Gastrointestinal Preview and Video

This section is a free preview of the Gastrointestinal Section of the Full PANCE/PANRE Review Course. Full Gastrointestinal course has 138 questions, and full Gastrointestinal Lecture Video (1:48:40)

Gastrointestinal Lecture Slides Preview

Title:  Gastrointestinal Lecture Slides Preview

Details:  This slide show is a preview of the full lecture slides from PANCE/PANRE Course from the Gastrointestinal section.

Total Length:  26 slides.  Full Gastrointestinal lecture is 156 slides

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Gastrointestinal Questions Preview (10 Questions)

Title: Preview Gastrointestinal  Questions

Details:  This slide show contains a preview of 10 Gastrointestinal PANCE style questions, answers, and detailed explanations.

Total Length:  20 slides.  Full Gastrointestinal course has 276 slides over questions, answers, and detailed explanations.

Full Course Questions Can Be Accessed:   Gastrointestinal Questions, Answers, and Explanations

Gastrointestinal Lecture Video Preview

Title:  Preview of Gastrointestinal Lecture Video

Details:  This video is a preview of the full Gastrointestinal Lecture Video.

Total Length:  15 minutes and 36 seconds.  Full Gastrointestinal Lecture Video is 1 hour and 48 minutes.

Full Lecture Video Can Be Accessed:  Full Gastrointestinal Lecture Video

Gastrointestinal Preview Lecture Notes

Gastrointestinal Blueprint
PANCE Blueprint

Esophagus
Esophagitis-
Many causes of esophagitis

Eosinophilic Esophagitis is found in up to 15 percent of patients with dysphagia.
Typically have stacked circular rings, strictures, linear furrows and white papules that can lead to food impaction
Diagnosis is made by biopsy

Esophagitis
Treated by elimination of dietary elements that cause allergic response.  Start patient on proton pump inhibitor.

Topical steroids can be helpful in eosinophilic esophagitis

Esophageal dilation necessary for patients with symptomatic strictures

Radiation esophagitis may occur in patients being treated for head, neck, or thoracic cancers.
These patients have dysphagia and odynophagia

Esophagitis
Lymphocytic esophagitis is when there is a dense peripapillary lymphocytic infiltrate involves the lower two thirds of the esophageal epithelium
Etiology is unknown
Usually seen in older patients
Treat with proton pump inhibitor if reflex present with it. May not be associated with GERD

Esophagitis
Infectious Esophagitis due to many causes.  Most common herpes simplex virus

Other causes of infectious causes such as cytomegalovirus (CMV), candidia, cryptococcosis, histoplasmosis, blastomycosis, and aspergilliosis

Immunosuppression should be suspected if present

Medication Induced Esophagitis caused by largely 3 groups of medications:  antibiotics, NSAIDS< and others

Esophagitis
Doxycycline is the most common antibiotic causing medication induced esophagitis
NSAIDS can cause but higher with ASA
Major players in the others category: KCl, quinidine, and biphosphonates
Mechanism is by caustic injury to the esophagus
Sometimes can be caused by retention of the capsule or scratching of the esophagus

Esophagitis
The most important therapy is to take the offending medication away

PPI’s, antacids, and carafate can be prescribed but their value has not been significantly demonstrated.

Reflux esophagitis is due to hydrogen ion diffusion into the mucosa leading to cellular acidification and necrosis

Impaired esophageal emptying or decreased salivary function can contributed to increased exposure of the esophagus to the acid and induce this pathology

Esophagitis
Treatment is directed as acid control or increasing esophageal emptying
If bleeding is present, melena is much more common the hematemesis
Other signs of esophagitis include pyrosis, dysphagia, bleeding, and possible pulmonary aspiration
History is important in the diagnosis. Non exertional and lasting for hours usually points to a non cardiac etiology

Esophagitis
Other key elements include possibly awakens from sleep, worse after meals, and aggravated by lying down.
Usually improved with standing or sitting up.
Treatment can involve PPI, H2 blockers, antacids, reglan (helps gastric emptying), and carafate
Non pharmacologic measures include weight loss, elevating head of the bed, and eliminating eating before bedtime or laying down.

Motility Disorders
Motility disorders of the esophagus can occur from the upper esophageal sphincter (UES) or lower esophageal sphincter (LES) and body of the esophagus

Oropharyngeal motility disorders may arise from dysfunction of UES such as Zenker’s diverticulum or cricopharyngeal bar.

Can also be caused by stroke, multiple sclerosis, amytrophic lateral sclerosis, brain tumors, muscular dystrophy, myasthenia gravis, cancer, goiter, or cervical spurs.

Motility Disorders
High incidence of aspiration with these disorders

Diagnosis with rapid sequence cine esophagography.  Endoscopy plays a supportive role

Treatment is directed at reversing potential causes, aspiration precautions, and considering PEG tube if the underlying disorder is at high risk of aspiration

The body of the esophagus can have motility disorders that arise from the smooth muscle or the intrinsic nervous system

Motility Disorders
Scleroderma affects the smooth muscle of the esophagus and achalasia and Chagas disease are affected by disorders of the intrinsic nervous system
Other disorders can cause diffuse esophageal spasm
Cine esophagography and esophageal manometry confirms the diagnosis
Achalasia usually responds to brisk dilation of the LES or surgical myotomy

Motility Disorders
Scleroderma patients should have aggressive treatment of GERD
Patients with diffuse esophageal spasm sometimes will get some relief with calcium channel blockers, nitroglycerin or anticholinergic patients
Rings and webs can affect the proximal or distal (Schatzki’s rings)
Can cause some intermittent dysphagia especially when eat solid foods

