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143 Cards in this Set
- Front
- Back
What muscle represents the upper esophageal sphincter? |
Fibers of the cricopharyngeus muscle |
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Anatomically where does the esophagus lie? |
In the thoracic cavity, posterior mediastinum posterior to the trachea |
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Which structure does the esophagus pass through to attach to the stomach? |
Diaphragmatic hiatus |
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How long is the LES? |
3-5 cm long |
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What is GERD also known as? |
Heartburn/Acid reflux/Pyrosis (this is the medical term) |
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What is one of the Most Common conditions leading to the need for healthcare in the US? |
Gastroesophageal Reflux Disease (GERD) |
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What can GERD feel like? |
Burning/warmth/pain that starts in the lower esophagus and rises substernally |
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True or False Prevalence of GERD does not increase with age. |
False. Prevalence increases with age 20% of US population affected every week |
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True or False Severity of heartburn DOES NOT correlate with the severity of esophageal disorder. |
True |
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When does GERD typically present? |
Within 1 hour of large meals |
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What is the definition of GERD? |
An insufficiency of physiologic anti-reflux barriers at the gastroesophageal junction |
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What is the etiology of GERD? |
Impaired LES function |
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What does Normal function of the LES depend on? |
LES pressure Intrabdominal location of the sphincter Extrinsic compression of the crural diaphragm |
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When an individual is bending down why will the contents of the stomach go up towards the LES and not the pyloric sphincter? |
The pyloric sphincter is stronger and will hold tight |
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What is the pathogenesis of GERD? |
GERD overwhelms the esophageal mucosal integrity due to dysfunction of the LES |
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What is the mechanism of esophageal acid clearance? |
It is cleared by peristalsis, gravity, neutralization by saliva and alkaline esophageal secretions |
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What is one way GERD is diagnosed? |
GERD diagnosis is established after evaluating response to a 4 week empiric trial of PPI (75% sensitivity/55% specificity) |
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How is GERD diagnosed in the ambulatory setting? |
pH monitoring |
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What is the Gold Standard for diagnosing GERD? |
Bravo Study (requires EGD, sensor, monitor, and food diary as well as compliance by patient) |
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What are the ALARM symptoms of GERD? |
Weight loss, dysphagia, odynophagia, bleeding, anemia, refractory to medical management |
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If there is no response to 4 week trial empiric treatment, what is the next step? |
Perform EGD |
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What are the symptoms of GERD? |
Substernal burning Radiating to the neck Reflux of acid |
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Non typical symptoms of GERD? |
Hoarse voice or voice changes |
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What labs should be ordered for a patient with uncomplicated GERD? |
CBC CMP TFT FOBT |
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What is the treatment for a patient with uncomplicated GERD? |
OTC PPI for 4-8 weeks then PRN |
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What are the H2 receptor antagonists used to treat GERD? |
cimetidine (Tagamet) ranitidine (Zantac) famotidine (Pepcid) nitazidine (Axid) |
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What are the PPIs used to treat GERD? |
omeprazole (Prilosec) esomeprazole (Nexium) lansoprazole (Prevacid) pantoprazole (Protonix) rabeprazole (Aciphex) |
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What does PPI block? |
Histamine, acetylcholine, and parietal cells |
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Which H2 receptor antagonists are better tolerated? |
ranitidine and famotidine |
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What is the mechanism of action for H2 blockers? |
H2 blockers competitively block H2 receptors on Gastric parietal cells so gastric secretion is inhibited |
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What is the mechanism of action for PPIs? |
Acts by irreversibly blocking the gastric proton pump of the parietal cells. |
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The proton pump is the __________ stage in gastric acid secretion, being directly responsible for secreting H+ ions into the gastric lumen. |
Terminal |
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What is the next step in treatment of GERD is medical management is ineffective? |
Esophagogastroduodenoscopy (EGD) |
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What are the 4 most common reasons to aggravate GERD? |
Alcohol Caffeine Tobacco Chocolate |
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What medications can aggravate GERD? |
Anticholinergic agents ASA & NSAIDS CCB Nitrates Progesterone |
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What are the extraesophageal manifestations? |
Asthma Non productive chronic cough Layngitis |
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Why is asthma an extraesophageal manifestations? |
It is due to micro aspiration of refluxate and/or vaguely medicated esophagobronchial reflux |
