Download GI SYMPTOMS - CatsTCMNotes

GI SYMPTOMS
Dyspepsia
Nature of complaint
pain
or discomfort centered in the
upper abdomen
acute, chronic, or recurrent
fullness, early satiety, burning,
bloating, belching, nausea, retching,
or vomiting
25% has got it
5/25/2017
Mandyam
2
Heartburn
Retrosternal
burning
Different from dyspepsia
Due to GERD
5/25/2017
Mandyam
3
Causes of Dyspepsia
Simple ‘self limiting’:
overeating
eating too quickly
eating ‘high-fat’ foods
eating during stressful situations
drinking ‘too much’ alcohol/coffee drugs
5/25/2017
Mandyam
4
Pathological dyspepsia
(LUMINAL )
Peptic
ulcer (5-15%)
GERD (20%)
Cancer stomach (1%) in 45+
Diabetics with GI motility issues
Lacking lactase
Malabsorption
Parasites- giardia/threadworm
5/25/2017
Mandyam
5
Helicobacter pylori
5/25/2017
Mandyam
6
Other causes for dyspepsia
Pancreatic
cancer/pancreatitis
Gall bladder related – always
dramatic
DD: heart attack/ hiatus hernia/
renal failure/ thyroid/pregnancy
5/25/2017
Mandyam
7
“functional”
chronic dyspepsia
2/3
of patients have no identifiable
cause
Difficult to treat
History may not always help!
Check if associated with other
serious complaints
25% of ulcers misdiagnosed as
functional
5/25/2017
Mandyam
8
Lab workup (45+)
CBC
Electrolytes
LFTs
Calcium
Thyroid
tests
Endosocpy- gold standard
5/25/2017
Mandyam
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?treat
Under
45- (serology/fecal/breath )
tests for H pylori (USEFUL IF
negative)
Treat symptomatically
If positive?- triple therapy
5/25/2017
Mandyam
10
? Functional dyspepsia
If mild- reassure/change the life style,
Keep food journal
30% have ‘placebo’ response
Antacids/ H2 blockers/ Purple pill (helps
10-15%)
?antidepressants
Increase gut motility
CAMS: Psycho/hypno therapy/
Peppermint/caraway- no SIDE EFFECTS!
5/25/2017
Mandyam
11
GI SYMPTOMS
Nausea and Vomiting
Description
Nausea:
“vague, intensely
disagreeable sensation of sickness or
"queasiness"
NOT
ANOREXIA/
REGURGITATION
Vomiting
5/25/2017
center:
H1 receptors/ muscarinic receptors
Mandyam
13
Vomiting center: (Medulla)
Afferent
inputs:
(1) Afferent vagal and splanchnic fibers
serotonin 5-HT3 receptors
(2) Fibers of the vestibular system, which
have high concentrations of histamine H1 and
muscarinic cholinergic receptors
(3) Higher central nervous system centers
(4) The chemoreceptor trigger zone
(CTZ)
5/25/2017
Mandyam
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The chemoreceptor trigger zone
(CTZ) (MEDULLA)
outside
the blood-brain barrier
rich in opioid, serotonin 5-HT3,
neurokinin 1 (NK1) and dopamine D2
receptors
stimulated by drugs and
chemotherapeutic agents, toxins, hypoxia,
uremia, acidosis, and radiation therapy
5/25/2017
Mandyam
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Complications
Dehydration
Hypokalemia
metabolic
alkalosis
Aspiration
rupture of the esophagus (Boerhaave's
syndrome), and
bleeding secondary to a mucosal tear at
the gastroesophageal junction
(Mallory-Weiss syndrome)
5/25/2017
Mandyam
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Red flags associated with vomiting
WITH
PAINperitonitis
Intestinal obstruction
Pancreatitis
Cholecystitis
CNS causes- headache/stiff neck/
vertigo/ focal paresthesias or weakness.
