05/31/2019

Esophageal Disorders:
Symptoms: Dysphagia, chest pain, esophageal spasms, odynophagia
Duration – progressive means its chronic in nature such as stricture or
cancer vs intermittent in nature.
Dysphagia – solids or liquids? Or both.
If there is a problem with peristalsis then you see dysphagia to liquids alone.
If its both liquids and solids then it’s a luminal problem -> stricture

Odynophagia: Think about inflammation in esophagus due to infectious

causes- HIV, CMV, and Candida, HSV OR reflux esophagitis

Chest pain: GERD. Positional, cough, regurg

If warning signs present with these symptoms then you should always do
EGD. Warning sings: Weight loss, Iron deficiency anemia, persistent
vomiting, symptoms not responding to PPI and dysphagia with GERD, age >
50 years (as age increases, the chances of malignancy increases)

Weight loss and IDA: possible cancer

IDA: bleeding. Dysphagia: ALWAYS a warning sign – EGD is done.

Dysphagia: First question? Predominantly to solids, or both liquids and

solids. Solids – luminal problem, and usually progressive. But is it
progressive- stricture, cancer, or peptic stricture – eventually do an EGD.
Intermittent dysphagia to solids – so what is luminal issue that comes and
goes? Schatzki ring (lower esophageal mucosal ring that protrudes into the
lumen and goes away again) – no diagnostic studies required, suspected via
history.
Dysphagia to both liquids and solid: Peristalsis problem. Motility disorder.
But is it intermittent or progressive? Progressive – Achalasia (inability to
relax LES, increase tone but decrease peristalsis movement) or scleroderma
(thickening of mucosa and esophageal wall muscle, decrease tone of LES, so
regurgitation and heart burn) – Esophageal manometry
For scleroderma look at skin or external manifestations
Do barium swallow, EGD – eventually you will have to do these
Motility disorder, which is intermittent: Diffuse esophageal spasm
(coordinated contractions), Nutcrackers esophagus (uncoordinated
contractions).
First step for motility disorder: Barium esophagram/swallow (where do you
suspect obstruction) then EGD (because dysphagia is warning sign)
Barium swallow – shows no obstruction but does show unable to initiate
contraction in initial phase- oropharyngeal dysphagia – Bulbar palsy, PKD,
H/O SVA, MS and MG – cannot have proper contractions in the mouth area –
oropharyngeal area- cant initiate contraction – tx underlying condition? How
can you feed these patients? PEG tube
How to confirm oropharyngeal dysphagia? Esophagoscopy
If the pressure is low in the proximal and distal esophagus then you are
dealing with scleroderma but if the pressure is low in the proximal
esophagus and high in the LE then you are dealing with Achalasia

Dysphagia – first do barium swallow and if it indicates a problem with

oropharyngeal phase – esophagoscopy but if its shows problem with
esophagus then do EGD if the EGD shows an obstruction get a biopsy and if
the EGD is normal then suspect motility disorder – and do manometry

TX of GERD is PPI however in some pts when pt are not responding to PPI
and with atypical symptoms such as cough, asthma they benefit with
surgical fundoplication – but consider motility disorder before surgical
fundoplication so do manometry

Only 2 indications for manometry: Dysphagia with normal endoscopy then

do manometry to r/o motility disorders and a gerd patient planning to go
under surgical fundoplication

Odynophagia: Painful swallowing – inflammation due to infection or

esophageal reflux due to esophagititis (GERD), Scleroderma
Patient is a young woman taking doxyclycine for acne – comes with painful
swallowing – pill induced esophagitis (alendodrate, NSAIDS, quinidine and
potassium chloride, vitamin C)
Pill gets stuck in mid-esophagus (aortic arch and left main bronchus) and it
causes inflammation – do an EGD
Tx is supportive, discontinue the pills if sxs persist then do EGD
Radiation induced esophagitis – tx supportive – PPI , will eventually improve
– recent radiation therapy
Infectious esophagitis: HIV (+) painful swallowing – thrush white curdy
patches that can be scraped off – Candida (mcc) – trial of Fluconazole
During the trial if sxs worsen or continues to have odynophagia then suspect
other agents – viral? So do EGD – multiple punched out ulcers (hsv) or
single large ulcer (cmv)
Empirical tx: cd count < 50 – start acyclovir and add gancyclovir
If cd > 50 then give just acyclovir
Sterile ulcers: HIV present in esophagus – giant aphthous ulcers – only
diagnosed when cultures are negative in biopsies – start steroids and HRT
therapy

