Dysphagia d/t esophageal webs; associated with long standing GERD

Triad - Iron deficiency anemia, glottitis, & cheilosis

Zenker - above UES

Traction - mid-esophagus

Epiphrenic - above LES

Achalasia

Triad?

Secondary association & treatment?

functional obstruction by impaired smooth muscle relaxation

Triad - incomplete LES relaxation, increased LES tone, and aperistalsis

Secondary to Chagas Disease

TX: dilatation; myotomy; botox

Esophageal varices

Presentation, pathophysiology, & clinical sequelae?

Collateral bv's secondary to portal hypertension

Present with upper GI bleeding; Sx&S of portal hypertension and possibly liver disease

Clinical sequelae: Rupture w/ massive hematemesis

longitudinal lacerations near GE junction

severe retching

distal esophageal rupture

severe retching followed by severe retrosternal chest pain

cardia ascends and pushes lower esophagus upward

common, usually asymptomatic

gastric fundus alongside esophagus

less common but more commonly symptomatic

surgical TX required

Eosinophilic/Allergic

Infectious

GERD

HSV - Herpes esophagitis herpetic ulcers

CMV - common in HIV-AIDS; well circumscribed ulcers

Candida - most common cause of esophageal infection in HIV-AIDS patients

small white mucosal plaques on endoscopy

most common cause of esophagitis

eosinophils are restricted to the distal esophagus

Pharmacologic: H2 receptor antagonists, PPI, promote motility

Surgical: reduce hernia, interrupt gastric vagal innvervation

neoplastic change in glandular epithelial cells in metaplastic area

Barrett esophagus - risk for esophageal adenocarcinoma

Progression from GERD to Adenocarcinoma:

squamous epithelium

esophagitis

barrett esophagus

dysplasia

carcinoma

distal 1/3 of esophagus

usually arise in backgroun od long-standing GERD or Barrett mucosa

Tobacco

EtOH

Obesity

Irradiation

middle 1/3 of esophagus

tobacco

EtOH

Therm/chem injury

Plummer-Vinson syndrome

achalasia

poverty

irradiation

HPV

invasion into or through the muscularis propria - poor prognosis

limited to mucosa or submucosa - better prognosis

overall 5 yr survival is POOR

superficial tumors - better

deep - worse

60% present w/ l.n. metastases

common metastases to LIVER or LUNG

overall 5 yr survival is POOR

diarrhea (malabsorptive)

dyspepsia

dysphagia

hemorrhage

fatigue (anemia)

early satiety

peripheral neuropathy

lymphadenopathy

acid production w/ mucosal damage

found in the esophagus & meckel diverticulum

common

assoc. w/ Turner syn. or Trisomy 18

projectile vomiting, palpable mass

Drugs:

 Aspirin & corticosteroids (decrease mucus)

NSAIDS (decrease PG = decrease HCO3, mucin, vasc perfusion & increase HCl)

Stress:

Curling ulcers (severe burns/trauma)

Cushing ulcers (CNS trauma)

EtOH & Ischemia

less common than non-autoimmune

pernicious anemia & achlorhydria

AutoAB against parietal cells and IF (malabsorption of VitB12 - megaloblastic anemia, peripheral neurophathy)

Increased serum gastrin

H. pylori

CagA - virulence factor

DX: CLO test

TX: ABx & PPI

non-autoimmune

sparse inflammatory infiltrate with reactive foveolar hyperplasia

typically chemical injury

1) epithelial dysplasia - "flat" lesions

chronic inflammation

atrophic changes - autoimmune & multifocal

May progress to invasive gastric adenocarcinoma

2) PUD (H.pylori hyperchlorhydria: most common cause)

Presentation of PUD

gastric ?