5/25/2017
Mandyam
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Red flags associated with vomiting
(TIMING)
morning
before breakfast –
pregnancy/ uremia/ alcohol intake, and
increased intracranial pressure
immediately after meals -bulimia or
psychogenic causes
one to several hours after meals –
gastroparesis/obstruction (succusion splash)
5/25/2017
Mandyam
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Lab workup in serious cases
Electrolytes-
hypokalemia / uremia/
alkalosis
LFTs/
Amylase
If in pain- plain axrEndosocpy
CT/MRI abdomen
5/25/2017
Mandyam
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Antiemetic Medications
Serotonin
(5-HT3)AntagonistsOndansetron (Zofran®)
Granisetron (Kytril®)
Dolasetron (Anzemet®)
Palonosetron (Aloxi™)
Indicated in- chemotherapy- and
radiation-induced emesis (pre treatment)
5/25/2017
Mandyam
20
Antiemetic Medications
Corticosteroids
Dexamethasone (Decadron®)
Methylprednisolone (Medrol®)
5/25/2017
Mandyam
21
Antiemetic Medications
Dopamine
(Dopastat®, Intropin®)
receptor antagonists
Metoclopramide (Reglan®)
Prochlorperazine (Compazine®)
Promethazine (Phenergan®)
Trimethobenzamide (Tigan®)
5/25/2017
Mandyam
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Antiemetic Medications
Sedatives
Diazepam (Valium®)
Lorazepam (Ativan®)
5/25/2017
Mandyam
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Cannabinoids
Marijuana
–
appetite stimulant and antiemetic
tetrahydrocannabinol (THC) is
the major active ingredient in
marijuana and is
available by
prescription as dronabinol
5/25/2017
Mandyam
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HICCUPS
GI SYMPTOMS
HICCUPS (SINGULTUS)
 benign and self-limited annoyance
1.
2.
3.
2.
3.
4.


5/25/2017
gastric distention:
carbonated beverages,
air swallowing, overeating
sudden temperature changes:
hot then cold liquids,
hot then cold shower
3. alcohol ingestion, and
4. states of heightened emotion/excitement:
stress, laughing
Mandyam
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recurrent or persistent hiccups
a
sign of serious underlying illness
Central nervous system: Neoplasms/
infections, cerebrovascular accident/ trauma.
Metabolic:
Uremia, hypocapnia –(decreased CO2 levels)
(hyperventilation)
5/25/2017
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recurrent or persistent hiccups

Irritation of the vagus or phrenic nerve:
(1)
Head, neck: Foreign body in ear, goiter, neoplasms.
Thorax: Pneumonia, empyema, neoplasms, myocardial
infarction, pericarditis, aneurysm, esophageal
obstruction, reflux esophagitis.
Abdomen: Subphrenic abscess, hepatomegaly, hepatitis,
cholecystitis, gastric distention, gastric neoplasm,
pancreatitis, or pancreatic malignancy.
(4) Psychogenic and idiopathic
Surgical: General anesthesia, postoperative.
(2)
(3)


5/25/2017
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Workup
CNS exam
Serum Creatinine
LFTs
CXR
CT chest/abdomen
Echocardiography/Bronchoscopy /
Endoscopy
5/25/2017
Mandyam
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Treatment
 acute
benign hiccups
(1) Irritation
of the nasopharynx- by tongue traction,
lifting the uvula with a spoon, catheter stimulation
of the nasopharynx, or eating 1 tsp of dry
granulated sugar.
(2) Interruption of the respiratory cycle by breath
holding- Valsalva's maneuver, sneezing, gasping
(fright stimulus), or rebreathing into a bag.
(3) Stimulation of the vagus, carotid massage.
(4) Irritation of the diaphragm by holding knees to
chest
(5) Relief of gastric distention by belching
5/25/2017
Mandyam
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Treatment
Chlorpromazine
(Thorazine®)
AnticonvulsantsPhenytoin (Dilantin®)
Gabapentin (Neurontin®)
Carbamazepine (Tegretol®)
Benzodiazepines- lorazepam diazepam
Others- Baclofen (Lioresal®)
metoclopramide,
5/25/2017
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CONSTIPATION
define constipation
as
infrequent stools (fewer than 3 in
a week)
hard stools
excessive straining, or
a sense of incomplete evacuation
5/25/2017
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Causes of Constipation
1 Most common
Inadequate fiber or fluid intake/ Poor bowel habits
2 Systemic disease
Endocrine: hypothyroidism, hyperparathyroidism,
diabetes mellitus
Metabolic: hypokalemia, hypercalcemia, uremia,
porphyria
Neurologic: Parkinson's, multiple sclerosis, sacral
nerve damage (prior pelvic surgery, tumor), paraplegia,
autonomic neuropathy
5/25/2017