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How long does the chronic cough in GERD last and how many patients does it affect? |
> 3 weeks and is associated in up to 40% of patients. |
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What should be considered after endoscopy, 12 weeks of therapy and lifestyle modification does not alleviate GERD? |
Gastrinoma (Zollinger Ellison Syndrome) Pill induced esophagitis Medications (NSAIDS, Steroids, Bisphosphonates) Resistance to PPI Medical noncompliance |
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What is a hiatal hernia? |
When the a small portion of the stomach is above the diaphragmatic hiatus |
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What is Zollinger Ellison Syndrome? |
Gastric ulcers in absence of H. pylori and duodenal ulcers. Caused by pancreatic tumors that release gastrin in excess. |
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What is Fundoduplication? |
The upper curve of the stomach (the fundus) is wrapped around the esophagus and sewn into place so that the lower portion of the esophagus passes through a small tunnel of stomach muscle |
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What percentage of patients is fundoduplication usually effective? |
50% |
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What is dysphagia? |
Difficulty swallowing |
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Dysphagia is most common in which population? |
People over 65 and alcohol users |
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What are ALARM symptoms of dysphagia? |
Recurrent Frequent Persistent |
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If a person cannot swallow liquids what is affected? |
Esophageal motility |
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If a person cannot swallow solid foods what type of esophageal dysfunction is this? |
Mechanical |
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When does oropharyngeal dysphagia occur? |
Immediately after deglutition, patient will have difficulty initiating a swallow |
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What type of sensation will a patient with oropharyngeal dysphagia feel and what is it associated with? |
Coughing or choking sensation and often associated with structural disorders or neuromuscular disorders |
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What are structural disorders than can cause orophayngeal dysphagia? |
Cervical osteophytes Cricoid web Phayrngeal (Zenker) diverticulum Thyromegaly |
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What is Zenker diverticulum? |
Protrusion of pharyngeal constrictor and the cricophayngeal |
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What is the etiology of oropharyngeal dysphagia? |
Loss of elasticity of the UES resulting in restricted opening during swallowing |
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What are signs and symptoms of Zenker diverticulum? |
Aspiration Neck mass Regurgitation Foul breath Inability to clear throat |
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If you suspect Zenker diverticulum what should you do first? |
Order a barium swallow |
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What is the treatment for Zenker diverticulum? |
Surgical (Upper esophageal myotomy or diverticulectomy) |
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What are some Neurologic/Myogenic disorders that can cause oropharyngeal dysphagia? |
ALS (will also see Upper and Lower motor neuron sign and fasciculations) CNS tumor Muscular dystrophy Myasthenia gravis Parkinson's disease |
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When does esophageal dysphagia occur? |
After the initiation of a swallow |
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What can cause esophageal dysphagia? |
Mechanical interference or structural disorders |
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How does a patient with esophageal dysphagia present? |
They will describe it as "food getting stuck" (make sure to ask patient to point where they feel it) |
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Where is esophageal dysphagia often localized? |
Lower sternum (but can be as high as suprasternal notch) |
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True or False An individual can rarely have esophageal dysphagia to liquids. |
True |
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What structural disorders can cause esophageal dysphagia? |
Dysphagia lusoria Traction diverticulum Esophageal strictures Esophageal webs Neoplasms |
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What is dysphagia lusoria? |
It is when there is double aortic arch and one wraps around the esophagus |
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What is traction diverticulum? |
A localized distortion, angulation, or funnel-shaped bulging of the esophageal wall, due to adhesions resulting from an external lesion (following lymph node infection and almost always TB) |
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What are the most common structural disorders of esophageal dysphagia? |
Esophageal strictures and webs |
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What are esophageal strictures? |
Build up of scar tissue due to acid exposure and almost always secondary to uncontrolled GERD |
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What are esophageal webs? |
Thin diaphragm like membranes of squamous mucosa typically in the mild or upper esophagus and may be multiple. |
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What is Schatzki's ring and how is it typically found? |
A type of esophageal web and is usually an incidental finding |
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What may be associated with iron deficiency anemia but is not the cause of it? |
Schatzki's Ring |
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What is Eosinophilic Esophagitis? |
Sensitization of the esophagus to respiratory and oral antigens |