GERD:
Gerd present with cough vs that is not responding to PPI vs more than 5
years, some may have bloating, regurgitation and sore throat in GERD,
mostly nocturnal symptoms

GERD can present in atypical symptoms: my throat is closing down,

postnasal drip, asthma, cough – cough is most common symptom especially
at night – TX ppi

GERD – not recommended for H pylori screening (only epigastric pain)

So try PPI such as omeprazole, pantoprazole

There are warning signs that prompt you to get EGD – r/o malignancy with
GERD – weight loss, IDA, strictures or age > 50

Counsel GERD patients on lifestyle changes – head elevation, left lateral

position that prevents reflux, reduce their weight, not overeat at once, small
meals are advocated, avoid trigger foods
If a patient is having GERD and not responding PPI: then EGD –
THERAPEUTIC AND DIAGNOSTIC test

EGD in GERD if GERD present > 5 years – to r/o barrets esophagus – and if
there is barrets esophagus – biopsy – if metaplasia no dysplasia present
then do EGD more frequently – every 2 years
If there is dysplasia – low vs high? Low – every 6 month- 1 year and high
grade – esophagetomy to prevent progression to adenocarcinoma

Surveillance in barrets esophagus is important!

UC if low grade then total colectomy

2 indications for PH monitoring: PPI not working and egd is normal you can
do 24 hour pH monitoring and also before fundoplication sx
- gold standard but never done!

When to do fundoplication surgery? Patients not responsive to PPI and EGD

shows esophagitis and when ppl have asthma

GI Bleeding

Occult vs obscure bleeding? Upper or lower GI?

In men do colonoscopy if IDA – loose blood in GI tract or malabsorption
(acholhydria, atrophic gastritis, gastric bypass) if you don’t have any of
those causes – suspect GI blood loss – rectal exam – stool guaic test – if
positive for blood – occult bleeding (not grossly positive) – cancer, PUD,
gastritis
Lower GI bleeding – BRBR
Upper GI bleeding – might have BRBR

The common cause of BRBR – diverticulosis, second mcc- angiodysplasia ,

then hemorrhoids (painful bleeding) – tough time locating bleeder and heavy
bleeding – shock – remove colon – total / partial colectomy
Upper GI bleeding – hemetasis – melena – PUD, GASTRITITS, VARICEAL
BLEEDING SUCH AS PORTAL HTN – always start PPI if there is any
suscipicion for bleeding somastostatin – next step is EGD
Vs Mallory Weiss tear- retching – EGD- ligate it
Variceal bleeding- banding
Consider TIPS in portal hypertension – bypass hepatic circulation so the
ammonia is not detoxified
Splenic thrombosis: Pancreatitis, pancreatic cancer and also patients in
hypercoaguable patients
No aspirin after polypectomy for 7 days

Capsule endoscopy – obscure bleeding after colonoscopy and EGD

Occult GI bleeding: stool guaic positive
False negative guaic: Vitamin C overuse

Nonselective beta blockers such as nadolol – to prevent re-bleeding or

further bleeding.

Ischemic disease: Two types – ischemic colitis (bloody diarrhea) this is like
MI and mesentric ischemia is like stable angina

Mesentric ischemia- pain with eating so presents with weight loss because
eating precipates pain so next step – angiogram – then eventually
angioplasty (dilatation of mesenteric artery)

Ischemic colitis: bloody diarrhea, pain out of proportion – management is

supportive –antibiotics used if pt is getting sick especially high possibility of
bacteremia and septic shock, initial steps x-ray – thumbprint sign –
submucosal edema – pneumatosis intestinalis
GI bleed- colonoscopy
Ischemic colitis – atherosclerosis is a problem, bloody diarrhea, AXR thumb
printing – supportive and partial colectomy

When all work-up normal and obscure bleeding- do capsule endoscopy

PEPTIC ULCER DISEASE:

EGD with warning signs is the first test!