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Causes of Constipation
3 Medications
Opioids/ Diuretics/ Calcium channel
blockers/ Anticholinergics/ Psychotropics/ Calcium and iron
supplements/ NSAIDs/ Sucralfate/ Cholestyramine/
4 Structural abnormalities
Anorectal: rectal prolapse, rectocoele, rectal intussusception,
anorectal stricture, anal fissure, solitary rectal ulcer syndrome,
Perineal descent, cancer colon, radiation
5 Slow colonic transit
Idiopathic: isolated to colon/ Psychogenic/ Eating disorders/
6 Irritable bowel syndrome
5/25/2017
Mandyam
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Dietary review
Add
10-20 grams of fiber per day
Add 1-2 glasses of fluids per meal
Elderly at risk
5/25/2017
Mandyam
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Structural issues
Cancers
Strictures
RED
FLAG symptoms or signs hematochezia, weight loss, anemia, or
positive fecal occult blood tests
(FOBT)
45-50+ having new onset
5/25/2017
Mandyam
37
Medical Issues
Neurological-
strokes/ paraplegias/
Myopathies
Endocrinal
Hyper
5/25/2017
calcemia or Hypokalemia
Mandyam
38
Treatment of Constipation
Fiber
laxatives – Psyllium
Methylcellulose (Citrucel®)
Polycarbophil (FiberCon®)
Guargum
Stool surfactants Docusate (Colace®)
Mineral Oil(Kondremul®)
5/25/2017
Mandyam
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Treatment of Constipation
Osmotic
laxatives -
Magnesium Hydroxide (milk of
magnesia®) Lactulose (Duphalac®)
Stimulant
laxatives –
Bisacodyl (Dulcolax®)
Senna (Ex-Lax®) Cascara
Enemas – Phosphate/Soapsuds/Tapwater
5/25/2017
Mandyam
40
GAS
Belching-
Normally 2–5 mL of air swallowed
every time
distention, flatulence, and abdominal pain
rapid eating, gum chewing, smoking, and the
ingestion of carbonated beverages
Chronic – aerophagia
Therapy-Behavior modification, medicines not
much help
5/25/2017
Mandyam
41
Flatus
Colonic
swallowed
air and bacterial fermentation
of undigested carbohydrate
Nitrogen (500 ml) + H2/CO2/Methane
Fermenters-
sucrose/lactose/fructose
(mushrooms/legumes/cruciferous vegetables)
?fructose intolerance
5/25/2017
Mandyam
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Cruciferous
Vegetables
Arugula,
Broccoli,
Cauliflower,
Brussel
Sprouts,
Cabbage,
Watercress,
Bok Choy,
Turnip
5/25/2017
Greens,
Mustard
Greens, and
Collard Greens,
Rutabaga,
Napa or Chinese
Cabbage,
Daikon, Radishes,
Turnips,
Kohlrabi, and Kale
Mandyam
43
Gas producing vegetables/Items
Beans
of all kinds
Peas, lentils
Brussels sprouts
Cabbage
Parsnips
Leeks
Onions
Beer and coffee
5/25/2017
Mandyam
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Foul odor
garlic,
onion,
eggplant,
mushrooms,
and
certain herbs and spices
5/25/2017
Mandyam
45
Gas Management
Eliminate
complex starches & fiber- but
highly unacceptable
only rice flour is gas-free.
‘Beano’ ( -d-galactosidase enzyme) reduces
gas caused by foods containing raffinose and
stachyose, (cruciferous vegetables, legumes,
nuts, and some cereals)
Activated
5/25/2017
charcoal
Mandyam
46
diarrhea
GI FLUID BALANCE
10
L of fluid enter the duodenum daily
8.5 l totally absorbed (small intestine)
Colon absorbs 1.3 l
200 ml lost in feces
DIARRHEA:
defined as a stool weight of more than 200–300
g/24 h
5/25/2017
Mandyam
48
CLUES IN ACUTE DIARRHEA
Preformed
toxins in food
Community outbreaks- viral/food
Food poisoning- vomiting prominent
Unpurified water
SMALL
5/25/2017
BOWEL: large volume
Watery/non bloody/ cramps/
bloating/dehydration/hypokalemia/
fecal test for WBC negative
Mandyam
49
CLUES IN ACUTE DIARRHEA
Inflammatory:
(Usually colonic
damage)
Small volume /fever/ bloody/
LLQ cramp/ urgency/painful/
Fecal WBC test positive
5/25/2017
Mandyam
50
Types of ACUTE diarrhea: (less than 2 weeks )
Noninflammatory
Inflammatory Diarrhea
Diarrhea
Viral
Noroviruses
Viral
Cytomegalovirus
Rotavirus
Protozoal
Giardia lamblia
Protozoal
Entamoeba histolytica
Cryptosporidium
Cyclospora
5/25/2017
Mandyam
51
Non-Inflammatory
Bacterial
1. Preformed enterotoxin
production – food poisoning
Staphylococcus aureus
Bacillus cereus
Clostridium perfringens
2. Enterotoxin production
Enterotoxigenic Escherichia coli
(ETEC)
Vibrio cholerae
5/25/2017
Inflammatory:Bacterial
1. Cytotoxin production
Enterohemorrhagic E coli O157:H5
(EHEC)
Vibrio parahaemolyticus
Clostridium difficile
2. Mucosal invasion
Shigella
Campylobacter jejuni
Salmonella
Enteroinvasive E coli (EIEC)
Aeromonas
Plesiomonas
Yersinia enterocolitica
Chlamydia
Neisseria gonorrhoeae
Listeria monocytogenes
Mandyam
52
Management



1.