&

duodenal ?

dyspepsia

gastric - pain soon after intake; relieved by fasting

duodenal - pain may be relieved by eating

mucous cells predominant

lymphocyte infiltrate

symptoms: hypoproeinemia, wt loss & diarrhea

Associated with adenocarcinoma

parietal cells predominant

neutrophils infiltrate

symptoms: peptic ulcers

Multiple endocrine neoplasia is a risk factor

tumor cells form glandular structures

metastasis to l.n. and liver

discohesive cells w/ large intracytoplasmic mucin

diffuse infiltration of gastric wall: linitis plastic - "leather bottle" stomach

Worse prognosis

flushing, seating, bronchospasm, diarrhea, colicky abdom. pain

Carcinoid syn. from GI NET - highly suggestive of metastatic tumor presentation outside protal drainage bed

spindled cells

>50% arise in the stomach, location & size important for prognosis

GIST

Gastrointestinal stromal tumors

characteristic genetic mutations

c-kit

PDGFRA - platelet derived GF receptor alpha

Imatinib

tyrosine kinase inhibitor

works well on c-kit+ tumors

diarrhea

pain

malabsorption Sx&S - diarrhea, steatorrhea, anemia, edema, ascites, distention, flatulence

neonatal intestinal obstruction

deficiency of pancreatic enzymes and increased viscocity of secretions

What are the rule of 2's ?

&

What pathology is it associated with?

Rule of 2's

Occurs in 2% of population

2 inches long

2 feet within ileocecal valve

2% symptomatic

2 year old

Assoc. with Meckel diverticulum

full thickness; SMA occlusion

thrbomboembolism; thrombosis

acute ischemia w/ infarction

mucosal

hypoperfusion; hypovolemic shock, profound hypotension

Reperfusion is major cause of injury

telescoping of bowel

"lead points"

cause of intussusception in children ?

&

cause of intussusception in adults ?

children - lymphoid hyperplasia of peyers patches

adults - mass (neoplasm)

constipation with fecal impation

more common in cecum or distal colon

most common causes of small bowel obstructions

overall most common ?

&

Most common in newborns ?

adhesions - overall most common

hernias (inguinal/indirect)

IBD (Chrons dz)

duodenal atresia - most common in newborns

Small bowel bacterial overgrowth

Problems

DX

TX

bacterial colonization of mucosa

Problems: impairs absorption; diarrhea, wt loss, pain, etc

DX: sm. bowel aspirate & culture

TX: broad spectrum ABx

Short Bowel Syndrome

Effects

Pathophysiology

<200 cm of sm. bowel remaining

Effect:

loss of significant absorptive surface; B12 & bile salts absorbed in terminal ileum

Can lead to SBBO

Pathophysiology: multiple resections for Crohns dz

"explosive" osmotic diarrhea

increased hydrogen d/t bacterial fermentation of lactose

defect in syn & transport of apoprotein B from enterocytes

cannot form chylomicrons

failure to thrive, steatorrhea/diarrhea

T cell infiltration

IgA mediated response - Anti-tissue transglutaminase IgA (very good indicator)

Pathology from tissue biopsy of celiac dz

where is tissue biopsy taken from & where is it most severe ?

villous blunting (flattening) with intraepithelial lymphocytes

biopsy from duodenum or proximal jejunum

proximal jejunum - most severe

systemic illness

fever

anemia

lymphadenopathy

arthritis

CNS involvement

pericarditis

endocarditis

skin pigmentation

Tropical sprue

causes

effects

TX

caused by E.coli or Haemophilus

Effects: injury to entire sm. bowel; villous atropy; malabsorption following acute diarrheal episode

TX: tetracycline, folic acid, B12

adenomas

peutz-jehger polyps

leioyomas

lipomas

BENIGN

tubular; tubolovillous; villous

adenocarcinoma

lymphoma

leiomyosarcoma

Cardinoid tumor (NETs)

BENIGN

hamartomatous polyps and mucocutaneous melanotic pigmentation

obstruction & intussusceptions

most common small bowel malignant neoplasm

Associated w/ which other pathologies (2)

adenocarcinoma

Assoc. w/ Celiac dz & Crohns dz

lymphoma

NHL, MALT, Burkitt, Enteropathy assoc. T cell lymphoma

Cardinoid tumor

NETs

Adenocarcinoma is typically advanced at time of DX ?

TRUE or FALSE