1/20/2016 GASTROENTEROLOGY Part One of Two Dipali Yeh, M.S. PA-C Rutgers Physician Assistant Program Certification/Recertification Examination Review Course June 2015 Rutgers, The State University of New Jersey PANCE/PANRE Review Course Infectious Esophagitis • Immunocompromised • Risks: AIDS/DM/Steroids • Odynophagia/dysphagia • CMV/HSV-other clinical features • Diagnosis: endoscopy – CMV esophagitis: large ulcers – Herpes: shallow ulcers – Candida: white plaques • Treatment: specific to the type of infection – CMV esophagitis: valgancyclovir/foscarnet – Herpes: acyclovir – Candida: Amphotericin B PANCE/PANRE Review Course Pill-induced esophagitis • Offending agents – Tetracycline – Doxycycline –KCl –NSAIDs • PPttiresentation – Odynophagia/dysphagia/retrosternal chest pain – Several hrs-days after ingestion • Endoscopy: varied findings • Study of choice: double contrast esophagram • Treatment: – Prevention – Remove offending agent 1 1/20/2016 PANCE/PANRE Review Course Radiation Esophagitis • Presentation – Dysphagia several months following radiation treatment • Acute >>> Chronic • Mucosal edema/inflammation>>>impaired peristalsis/motility PANCE/PANRE Review Course Reflux Esophagitis • Etiology – Lower sphincter fails as barrier to stomach contents • Predisposing factors –GERD, PUD – Prolonged vomiting • Presentation – Heartburn, retrosternal burning – Radiation into the neck – Postprandial component • Findings – Superficial ulcerations – Distal esophagus • Definitive diagnostic: endoscopy PANCE/PANRE Review Course Motility Disorders • Achalasia • Scleroderma • Esophageal spasms • Zenker’s diverticulum 2 1/20/2016 PANCE/PANRE Review Course Achalasia • Etiology unknown • Common in adults 30-60 yrs • Presentation – Gradual dysphagia: solids + liquids – Cough/choking/aspiration/pneumonia • Diagnostics – Barium swallow: Bird’s beak – endoscopy – Manometry: most sensitive • Treatment – Pharmacological: Ca+ channel blockers, isosorbide, local LES botox injections – Surgical: Dilatation, myotomy PANCE/PANRE Review Course Achalasia http://commons.wikimedia.org/wiki/File%3AAcha.JPG By Farnoosh Farrokhi, Michael F. Vaezi. [<a href="http://creativecommons.org/licenses/by/2.0">CC‐BY‐2.0</a>], <a href="http://commons.wikimedia.org/wiki/File%3AAcha.JPG">via Wikimedia Commons</a> PANCE/PANRE Review Course Scleroderma • 90% patients have esophageal involvement • Part of CREST syndrome • Clinical: GERD, dysphagia to solids & liquids • Diagnosis – Barium swallow: aperistalsis – Manometry: most sensitive; decreased LES tone • Treatment: proton pump inhibitors – omeprazole (Prilosec), pantoprazole (Protonix) • Complication: GERD 3 1/20/2016 PANCE/PANRE Review Course Esophageal spasms • Etiology: not understood; possible nitric oxide deficiency • Clinical: chest pain/dysphagia • Diagnosis: “corkscrew” esophagus on barium • Treatment: Ca+ channel blockers, hycosamine, tricyclic antidepressants PANCE/PANRE Review Course Esophageal spasms http://commons.wikimedia.org/wiki/File%3ADiffuser_Oesophagusspasmus_002‐13.jpg By Hellerhoff (Own work) [GFDL (http://www.gnu.org/copyleft/fdl.html) or CC‐BY‐3.0 (http://creativecommons.org/licenses/by/3.0)], via Wikimedia Commons PANCE/PANRE Review Course Zenker’s diverticulum • Outpouching of posterior hypopharynx • History: esophageal spasms, hiatal hernia • Older patients/insidious onset • Clinical: dysphagia/regurgitation/halitosis • Diagnosis: Barium swallow • Asymptomatic = no treatment • Symptomatic = myotomy/diverticulectomy 4 1/20/2016 PANCE/PANRE Review Course Mallory-Weiss tear • Tear in the GE junction • Forceful vomiting/retching • Clinical feature: hematemesis, self-limiting • Diagnosis: generally clinically, also endoscope • Treatment: – Most heal w/in 48 hours – Endoscopic epi/thermal coagulation PANCE/PANRE Review Course Esophageal neoplasms • General Considerations – 50-70yrs old – M:F=3:1 – Squamous cell: 95% – Adenocarcinoma – Risk Factors • Squamous Cell: tobacco and alcohol abuse • Adenocarcinoma: Barrett’s, obesity PANCE/PANRE Review Course Esophageal neoplasms • Clinical features – Dysphagia>solid food + wt loss – Pneumonia/Voice hoarseness – Chest pain • Diagnosis – iiiillnitially-bbiarium study d – definitive-endoscopy • Treatment: surgery • Prognosis: 5-yr survival rate < 20% 5 1/20/2016 PANCE/PANRE Review Course Esophageal strictures • Complication of GERD/Esophagitis • Clinical presentation – Dysphagia to solid foods over months-years • Diagnosis-biopsy • Treatment – Endoscopic dilatation – Long term PPIs – Refractory: endoscopic triamcinolone PANCE/PANRE Review Course Esophageal varices • General considerations – Most common cause of UGIB secondary to portal HTN • Risk factors ↑ chance of bleeding –Size – Red wale markings – Liver di sease severi ty – Active ETOH use • Presentation – High-grade: hematemesis/hypovolemia – Low-grade: melena + iron-deficiency anemia PANCE/PANRE Review Course Esophageal varices Treatment • Acute – Hemodynamic stability: fluids/blood products – Pharmacological • Octreotide-vasoactive agent • Vitamin K-abnormal PT • Lactulose-encephalopathy • Antibiotic prophylaxis • Endoscopic • Sclerotherapy • Mechanical tamponade • TIPS procedure • Mortality – 30% during 1st bleeding episode – 50% within 6 weeks 6 1/20/2016 PANCE/PANRE Review Course Esophageal obstructive entities • Esophageal Webs • Schatzkiʼs ring – Plummer-Vinson – GERD/hiatal hernia – Proximal esophagus – Distal esophagus – Presentation – Presentation • Food impaction • Food impaction – Barium swallow – Barium swallow •shelf • Lower esophageal narrowing PANCE/PANRE Review Course GERD • 3 mechanisms – Transient LES relaxation, increased intra-abdominal pressure, spontaneous reflux • Risk factors – Alcohol, caffeine, obesity, smoking • Clini cal f eat ures – Heartburn – Chest pain/halitosis/cough • Diagnosis: – Ambulatory 24hr pH monitoring: most sensitive/gold standard – Endoscopy • refractory to secretory therapy • Alarm symptoms (next slide) • Long-standing history (Barrett’s) PANCE/PANRE Review Course GERD • Alarm symptoms – Refractory heartburn – Dysphagia – Unintentional Weight loss – GI bleed/anemia 7 1/20/2016 PANCE/PANRE Review Course Diagnostic testing in Upper GI Pathology • 1. Endoscopy – Refractory to secretory therapy – Patients with alarm symptoms (next slide) – Chronic reflux – Barrett’s predisposition • 2. ambulatory pH monitoring – Confirm GERD – GERD sx + negative endoscopy – Refractory to longstanding PPI treatmetn – Refractory to antireflux surgery • 3. Manometry – peristaltic abnormalities; – Preop antireflux surgery PANCE/PANRE Review Course GERD Treatment options • Lifestyle/diet modifications: 20% effective – *weight loss • Three main options – Antacids • Maalox, mylanta, gaviscon – H2 bl ock ers • Cimetidine, ranitidine, famotidine, nizatidine – Proton pump inhibitors • Omeprazole, lansoprazole, pantoprazole, rabeprazole, esomeprazole, dexlansoprazole – ..also…Prokinetics (metoclopramide)/Baclofen only after diagnostic eval • Surgery – Nissen fundoplication – Stretta procedure – Endocinch PANCE/PANRE Review Course GERD Treatment approach • Intermittent/mild symptoms: – Weight loss – Antacids – H2blockers twice daily • Moderate symptoms: – Once a d ay PPI x 8 week s: th erapy of ch oi ce – If symptoms continue thereafter, maintenance PPI – H2 blockers + PPI combination therapy • Risks associated with PPIs – If (+)osteoporosis, can remain on PPI therapy – Risk factor for Clostridium difficile – short term PPIs: CAP – No need for alteration with clopidogrel (re: adverse cardiovascular events) 8 1/20/2016 PANCE/PANRE Review Course Gastritis • Atrophic – Risk for gastric CA, pernicious anemia, autoimmune • Hemorrhagic – ICU/Burn • Infectious – H. pylori- most common cause • Presentation – Nondescript abd pain, anorexia, bloating, nausea • Treatment – Etiology-dependent PANCE/PANRE Review Course Helicobacter pylori • Gram-negative spiral-shaped bacillus • Clinical presentation: nausea/abdominal pain • Diagnosis: based on history – Urea breath test (most sensitive)/fecal antigen assay – Endoscopy-but not for uncomplicated disease PANCE/PANRE Review Course Helicobacter pylori • Treatment • combination therapy x 14d –1st line: Triple therapy: PPI + amox + clarithromycin – Quadruple therapy: PPI + bismuth + 2 antibiotics • (cl arith romyci n + amoxi cilli n, t et racycli ne + met ronid azol e) 9 1/20/2016 PANCE/PANRE Review Course PUD • Break in the mucosa • Duodenal > gastric • Risks: smokers/long-term NSAID use • 2 major causes – Chronic NSAID use – Hpylori infection- most common PANCE/PANRE Review Course PUD • Clinical features – Hallmark: epigastric pain – Duodenal: improves with food – Gastric: worsens with food • Diagnosis: upper endoscopy • Treatment – Avoid irritating factors – Combination therapy – misoprostol PANCE/PANRE Review Course Gastric neoplasms • 3 types – Adenocarcinoma: 90-95% – Lymphoma – Gastrinoma (Zollinger-Ellison Syndrome) 10 1/20/2016 PANCE/PANRE Review Course Gastric neoplasms • Adenocarcinoma – 50-70yrs old – M:F = 2:1 – 5 year survival < 20% – Risk factors • Genetic: Familial/Blood Group A • Environmental: H. pylori/smoking/low socioeconomic • Predispositions: chronic gastritis/pernicious anemia PANCE/PANRE Review Course Gastric neoplasms • Adenocarcinoma – Clinical features • Early: can be asymptomatic • Later: cachexia, dyspepsia, weight loss, GIB • Virchow’s node • Sister Mary Joseph nodule • Krukenberg tumor PANCE/PANRE Review Course Gastric neoplasms • Adenocarcinoma – Diagnosis • endoscopy with biopsy – (>55 yrs old w/ new sx/fails antisecretory