2.
3.
4.
5.
6.
7.
5/25/2017
90% mild need oral rehydration
If persists more than 7 days needs further testing
RED FLAGS:
High Fever
Bloody Diarrhea
More than 6 watery stools in 24 hrs
dehydration
frail older patient
HIV/AIDS
Nosocomial
Mandyam
53
Oral Rehydration
½
tsp salt (3.5 g)
1 tsp baking soda (2.5 g NaHCO3)
8 tsp sugar (40 g) and
8 oz orange juice (1.5 g KCl) diluted to
one liter with water
OR Pedialyte, Gatorade
5/25/2017
Mandyam
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Antidiarrheals
Imrpoves
comfort/ symptom relief
But not to be used in RED FLAG cases
Loperamide (Imodium®)
Bismuth Subsalicylate (Pepto-Bismol® )
Diphenoxylate (Lomotil®)
Antibiotics:
Ciprofloxacin (Cipro®)/ Sulfa/ Doxycycline
(Atridox™ )/ Rifaximin (Xifaxan™)
5/25/2017
Mandyam
55
Acute Diarrhea: when to refer?
Algorithm for RED FLAGS
5/25/2017
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Acute Diarrhea: when to refer?
Algorithm for RED FLAGS
5/25/2017
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57
Chronic Diarrhea
Osmotic diarrhea
CLUE: Stool volume decreases with
fasting
1. Medications: antacids, lactulose, sorbitol
2. Disaccharidase deficiency:
lactose intolerance
3. Factitious diarrhea:
magnesium (antacids, laxatives)
5/25/2017
Mandyam
58
Chronic Diarrhea
Secretory diarrhea
CLUES: Large volume (> 1 L/d); little change with fasting
1. Hormonally mediated:
VIPoma, carcinoid,
medullary carcinoma of thyroid (calcitonin),
Zollinger-Ellison syndrome (gastrin)
2. Factitious diarrhea (laxative abuse);
phenolphthalein, cascara, senna
3. Villous adenoma
4. Bile salt malabsorption:
(ileal resection; Crohn's ileitis; postcholecystectomy)
5. Medications
Mandyam
5/25/2017
59
Chronic Diarrhea
Inflammatory conditions
CLUES: Fever, hematochezia, abdominal pain
1. Ulcerative colitis
2. Crohn's disease
3. Microscopic colitis
4. Malignancy: lymphoma,
adenocarcinoma (with obstruction and
pseudodiarrhea)
5/25/2017
5. Radiation enteritis
Mandyam
60
Chronic Diarrhea
Malabsorption syndromes
CLUES: Weight loss, abnormal laboratory values; fecal
fat > 10 g/24h
1. Small bowel mucosal disorders:
celiac sprue, tropical sprue, small bowel resection (short
bowelsyndrome), Crohn's disease
2. Lymphatic obstruction:
lymphoma, carcinoid, infectious (tuberculosis,
Mycobacterium Avium Infection), Kaposi's sarcoma,
sarcoidosis, retroperitoneal fibrosis
5/25/2017
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Malabsorption syndromes
3. Pancreatic disease: chronic
pancreatitis, pancreatic cancer
4. Bacterial overgrowth: motility
disorders (diabetes, vagotomy),
scleroderma, fistulas, small intestinal
diverticula
5/25/2017
Mandyam
62
Chronic Diarrhea
Motility disorders
CLUES: Systemic disease or prior
abdominal surgery
1. Postsurgical: vagotomy, partial
gastrectomy, blind loop with bacterial
overgrowth
2.Systemic disorders: scleroderma
diabetes mellitus,
hyperthyroidism
3.Irritable bowel syndrome
5/25/2017
Mandyam
63
Chronic Diarrhea
Chronic infections
Parasites:
Giardia lamblia, Entamoeba
histolytica
2. AIDS-related:
1.
