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G6 Gastroenterology
Esophagus
Toronto Notes 2019
Table 2. Differential Diagnosis of Common Presenting Complaints (continued)
Bowel Ischemia
The splenic flexure and rectosigmoid junction are watershed areas and are susceptible to ischemia. History and symptoms include acute onset crampy left abdominal pain, absence of abdominal tenderness on
exam, rectal bleeding, and risk factors for embolization, atherosclerosis and atrial fibrillation
JAUNDICE (UNCONJUGATED BILIRUBIN)
JAUNDICE (CONJUGATED BILIRUBIN)
Overproduction
Hemolysis
Ineffective erythropoiesis (e.g. megaloblastic anemias)
Common
Decreased Hepatic Intake
Gilbert’s syndrome Drugs (e.g. rifampin)
Decreased Conjugation
Drug inhibition (e.g. chloramphenicol) Crigler-Najjar syndromes type I and II Gilbert’s syndrome
Neonatal jaundice
Uncommon
Intraductal obstruction
Gallstones
Biliary stricture
Parasites
Malignancy (cholangiocarcinoma)
Sclerosing cholangitis
Extraductal obstruction
Malignancy (e.g. pancreatic cancer, lymphoma) Metastases in peri-portal nodes
Inflammation (e.g. pancreatitis)
Hepatocellular disease
Drugs
Cirrhosis (any cause)
Inflammation (hepatitis, any cause)
Infiltrative (e.g. hemochromatosis)
Familial disorders (e.g. Rotor syndrome, Dubin-Johnson syndrome, cholestasis of pregnancy)
PBC
PSC
Sepsis Post-operative/TPN
Esophagus
Dyspepsia = postprandial fullness, early satiety, epigastric pain, or burning
Foods/Substances that may aggravate GERD Symptoms (but diet does not change the underlying disease)
• EtOH
• Caffeine
• Tobacco
• Fatty/fried foods
• Chocolate
• Peppermint
• Spicy foods
• Citrus fruit juices
Gastroesophageal Reflux Disease
Gastroscopy
Gastroesophageal Reflux Disease
Definition
• aconditionwhichdevelopswhentherefluxofgastriccontentcausestroublesomesymptomsor complications
Etiology
• inappropriatetransientrelaxationsofLES–mostcommoncause
• lowbasalLEStone(especiallyinscleroderma)
• contributing factors include: delayed esophageal clearance, delayed gastric emptying, obesity,
pregnancy, acid hypersecretion (rare) from Zollinger-Ellison syndrome (gastrin-secreting tumour) • hiatusherniaworsensreflux,doesnotcauseit(seeGeneralSurgery,GS13)
Clinical Features
• “heartburn”(pyrosis)andacidregurgitation(togetherare80%sensitiveandspecificforreflux)±sour regurgitation; less sensitive and less specific: water brash, sensation of a lump in the throat (globus sensation), and frequent belching
• non-esophagealsymptomsareincreasinglyrecognizedofbeingpoorpredictorsofreflux
GERD signs/symptoms
Non-esophageal
Respiratory
Chronic cough Wheezing Aspiration pneumonia
Figure 2. Signs and symptoms of GERD
Investigations
Esophageal
Non-respiratory
Sore throat
Hoarseness Dental erosions
Typical
Heartburn Acid regurgitation
Atypical
Chest pain Dysphagia (late) Odynophagia (rare)
Non-erosive reflux disease (NERD) Normal esophagus Aim for symptom relief only; proton pump inhibitor PRN
Esophagitis
Esophageal inflammation Aim to heal inflammation; proton pump inhibitor indefinitely or surgical fundoplication
• usually,aclinicaldiagnosisissufficientbasedonsymptomhistoryandrelieffollowingatrialof pharmacotherapy (PPI: symptom relief 80% sensitive for reflux)
• however,responsetoanti-secretoryagentssuchasPPIisnotarequirementforGERDdiagnosis • gastroscopyindications(AnnInternMed2012;157:808-816)
■ absolute indications
• heartburnaccompaniedbyred-flags(bleeding,weightloss,dysphagia,persistingvomiting,family
history of GI cancer etc.)
• persistentrefluxsymptomsorpriorsevereerosiveesophagitisaftertherapeutictrialof4-8wkofPPI2x
daily
• history suggests esophageal stricture especially dysphagia
• high risk for Barrett’s (male, age >50, obese, white, tobacco use, long history of symptoms)
• repeatendoscopyafter6-8wksofPPItherapyindicatedif:severeesophagitisbecauseitcanmask
Barrett’s esophagus or symptoms
Figure 3. Classification and gastroscopic findings of GERD
Esophageal damage from reflux is most severe at first gastroscopy, therefore gastroscopy is necessary only once for patients with NERD