • IR or Surgery if endoscopy fails

    33. Management of UGI Bleed • Evaluate severity of bleed • NGT lavage that does not clear = emergent endoscopy • Coffee ground or NGT that clears in hemodynamically stable patient can wait • Hemodynamically unstable patient should be admitted to the ICU • Remember ABCs • Elevated BUN (normal creat) = UGI bleed • Look for signs of liver disease

    34. Gastric Adenocarcinoma • Risk factors: smoking, blood type A, H.Pylori, family history of gastric cancer, environmental • Clinical Presentation: wt. loss, abd pain, early satiety, GOO, anemia • Diagnosis: Endoscopy with biopsy • EUS for depth of invasion

    35. Gastroparesis • Causes - Idiopathic - DM - Postoperative - Autoimmune disorders • Diagnosis - Rule out mechanical obstruction with EGD/UGI - 4 hr Gastric emptying test

    36. Gastroparesis Management • Low fat and low fiber diet • Small/frequent meals • Antiemetics • Prokinetics • GES • Feeding jejunostomy tube • TPN

    37. Gastric Bypass • Roux-en-Y is the most common in US • PE is the most common cause of death post-procedure • IDA • B12 deficiency • Calcium and Vit D deficiency

    38. Dumping Syndrome • Early: - within 30 minutes of eating - nausea, bloating, and diarrhea • Late: - 1-3 hrs after eating - hypoglycemia, tachycardia, sweating • Treatment: - low carb diet - small meals - more protein and fat in diet

    39. Gastric volvulus • Abnormal rotation of the stomach around its axis • Acute volvulus: pain in the upper abdomen or lower chest, inability to pass NG tube, vomiting • Radiographic findings • Acute gastric volvulus is a surgical emergency. However, if the patient is a poor surgical candidate, endoscopic methods can be tried. • Chronic volvulus usually has vague upper abdominal symptoms Images from Uptodate.com

    40. Lower GI Bleeding Etiologies • Diverticuli Hemorrhoids • Ischemic colitis NSAIDs/ulcers • AVMs IBD • Post-polypectomy bleed Dieulafoy lesion • Meckel’s Diverticulum Radiation colitis • UGI cause in 10-15%

    41. Acute Diverticular Bleeding • Painless bleeding with hypotension/syncope • Usually elderly patients • 85% of cases have spontaneous remission • Diagnosis/treatment: - Volume resuscitation with fluids/blood - Colonoscopy & endotx - Angiography

    42. Ischemic colitis • Due to decreased mesenteric blood flow and hypoperfusion in “watershed” areas • Due to non-occlusive ischemia • Sudden LLQ pain with tenesmus, then passage of red-to-maroon stool • Virtually never embolic • Dx with colonoscopy or CT • Rx: Supportive care with IVF, pain control, risk factor modification, +/- antibiotics

    43. Management of LGIB • Identify contributing factors by history (NSAIDS, antiplatelets, anticoagulants, radiation) • Volume resuscitation with blood and IVF • Colonoscopic treatment with epi/coag/clips • Tagged RBC scan • Angiography with possible embolization • Small bowel eval with push enteroscopy or Pillcam

    44. Obscure GI bleeding • Dieulafoy lesion • Hemobilia • Missed lesions • Meckel’s

    45. Meckel’s diverticulum • Outpouching of the ileum • Can have ectopic gastric mucosa • Maroon painless bleeding per rectum • Can present with intestinal obstruction or appendicitis-like symptoms • Can be diagnosed by Meckel’s scan (99mmtechnetium-pertechnetate study)

    46. Diverticulitis • Acute LLQ pain with fever and leukocytosis • Diagnosis: - CT scan with contrast - Avoid colonoscopy • Treatment: - Needs to cover Gram negatives and anaerobes - Cipro/Flagyl - Ampicillin-sulbactum

    47. Pericolonic diverticular abscess • IF < 3-4 cm: - antibiotics - supportive care • IF > 3-4 cm: - CT guided drainage - antibiotics

    48. Acute Mesenteric Ischemia • Do not confuse with ischemic colitis • Pain out of proportion to examination, acutely ill • Due to loss of blood flow to SB and/or ascending colon • Commonly embolic • Older patients with h/o CHF, recent MI, cardiac arrhythmias • Do angiography unless there are signs of perforation

    49. Chronic mesenteric ischemia • “Intestinal angina” • Postprandial abdominal pain, abdominal bruit, weight loss • Caused by atherosclerosis of intestinal arteries • Often have signs of other PVD and smoking hx • Diagnosis often based on sx although MRA or spiral CT have been used • Tx: angioplasty with stent placement in patients who can tolerate this

    50. Question 54 y/o WF with protein S deficiency presents with a 2 day history of severe epigastric abdominal pain with nausea/vomiting. She had this CT in the ER. What is the cause of her pain? Peptic ulcer disease Mesenteric venous thrombosis Biliary colic Functional abdominal pain