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
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
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PANCE Blueprint-PANCE/PANRE Review Course
-Physician Assistants can claim Category 2 CME for these courses.
-17 Hours Lecture Video
-1672 PANCE Style Board Review Questions, Answers, and Detailed Explanations
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