5/25/2017
Viral:Cytomegalovirus, HIV infection (?)
Bacterial: Clostridium difficile,
Mycobacterium avium complex (MAC)
Protozoal: Microsporida (Enterocytozoon
bieneusi), Cryptosporidium, Isospora belli
Mandyam
64
LAB WORKUP
FECAL
FAT:
>300g/24 hrs- diarrhea
>500g/24 hrs-excludes IBS
>0.3 (g/kg)/day Steatorrhea
CBC/Albumin/Electrolytes
5/25/2017
Mandyam
65
Causes of steatorrhea include:
Increased
duodenal acid,
Abnormal bile output,
Pancreatic insufficiency,
Intestinal mucosal impairment:
Whipple's disease, and various forms
of enteritis, celiac disease and sprue.
5/25/2017
Mandyam
66
Protein Losing Enteropathy
excessive
loss of serum proteins into the
gastrointestinal tract
hypoalbuminemia and an elevated fecal α1antitrypsin level.
1) mucosal disease with ulceration
2) lymphatic obstruction
3) idiopathic change in permeability of
mucosal capillaries –’weeping’
5/25/2017
Mandyam
67
Mucosal disease with
ulceration
Chronic
gastric ulcer
Gastric carcinoma
Lymphoma
Inflammatory bowel disease
 Idiopathic ulcerative jejunoileitis
5/25/2017
Mandyam
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Lymphatic obstruction
Primary
intestinal
lymphangiectasia
Secondary obstructionCardiac disease: constrictive pericarditis,
congestive heart failure
 Infections: tuberculosis, Whipple's disease
Neoplasms: lymphoma, Kaposi's sarcoma
Sarcoidosis
5/25/2017
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Idiopathic mucosal
transudation
Acute viral gastroenteritis
 Celiac sprue
 Eosinophilic gastroenteritis
 Allergic protein-losing enteropathy
Parasite infection: giardiasis, hookworm
Amyloidosis
Common variable immunodeficiency
Systemic lupus erythematosus

5/25/2017
Mandyam
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Test
gut
alpha 1-antitrypsin clearance
(24-hour volume of feces x stool
concentration of alpha 1-antitrypsin
÷ serum alpha 1-antitrypsin
concentration). A clearance of more
than 13 mL/24 h is abnormal.
5/25/2017
Mandyam
71
Labworkup
serum
protein electrophoresis,
lymphocyte count, and serum
cholesterol to look for evidence of
lymphatic obstruction
Fecal fat
Giardiasis/ ova
Serum albumin
5/25/2017
Mandyam
72
Therapy
Octreotide
Sandostatin LAR® | Sandostatin®
Print low-fat diets supplemented
with medium-chain triglycerides
5/25/2017
Mandyam
73
Treatment
benefit
from low-fat diets
supplemented with medium-chain
triglycerides
Rich sources of MCTs include
coconut oil and palm kernel oils and
are also found in camphor tree drupes.
5/25/2017
Mandyam
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APPENDICITIS
Facts
Most
common abdominal emergency
10% population affected
10-30 age group
Ax obstruction by fecolith
5/25/2017
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FEATURES
Early:
periumbilical pain; (12 hrs)
later: right lower quadrant pain and
tenderness.
Anorexia,
nausea and vomiting,
obstipation.
Tenderness or localized rigidity at
McBurney's point.
Low-grade fever and leukocytosis.
5/25/2017
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Lab workup
WBC-
10-20,000
US or CT scan (94%)
20% at operation have normal Ax
DD: gyn?/ectopic
Danger- perforation
5/25/2017
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GI SIGNS
Upper Gastro Intestinal BLEED
Acute Upper Gastrointestinal Bleeding
Hematemesis
(bright red blood or "coffee grounds").
Melina (black stools) in most cases;
hematochezia (blood in stools) in massive
upper gastrointestinal bleeds.
Volume status to determine severity of blood
loss
Endoscopy diagnostic and may be therapeutic.
