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Gastroenterology for the Boards - Part I

Gastroenterology for the Boards - Part I. Adib Chaaya, MD ACP, ACG, ASGE 11/19/2008. Lips . Herpes blisters. Impetigo Honey crust Group A strep Azithro / Clarithro. Lips . Lips. Lips /Peutz-Jeghers Syndrome. Associated with benign harmatoma Polyps of the intestine

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Gastroenterology for the Boards - Part I

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  1. Gastroenterology for the Boards - Part I Adib Chaaya, MD ACP, ACG, ASGE 11/19/2008

  2. Lips

  3. Herpes blisters Impetigo Honey crust Group A strep Azithro / Clarithro Lips

  4. Lips

  5. Lips /Peutz-Jeghers Syndrome • Associated with benign harmatoma • Polyps of the intestine • Complicated with cancers (mainly small bowel), and cancers of the lung, breast, uterus and ovary

  6. Tongue

  7. Tongue

  8. Tongue / Geographic Tongue • Temporary loss of the papillae • No treatment needed

  9. Mouth Ulcers

  10. Painful : Aphthous ulcers (Celiac, IBD) Behcet’s Disease Herpes Pemphigus vulgaris Painless : SLE AIDS Reiter’s Syndrome Mouth Ulcers

  11. Esophagus • 66 y/o M p/w dysphagia for solid food initially that gradually progressed to dysphagia to solids. • What is the first test to order?

  12. Esophagus • Barrium swallow showed a stricture of the esophagus: • What is your next step?

  13. Esophagus/ Dysphagia

  14. Esophagus/ Dysphagia • Dysphagia: • Weight loss: think Cancer • Intermittent: web, ring • Solid and liquid: neuromuscular, diffuse esophageal spasm, scleroderma, achalasia • Chronic GERD: peptic stricture

  15. Risk factors for Esophageal Ca • Smoking (SCC) • Alcohol (excessive ingestion)- (SCC) • Barrett’s esophagus • Achalasia

  16. Esophagus /Benign Stricture • 34 y/o M p/w Dysphagia. Work up showed benign peptic stricture treated with dilatation and a PPI. • He improved a lot and has no more dysphagia. • How long would you continue the use of the PPI?

  17. Achalasia Lack of peristalsis Incomplete relaxation of LES Dg on esophageal manometry Pneumatic dilation or surgical myotomy Diffuse Esoph Spasms Simultaneous contractions with intermittent normal peristalsis Nitrate, calcium channel blocker Nutcracker Esophagus High amplitude peristaltic contractions Hypertensive LES High LES pressure Normal LES relaxation Ineffective motility With scleroderma Weak peristalsis Low LES Esophagus

  18. Esophagus • 35 y/o F has dysphagia for solids and liquids. Barium swallow showed dilated esophagus with bird beak appearance. • What is you next best test: • 24 h PH monitoring • EGD • Motility studies • Trial of PPI

  19. Achalasia vs pseudoachalasia • Cancer of the fundus can invade around the esophagus and cause symptoms similar to achalasia. • Biopsies of the lower esophagus must be done to rule out malignancy.

  20. When to do motility studies? • Achalasia • Esophageal spasm • Scleroderma

  21. Esophagus • 25 y/o F p/w couple of month history of severe heartburn. • What do you do? • EGD • PH monometry • Trial of PPI • Clinical monitoring

  22. Esophagus/ GERD • Lifestyle modification • Weight loss • Stop smoking • Elevate head of bed • Allow enough time between dinner and sleeping

  23. Esophagus/ GERD • H2Receptor blocker • PPI • Most rapid and complete symptom relief • Faster mucosal healing • Endoscopy • Screen for Barrett’s in long standing symptoms • If alarm symptoms • Dysphagia • Anemia/Bleeding • Weight loss

  24. Esophagus/ GERD • Antireflux surgery • Same efficacy as PPI • Before surgery esophageal manometry is necessary • pHmetry • To confirm the diagnosis in non erosive GERD • Evaluate patients not responding to therapy • Evaluate extraesophageal manifestations of GERD

  25. Esophagus/ GERD • GERD is the most common cause of non cardiac chest pain • The diagnosis is confirmed by 24h pHmetry or successful trial of PPI (usually high dose and for long term)

  26. Esophagus / Barrett’s • 63 y/o M with Barrett’s esophagus is found to have NO dysplasia . Started on PPI. • What is your next step? • EGD in 1 year • Esophagectomy • EGD in 3 years. • NPO/ TPN and monitoring

  27. Esophagus / Barrett’s • Barrett’s occurs in patients with early age at onset and long standing heartburn • Adenocarcinoma is now as frequent as squamous cell carcinoma • Barrett’s is present in up to 10% of patients with GERD • Screening for Barrett’s is appropriate in • Older patients (>50) • Long-standing GERD symptoms (>5 years) • Especially white men

  28. Management of Barrett’s • No dysplasia: PPI + EGD Q2-3 years with biopsies to r/o dysplasia • Low grade dysplasia: PPI + EGD Q6-12 months with biopsies to r/o high grade dysplasia. • High grade dysplasia: esophagectomy

  29. Esophagus • 27 y/o F with history of GERD p/w throat pain and odynophagia; she takes doxyclcline for acne. • What is your differential diagnosis? • How do you confirm it?