If no warning signs- PPI
PUD is clinical diagnosis- dyspepsia, epigastric pain, flatulence, bloating

Duodenal ulcer – improves epigastric pain with food

H. pylori screening if you plan to treat- persistent dyspepsia, and MALT

lymphomas – treat the H pylori and do EGD again.

Screening for H pylori: Stool antigen testing and urea blood test

Stop ppi at least 2 weeks prior to urea testing

Triple therapy if infection still persistent then use quadruple therapy

DYSPEPSIA: bloating, flatulence, early satiety, n/v, epigastric discomfort

- mcc is functional or non-ulcer dyspepsia
- Functional dyspepsia is a diagnosis of exclusion, first r/o organic
causes
- Aggravated by food? Mainly at night? PUD
- Gallstone induced dyspepsia- remove gallbladder – if gallstone
present and asymptomatic then no need to remove gallbladder, but if
symptomatic cholecystectomy
- IBS: constipation or diarrhea predominant- pain is relieved by defecation

Biliary Tract Disease:

Gallstones: symptomatic- cholecystectomy
Biliary colic- stone passes to cbd

CBD obstruction: biliary colic pain lasts > 12 hours, persistent pain, painful
jaundice – choledocholiathiasis

Bile infected is called cholangitis – triad of charcot- persistent pain, fever,

jaundice- start abx pip-tazobactam, npo –if develop AMS, hypotension,
shock then it is called suppurative cholangitis– drain the pus – percutaneous
drainage of cbd

Gallstone obstructs ampulla of duodenal: acute pancreatitis – gallstone

pancreatitis – epigastric pain, elevated lipase
Gallstone pancreatitis: ALT > AST , high direct bilirubin then elevated ALP

Alcohol pancreatitis: AST > ALT

Always get an ultrasound for gallstone pancreatitis – if CBD diameter is
elevated > 10 mm – cholecystectomy for gallbladder pancreatitis
Alcohol pancreatitis: supportive therapy
ERCP is test of choice in CBD stones but it should follow ultrasound (to
look at gallstone and see cbd and see the diameter if > 1 cm then its leaning
towards cbd obstruction- so then do ERCP)

Post-ERCP pancreatitis: tx is supportive

If US non-diagnostic but clinical signs indicate acute cholecystitis then the
next test is HIDA scan – non-visualization of gallbladder is diagnostic of
acute cholecystitis - laprascopic cholecystectomy

TPN- false positive HIDA – gallbladder distended – cck stimulates gallbladder

but in tpn no cck –
False positive HIDA seen in advanced liver failure

Severe pancreatitis: look at hematocrit concentration

Stool osmolar gap: 290 – 2 (na)+ (K) if > 50 then it is osmotic diarrhea but
if it is < 50 then it is secretory diarrhea

E.coli diarrhea- travels diarrhea can be treated with cipro

EHEC O157 can lead to bloody diarrhea -> HUS, renal failure and hemolysis
with drop in platelet count – DO NOT treat with antibiotics

Inflammatory diarrhea: occult blood and stool leukocytes – bacterial and

non-bacterial – obtain stool cultures – do not treat empirically

Celiac disease: chronic diarrhea, small bowel disease, look for anti-
transglutaminase antibody – stay away from gluten
Whipples disease: lymphadenopathy and migratory arthritis

Chronic pancreatitis- avoid fatty food

Tropical sprue- clear history patient returned from tropical – tetracyclines

Erythema nodusum can be treated with Ibuprofen

Erythema nodusum in UC is bad prognosis
Erythema nodusum in Sarcoidosis is good prognosis

UC – colonoscopy 10 year after initial diagnosis and then every year-

because UC is a premalignant condition

Anytime biopsy shows low grade dysplasia- get total colectomy

LIVER DISORDERS

Hep A- traveling to tropics

ALT > AST – viral hepatitis

AST > ALT – alcoholic hepatitis
Also look at ALP and GGT – to see where ALP is coming from and ensure
liver origin
ALP can be seen in bone mestases
05/31/2019