5/25/2017
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RED FLAG: UGI Bleed
7-10%
mortality
50% older than 60
Peptic Ulcer Disease
Portal Hypertension
(50% rebleed)
5/25/2017
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Mallory-Weiss Tears
Lacerations of the gastroesophageal
junction
History of heavy alcohol use or retching
Other causes:
Erosive gastritis
Gastric cancer
5/25/2017
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ACID-Drug Therapy
IV
proton pump inhibitors stop
bleedingOmeprazole (Prilosec®) Lansoprazole
(Prevacid®) Pantoprazole
(Protonix®)
5/25/2017
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83
Varicies- Therapy
Vasopressin,
ADH
(Pitressin®)
terlipressin
Transvenous
intrahepatic
portosystemic
shunts (TIPS)
5/25/2017
Mandyam
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GI SIGNS
Lower Gastro Intestinal BLEED
Acute Lower GI Bleeding
Hematochezia
usually present. (10%
UGI)
Evaluation with colonoscopy in stable
patients.
Massive active bleeding calls for
evaluation with sigmoidoscopy, upper
endoscopy, angiography, or nuclear
bleeding scan.
5/25/2017
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Mild
bleeding -Bright red blood that
drips into the bowl after a bowel
movement or is mixed with solid brown
stool (anorectosigmoid source )
LGI bleed serious in older men
5/25/2017
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Etiology
<50 years age: infectious colitis,
anorectal disease, and inflammatory
bowel disease
>50 years age: diverticulosis,
vascular ectasias, malignancy, or
ischemia / cause unknown (20%)
5/25/2017
Mandyam
88
diverticulosis,
vascular ectasias,
malignancy
5/25/2017
Mandyam
89
Other causes for LGI BLEED
Inflammatory
Bowel Disease
(IBD)- Ulcerative colitis
Anorectal disease
Ischemic colitis
5/25/2017
Mandyam
90
Investigations for GI Bleed
Anoscopy
Sigmoidoscopy
Colonoscopy
Nuclear
Bleeding Scans (Technetiumlabeled RBC) and Angiography
Small Intestine Video Capsule Imaging
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91
Occult & Obscure Gastrointestinal
Bleeding
FOBT
(1% to 2.5% ) or
iron deficiency anemia
5% of patients admitted cause not
found
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92
Review of causes of GI Bleed
(1)
neoplasms
(2) vascular abnormalities (vascular ectasias, portal
hypertensive gastropathy)
(3) acid-peptic lesions (esophagitis, peptic ulcer disease,
erosions in hiatal hernia)
(4) infections (nematodes, especially hookworm;
tuberculosis)
(5) medications (especially NSAIDs or aspirin) and
(6) other causes such as inflammatory bowel disease.
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93
Esophageal Disease
Primary Esophageal symptoms
Heartburn,
dysphagia,
and
odynophagia – Erosions
(corrosives/pills)/ Infections
(CMV/Herpes/Candidiasis)
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95
Investigations
Endosocpy
Videoesophagography
Barium
studies
Esophageal Manometry
Esophageal pH Recording
5/25/2017
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96
GERD
20%
affected
Incompetent Lower Esophageal
Sphincter
5/25/2017
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97
Hiatal hernia
common
and usually cause no symptoms
leading to more severe esophagitis,
especially Barrett's esophagus if gerd is
present
Heartburn an hour after meals and lying
down
Regurgitation
Dysphagia
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98
GERD
Manage
symptomatically for 4 weeks
Then-Endosocpy- ?nerd
Erosions present- Reflux esophagitis
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99
5/25/2017
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100
Barrett’s esophagus: intestinal
metaplasia
squamous epithelium of the
esophagus is replaced by metaplastic
columnar epithelium
treated with long-term proton pump
inhibitors /Surgery
serious complication : cancer esophagus/
Stricture
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101
Management of GERD
lifelong
disease that requires lifestyle
modifications:avoid lying down within
3 hours after meals
Elevating the head of the bed on 6inch blocks or a foam wedge to reduce
reflux and enhance esophageal
clearance
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102
Management of GERD
avoid
acidic foods (tomato products,
citrus fruits, spicy foods, coffee)
Avoid agents that relax the lower
esophageal sphincter or delay gastric
emptying (fatty foods, peppermint,
chocolate, alcohol, and smoking)
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103
Management of GERD
Weight
loss/ avoidance of bending after
meals /and reduction of meal size
Antacids - rapid relief of occasional
heartburn (2 hrs of action) Gaviscon is an
alginate-antacid combination that
decreases reflux in the upright position
H2 blockers
? Proton pump inhibitors
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104
Barrett’s Esophagus
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105
Chest Pain of Undetermined Origin
(‘atypical chest pain’)
30%
are non-cardiac
Exclude cardiac causes first
Chest Wall and Thoracic Spine Disease
Gastroesophageal Reflux (50%)
Heightened Visceral Sensitivity
Psychological Disorders
Esophageal Dysmotility
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106
Cancer of the
Esophagus
Incidence and Mortality
in 2005
Esophageal
Cancer
14,520 new
cases
13,570 deaths
Gastric Cancer
21,860 new cases
11,550 deaths
U.S.:
1,372,910 new cancer cases and 570,280 deaths
CA Cancer J Clin 2005; 55:10-30
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Esophageal
Cancer in the U.S.