  30. What is your differential diagnosis? Pill induced esophagitis • How do you confirm it? EGD shows esophagitis with a solitary small ulcer in the lower esophagus..

  31. Esophagus/ Odynophagia

  32. Esophagus/ Odynophagia • Pill esophagitis: always on the board • HIV patient with odynophagia: • Candida • HSV • CMV • Idiopathic ulcer • Severe esophagitis secondary to GERD can cause odynophagia

  33. Differential diagnosis for Odynophagia • Monilia : • white lesion • Bx/brushing shows hyphae • Candia is the most common cause • Treatment: fluconazole

  34. Differential diagnosis for Odynophagia • HSV: • Many small ulcers • Bx: multinucleated giant cells • Tt: acyclovir

  35. Differential diagnosis for Odynophagia • CMV: • 1-2 ulcers • Bx: CMV inclusion bodies • Tt: gancyclivir

  36. Esophagus • 45 y/o p/w chest pain. Was having for 2 days retching and vomiting. • X ray showes Left pleural effusion. Pleural tap showed high amylase. • What is your next step? • Gastrographine study • CPK • EDG • CT scan

  37. Esophagus / Boerhaave syndrome • Mimics acute MI • Mediastinal emphysema can develop • Diagnosed by swallowing gastrographine (for the Boards) • Treatment: • Esophageal and gastric suction • Antibiotics • Surgical drainage • Repair of laceration

  38. Stomach / PUD • What are the 2 most common causes of PUD? • NSAID • H.Pylori • Steroids • Idiopathic

  39. Stomach / PUD • H.Pylori is responsible of • 50 to 80% of duodenal ulcers • 40 to 60% of gastric ulcers • 80% of gastric cancers • 90% of gastric lymphomas (if MALT=> treat H pylori) • The lifelong incidence of ulcer disease in those infected with H.Pylori is only 20%

  40. Stomach / PUD • Gastric ulcers should be biopsied to R/O malignancy, as opposed to duodenal ulcers. • H.Pylori should be checked, usually on biopsy, if not possible serology is appropriate • Detection of H.Pylori • Endoscopic • Culture • Histology • Urease testing • Non Endoscopic • Antibody tests • Urea breath test • Fecal antigen test

  41. Stomach / PUD • Treatment regimens • PPI/Amox/Clarithromycin • PPI/Flagyl/Clarithromycin • PPI/Peptobismol/Flagyl/Tetracycline • 14 days better than 10 days

  42. Stomach / PUD • Risk factors for NSAID induced GI complications • Advanced age (>75) • Pre-existing ulcer disease • Multiple NSAIDs or high dose NSAIDs • Concomitant steroid therapy or anticoagulant therapy • Comorbid diseases

  43. Stomach / PUD • Eradicating H.Pylori in NSAID users is still controversial • But if NSAID induced gastropathy with H.Pylori, eradication is indicated • NSAID gastropathy is a dose related phenomenon • COX-2 selective NSAID result in fewer GI ulcers

  44. Stomach / GI prophylaxis • When indicated to give GI prophylaxis: • Ventilator for > 48 hours • Coagulopathy

  45. Stomach / H pylori • 41 y/o patient with history of duodenal ulcer treated for H pylori gastritis, but returns with the same symptoms • Which of the following would best indicate continous infection with H pylori? • IgG serology for H pylori • Duodenal aspirate for H pylori • Breath urease test /stool Ag for H pylori

  46. MALT / ZE • 70 to 80% of MALT will regress when H.Pylori is eradicated • Think about ZE when • Recurrent ulcers on treatment • Chronic diarrhea • Other endocrine disorders (MEN)

  47. Stomach • 46 y/o with type I diabetes presents for N/V, early satiety, vague epigastric pain for the past 4 months. His condition will improve with: • PPI • Low fat diet, small meals, control of DM, and Reglan • Eradication of H.Pylori if present

  48. Stomach /Gastroparesis • Causes • Drugs • Systemic disease (DM, Scleroderma..) • Idiopathic, post viral • Diagnosis • Gastric Emptying Scan • Treatment • Prokinetics • Surgery • Nutritional support

  49. Stomach • 51 y/o M h/o severe CAD has diffuse abdominal pain for 3 hours after eating any kind of food. • The pain decreases with decreasing amount of food eaten. • What is you diagnosis? • What is you next step?

  50. Stomach / Abdominal Angina • What is you diagnosis? =>abdominal angina • What is you next step? => mesenteric angiogam

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