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What does increased incidence of Eosinophilic Esophagitis parallel? |
That of allergic disease and asthma |
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What are important therapeutic difference between EoE and GERD? |
EoE can be treated with oral corticosteroids (2 puffs and swallow) and avoidance of dietary allergens |
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How is EoE diagnosed? |
Endoscopic biopsy (> or = to 15 eosinophils per high power microscopy field) |
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True or False EoE can cause dysphagia to both food and liquids. |
True |
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What are clues for mechanical obstruction? |
Solids foods worse than liquids |
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What are clues for Schatzki ring? |
Intermitten dysphagia and is not progressive |
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What are clues for Esophageal stricture/stenosis? |
Chronic heartburn, progressive dysphagia |
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What are clues for Esophageal cancer? |
Progressive dysphagia, age > 50 years |
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What are clues for EoE? |
Young adults, small caliber lumen, proximal stricture, corrugates rings or white papules |
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What is odynophagia? |
Painfull swallowing |
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What is a hallmark sign for odynphagia? |
Sharp substernal pain on swallowing |
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What is Odynophagia most commonly associated with? |
Esophageal ulceration |
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What is the etiology for odynophagia? |
Infectious esophagitis (Most common Candida, others Herpes virus and CMV) |
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What is Achalasia? |
Failure of the LES to relax with swallowing (can be functional obstruction or degeneration of the myenteric plexus) |
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Which population is more susceptible to Achalasia? |
Male=Female 30-50 year old |
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What can you find on a Barium swallow study for Achalsia? |
"Birds Beak" finding |
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What are pharmacologic treatment for Achalasia? |
Calcium Channel blockers/nitrates Botulism toxin injection |
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What are mechanical treatments for Achalasia? |
Balloon dialation Surgical myotomy |
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True or False All patients with Achalasia do not require EGD to rule out cancer relates pseudoachalasia? |
False. It is required |
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What is esophageal spasm? |
A hypertonic motility disorder. |
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What are the different types of esophageal spasm? |
Diffuse esophageal spasm Intermittent non-peristalic contractions Nutcracker esophagus |
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What does esophageal spasm look like on a barium study? |
Corkscrew esophagus |
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What is the treatment for esophageal spasm? |
Smooth muscle relaxants (CCB/nitrates) Antidepressants (Trazadone, Imipramine) |
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What does esophageal spasm feel like? |
Pain just all the time |
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True or False Hypotonic motility disorders is more common than hypertonic motility. |
False. It is far less common |
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What is 50% of hypotonic motility disorder diagnosed with? |
Scleroderma |
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How do you treat hypotonic motility disorder? |
Control GERD |
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What are the three disorders of esophageal odynophagia? |
Achalasia Diffuse esophageal spasm Scleroderma |
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What are the clues for achalasia? |
Solids and liquids foods |
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What are the clues for diffuse esophageal spasm? |
Intermitten, not progressive, may have chest pain |
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What are the clues for scleroderma? |
Chronic heartburn, Raynaud phenomena |
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What is hiatal hernia? |
Protrusion of the upper portion of the stomach through an abnormal opening in the hiatus of the diaphragm |
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What leads to higher amounts of acid reflux and delayed esophageal acid clearance? |
Hiatal hernia |
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True or False Hiatal hernia is associated with moderate to severe esophagitis. |
True |
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True or False 75% patients with Barrett's esophagus have a hiatal hernia. |
False. 90% patients with Barrett's esophagus have a hiatal hernia |
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What is Barrett's esophagus? |
Intestinal metaplasia-basically starts growing duodenal tissue in the esophagus, sign of chronic uncontrolled said reflux |
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True or False If the GERD is controlled then the Barrett's esophagus can change back into normal tissue |
True |
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True or False Barrett's esophagus is considered a "pre-cancerous" condition and a complication of GERD |
True |
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True or False Barrett's esophagus is not the most common in patients with large hiatal hernias, low LES pressures and abnormal esophageal motility. |
False Most common in patient with large hiatal hernias, low LES pressures and abnormal esophageal motility |
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How do you diagnose Barrett's esophagus? |