Esophageal Cancer
1%
of all cancers
diagnosed.
Rapidly fatal.
One of the most rapidly
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109
5 Year Survival (%)
Year of diagnosis
Esophageal
Gastric
1974 - 1976
1980 - 1982
1989 - 1996
2003
15
18
21
22
5
7
12
14
CA Cancer J Clin 51:15-36; 2001; cancer.gov 2003
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110
Types of Esophageal Cancer
Squamous cell
carcinoma (SCCA)
Adenocarcinoma of the
distal esophagus
Cancer of the cardia
Subcardial cancer
Non-cardia cancer
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111
Esophageal Cancer
5/25/2017
Mandyam
112
SEER Cancer Statistics
Esophageal Cancer
5/25/2017
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113
Predisposing Factors
for SCCA Esophagus
Tobacco
Age
Alcohol
Race
Diet
Gender
Chronic
Role
esophagitis
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of HPV?
114
Other Risk Factors
Previous
head and neck or lung cancer
(annual rate 3-7%).
Plummer-Vinson syndrome (Iron deficiency).
Esophageal diverticulae.
Lye strictures: long latent period.
Radiation injury (therapeutic, atomic bomb).
Non-tropical sprue.
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115
Adenocarcinoma
of the Esophagus
Incidence
rates increased >350%
since the mid 1970s.
Increasing 20% per year in U.S.
Even higher in U.K., Australia,
Holland.
Rates for gastric cardia
adenocarcinoma also increased.
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Adenocarcinoma
of the EsophagusAssociated Factors
Obesity
Reflux
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disease and Barrett's
esophagus.
Diet
Smoking
Scleroderma
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Esophageal Adenocarcinoma
and Obesity
US
study: 4 x risk, highest quartile
BMI compared to lowest.
BMI >30 vs BMI <22, risk 16 fold.
Similar trends in gastric cardia
adenoca.
JNCI 90:150-155, 1998
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118
Esophageal Adenocarcinoma
and Reflux Disease
Swedish
study: Having reflux
symptoms more than 3 times a week
associated with 17 fold increased
risk.
U.S. study: daily GERD symptoms
risk 5 times.
NEJM 340:825-831, 1999; Cancer Causes Control 11:231-238, 2000
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119
Barrett's Esophagus
Dysplastic
changes in distal esophagus
and gastroesophageal junction.
30-40 fold increase in adenocarcinoma of
the esophagus.
10-15% of Barrett’s patients will develop
adenocarcinoma.
Risk of cancer is about 0.5% per year.
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120
Malignant Transformation
in Barrett's
Long-standing gastroesophageal reflux.
Field cancerization effect.
Medical therapy does not reverse
progression to malignancy.
With ablation, new epithelium may grow
over dysplastic clones.
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121
Endoscopic Surveillance
of Barrett’s Esophagus
With
high-grade dysplasia, 19-26%
develop invasive cancer within 2 to
7.5 years.
American College of
Gastroenterology:
No dysplasia x 2 years: q 2 years
Low-grade dysplasia: q 6 mo. x 2,
then q year
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122
Presenting Symptoms
Retrosternal
discomfort or indigestion.
Friction or burning when swallowing
food.
Dysphagia, odynophagia
Weight loss.
Hoarseness, cough
Regurgitation, vomiting
Hematemesis or melena (uncommon)
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123
Poor Prognosis
Significant
dysphagia
Occurs
after 50-75% of the esophageal
lumen is occluded.
Extensive involvement of esophagus and
surrounding structures in 90% of cases.
Persistent substernal pain unrelated to
swallowing
May indicate mediastinal disease.
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124
Poor Prognosis
Coughing
after swallowing
Indicates tracheoesophageal fistula
is present.
Hiccups
Indicates involvement of diaphragm
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125
Diagnosis of Esophageal Ca.
In
the United States, most patients
present with advanced stage disease.
At least have 75% have locoregional
extension or distant metastases that
prevent surgical cure.