Mallory Weiss Tear
Mallory Weiss tear is defined as longitudinal mucosal lacerations (intramural dissections) in the distal esophagus and proximal stomach which are caused by retching.
Hiatal hernia is found in a high percentage of patients with Mallory Weiss tears
Alcoholism is a predisposing factor.  Bleeding can be more severe with portal hypertension or esophageal varices

Mallory Weiss Tear
Presenting symptoms are acute GI bleeding, epigastric abdominal pain or back pain
Bleeding occurs because of a tear that involves the esophageal venous or arterial plexus
Patients usually have non bloody vomitus before the bleeding starts
High percentage of patient need a blood transfusion but bleeding is self limited

Mallory Weiss Tear
Endoscopic therapy is first line treatment in actively bleeding lacerations
Injections with epinephrine, ethanol, or other sclerosing agents are helpful
Can use thermal devices also

Esophageal Neoplasms
Most esophageal cancers are squamous cell or adenocarcinomas
Barrett’s esophagus can give rise to adenocarcinoma
Small cell carcinoma and sarcoma can arise out of the distal esophagus
Family aggregation has been described with a high incidence of squamous cell carcinoma in China.
Family history is a good indicator for Barrett’s esophagus

Esophageal Neoplasms
The presence of underlying esophageal disease such as achalasia and caustic strictures increases the risk of esophageal cancer
Prior gastrectomy increases the risk for squamous cell carcinoma
Atrophic gastritis, human papilloma virus, tylosis, biphosphonates, and poor oral hygiene have been shown to increase the risk of esophageal cancer
Most all of adenocarcinomas arise from a region of Barrett’s esophagus which is due to GERD

Esophageal Neoplasms
Smoking increases the risk form adenocarcinoma of the esophagus
Alcohol consumption does not increase the risk for esophageal adenocarcinoma
Obesity has been liked to esophageal adenocarcinoma and adenocarcinoma of the gastric cardia
Zollinger Ellison Syndrome may be at increased risk for adenocarcinoma

Esophageal Neoplasms
Use of drugs that decreased lower esophageal sphincter pressure may increases the risk of adenocarcinoma
Cholecystectomy and nitrosative stress have been associated with carcinogenesis
NSAIDS may have a protective effects
Patients with locally advanced cancer can cause some solid food dysphagia

Esophageal Neoplasms
Weight loss may happen from dysphagia
Aspiration pneumonia can happen but infrequent
Chronic GI blood loss is common with esophageal cancer with melena
Tracheobronchial fistulas are a late complication of esophageal cancer because of the direct invasion through the esophageal wall to the main stem bronchus
Esphogectomy is the treatment of choice for superficial esophageal cancers

Esophageal Neoplasms
The cancer has to be staged as well as the depth determined
Evaluation for distant metastasis can be done with CT or PET scanning
Criteria for unresectable disease includes: distant metastasis to peritoneal, lung, bone, adrenal, brain, or liver mets, thoracic or abdominal esophagus near great vessels, heart or trachea, cervical esophageal tumors
Palliative surgical resection is usually not indicated
External beam radiation therapy (EBRT) is indicated for unresectable cancer
Chemotherapy and radiation therapy is the standard nonoperative management for unresectable therapy

Esophageal Stricture
Most benign esophageal strictures result from a complication of long standing GERD
Treated with acid reducers as well as esophageal dilation therapy
Other causes of strictures can be secondary to external beam radiation, esophageal sclerotherapy, caustic ingestions, surgical anastomosis, and rare dermatologic diseases
The cardinal symptom of strictures is dysphagia

Esophageal Stricture
Contraindications to esophageal dilation include:  incomplete healed perforation, potentially malignant stricture, pharyngeal or cervical deformity, caution with eosinophilic esophagitis, large thoracic aneurysm, and impacted food bolus
Can be dilated with balloon dilators or mechanical dilators
Simple strictures are related to reflux esophagitis
Complex strictures are long, narrow, tortuous, or strictures associated with hiatal hernias and esophageal diverticulae.

Esophageal Varices
Varices are expanded blood vessels in the esophagus and sometimes the stomach
Cirrhosis blocks the blood flow through the liver and this increases the pressure in the portal vein causing portal hypertension
Without treatment 25-40 percent of patients with esophageal varices will have one major episode of bleeding
Fifteen percent of the people who bleed from varices will die

Esophageal Varices
Varices do not cause symptoms until the bleed or ruptures
Treatment involves beta blockers for those that have refractory ascites
patients need to avoid alcohol and lose weight
Variceal band ligation can be placed around the varices to prevent them from bleeding
PPI’s help speed the healing of erosions and ulcers that develop when the band falls off the varices.
If they rupture will need massive blood transfusion, volume replacement, and emergent endoscopy

NCCPA Topic List  GI Blueprint

Esophagus
Esophagitis
Motility disorders
Mallory-Weiss tear
Neoplasms
Strictures
Varices
Stomach
Gastroesophageal reflux disease
Gastritis
Neoplasms
Peptic ulcer disease
Pyloric stenosis
Gallbladder
Acute/chronic cholecystitis
Cholangitis
Cholelithiasis
Liver
Acute/chronic hepatitis
Cirrhosis
Neoplasms

Pancreas
Acute/chronic pancreatitis
Neoplasms
Small Intestine/Colon
Appendicitis
Celiac disease
Constipation
Diverticular disease
Inflammatory bowel disease
Intussusception
Irritable bowel syndrome
Ischemic bowel disease
Lactose intolerance
Neoplasms
Obstruction
Polyps
Toxic megacolon

Rectum
Anal fissure
Abscess/fistula
Fecal impaction
Hemorrhoids
Neoplasms
Hernia
Infectious and Noninfectious Diarrhea
Vitamin and Nutritional Deficiencies
Metabolic Disorders
Phenylketonuria