Endoscopy and pathology |
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What is the next step is Barrett esophagus is confirmed? |
Long term treatment with PPI Repeat endoscopy 6 mo after initial diagnosis then every 2 yrs until intestinal metaplasia and macroscopic findings are resolved |
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What is the next step is Peptic Stricture is present? |
After dilatation (long term treatment with PPI and mechanical soft diet) Address underlying pathology (such as Scleroderma) If non Barrett repeat endoscopy PRN |
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What is paraesophageal hernia? |
An uncommon type of gastric hernia that includes a peritoneal layer that forms a true hernia sac (Hernia next to the esophagus) |
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What are the clinical Hx findings for paraesophageal hernia? |
Heartburn (30-60 minutes after meals) Upon reclining Atypical symptoms (dry cough, asthma) |
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What are some general considerations with infectious esophagitis? |
Most common in immunosuppressed patients HIV/AIDS Solid organ transplants Leukemia Lymphoma Immunosuppressive drugs |
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What are the clinical findings hx for infectious esophagitis? |
Odynophagia Dysphagia |
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What can be found on physical examination for infectious esophagitis? |
Oral Thrush (white cheesy exudate on oral mucosa) Evidence of CMV Retinopathy Evidence of herpetic ulcers on oral mucosa |
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What is the treatment for infectious esophagitis? |
Often empiric Confirm by endoscopy
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What is the treatment for Candida Esophagitis? |
Fluconazole 200mg PO 1st day then 100 mg PO QD for 14 days Amphotericin B IV 0.3-0.7 mg/kg/d |
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What is the treatment for CMV Esophagitis? |
Follow highly active antiretroviral therapy (HAART) Ganciclovir 5 mg/kg IV Q 12h for 3-6 weeks then Valganciclovir 900 mg qd |
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What is the treatment for Herpetic Esophagitis? |
Acyclovir 400 mg 1 tab po Q 4h for 7-10 days Vancyclovir 1gm po qd for 7-10 days
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True or False You will always request blood work up to check for HIV with Herpetic esophagitis? |
True |
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What is Mallory-Weiss Syndrome? |
Vertical mucosal laceration of GEJ Non penetrating mucosal tear at the GEJ
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What is Mallory-Weiss Syndrome usually associated with? |
EtOH use |
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What are clinical hx findings for Mallory-Wiess Syndrome? |
Heavy lifting Retching Vomiting Hematemeis Melena may or may not be present
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What is the Differential Dx for Mallory-Weiss Syndrome? |
Peptic ulcer disease Erosive esophagitis AV malformation Portal Hypertension |
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What tests should be performed if Mallory-Weiss Syndrome is suspected? |
Endoscopy |
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What is the treatment for Mallory-Weiss Syndrome? |
Endoscopic hemostatic therapy |
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What is Boerhaave syndrome? |
Full thickness tear of the esophagus Effort rupture, almost ALWAYS caused by vomiting |
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True or False There is high morbidity in the absence of surgery for Boerhaave syndrome. |
True |
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Where is Boerhaave syndrome typically located? |
Almost always left, posterolateral aspect of the distal esophagus |
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What sign can be seen on clinical examination of Boerhaave syndrome? |
Herman's sign (rasping sound caused by the heart beating against air filled tissue, has been described as popping of Rice Krispies) |
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What are esophageal varices? |
Dilated submucosal veins that develop in patients with underlying portal hypertension |
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What percentage of patients with Cirrhosis have esophageal varices? |
50% |
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True or False Esophageal varices may result in serious upper gastrointestinal bleed |
True Distal 5cm of the esophagus |
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After an initial bleed the patient has a _____ chance of recurrence. |
60% Usually within 6 weeks of initial incident |
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What is the mortality rate of in house patients with bleeding varices? |
15% |
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What are the clinical findings of esophageal varices? |
Hematemesis (Bright red blood or coffee grounds) Melena Severe bleeding Postural hypotension Tachycardia Tachypnea |
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What labs should be ordered when esophageal varies is suspected? |
Start 2 large bore IV lines CBC PT/INR CMP Blood type and cross match |
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What is included in the initial management of esophageal varices? |
NGT 0.9 NS or lactated Ringer's solution if Hgb < or =7 mg/dL transfuse 2 units of packed RBCs (may need 4 units) Is platelet count < or = 50,000 transfuse platelet If INR > 1.5 transfuse fresh frozen plasma (one unit for ever 5 units of packed RBCs) If there is uremia 3 doses of Ddvap (desmopression) Transfer to ICU |
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What are the pharmacologic therapy for esophageal varices? |
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Tx for esophageal varices |
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