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126
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127
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128
Staging: Primary Tumor (T)
T1
Tumor invades lamina propria or
submucosa
T2 Tumor invades muscularis
propria
T3 Tumor invades adventitia
T4 Tumor invades adjacent
structures
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129
Staging
Endoscopy
Endoscopic
ultrasound
CT
scans
Mediastinoscopy or
Laparoscopy
(PET Scan)
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130
Endoscopic Esophageal Ultrasound
Accurate
in determining depth of tumor
invasion in 60-90% of cases.
Demonstrates transition between normal
and pathologic esophagus.
Can be used to identify lymph node
metastases (accuracy 73-81%).
Limitation: must be able to pass through
malignant stenosis.
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131
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132
Therapy: Cancer
of the Esophagus
Complete
resection is the goal.
If complete resection not possible,
no role for palliative resection.
No survival benefit.
Palliation of dysphagia with stents
or combined chemoradiotherapy.
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133
Surgical Approaches for Esophageal Cancer
Ivor-Lewis
Esophagectomy
3 Field
Esophagectomy
Transhiatal
Esophagectomy
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134
Five Year Survival in
Resected Patients
Tumor
confined to esophagus: 50%
Involvement of adjacent tissues: 15%
Involvement of regional nodes: 10%
Overall survival: 20-25%
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135
Comparison of Treatment
Modalities: Median Survivals
Surgery:
16.5
months
Radiotherapy and Chemotherapy
14.5 months
Surgery, Radiotherapy,
Chemotherapy
16-18.6 months
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136
Stents
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137
Gastric
Diseases
Peptic Ulcer
Peptic Ulcer
nonspecific
epigastric pain (80–90%
) related to meals
characterized by rhythmicity and
periodicity.
20% present with ulcer
complications without prior symptoms
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139
Peptic Ulcer
Of
NSAID-induced ulcers, 30–50% are
asymptomatic.
Upper endoscopy with antral biopsy for
H pylori is the diagnostic procedure of
choice in most patients.
Gastric ulcer biopsy or documentation of
complete healing necessary to exclude
gastric malignancy.
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140
Peptic Ulcer
500,000
new cases per year of peptic
ulcer and 4 million ulcer recurrences
Life time risk 10%
95% duodenal; M>F
DU: 30-55 ages/ GU: 55-70 ages
More in smokers and NSAID users
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141
Peptic Ulcer: Causes
NSAIDs:
GU risk increases by 40%
chronic H pylori infection, and
acid hypersecretion
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142
H pylori-Associated Ulcers
one
in six infected patients will
develop duodenal ulcer
Without antibiotics 85% ulcers will
recur within 1 year
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143
Peptic Ulcer
Epigastric
pain (dyspepsia) 80-90%
Can be ‘silent’
Related to meals 50%
Nocturnal pain
Periodic pain
Nausea/vomiting
Anemia+
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144
Peptic Ulcer: Diagnosis
Endosocpy
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145
Testing for H pylori
Biopsy
noninvasive
assessment for H pylori
with fecal antigen assay or urea
breath testing
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146
Peptic Ulcer: Therapy
(1)
acid-antisecretory agents,:
Proton pump inhibitors –
rabeprazole 20 mg,
lansoprazole 30 mg,
esomeprazole or pantoprazole 40 mg
(2) mucosal protective agents: Misoprostol (Cytotec®) a
prostaglandin analog
and
(3) agents that promote healing through eradication of H
pylori.
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H pylori Eradication Therapy
Combination
regimens that use two antibiotics with a proton
pump inhibitorProton pump inhibitor twice daily1
Clarithromycin (Biaxin® )500 mg twice daily
Amoxicillin (Amoxil® ) 1 g twice daily
Given for 7-14 days
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148
Cancer Stomach
Dyspeptic
symptoms with weight loss in age 40+
Iron deficiency anemia; occult blood in stools.
detected on endoscopy
Declining in USA M>F
higher in Latinos, African-Americans, and Asian-Americans
Chile, Colombia, Central America, and Japan have high rates
H pylori gastritis a risk factor
pernicious anemia and past gastric surgery
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Signs
Epigastric
mass 20%
Supraclavicular
lymphnode
Umbilical/Ovarian
Metastases
FOBT/ Anemia
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Therapy
Surgery-
if early
Palliation- 30%
fluorouracil, 5-FU (Adrucil®) ,
Doxorubicin(Adriamycin®) , and
Cisplatin (Platinol®) or
mitomycin (Mutamycin®)
Prognosis- 15%
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