Pharmacology and Gastroenterology Quiz

Esophageal Disorders

• Gastroesophageal Reflux Disease (GERD) involves gastric juice refluxing into the esophagus.

• GERD results from a malfunction of the lower esophageal sphincter, leading to a decrease in its tone.

• The precise mechanism behind GERD isn't fully understood.

• Reflux Esophagitis:

  • Characterized by epithelial layer inflammation (erythema and edema) within the esophagus' mucosa.
  • Erosions (loss of the epithelial layer) are evident features.

• Histology of Reflux Esophagitis:

  • Basal zone (epithelium) shows hyperplasia.
  • Papillae of the lamina propria elongate.
  • Increased eosinophils and neutrophils are present.

• Pediatric GERD often presents with an immature lower esophageal sphincter, causing vomiting and crying.

• GERD Risk Factors:

  • Alcohol consumption.
  • Smoking.
  • Obesity.
  • Fatty foods.
  • Caffeine.
  • Hiatal hernia.

• GERD Symptoms:

  • Heartburn (retrosternal "burning" sensation, often after meals or when lying down).
  • Dysphagia (difficulty swallowing).
  • Painful esophagitis.
  • Respiratory symptoms (e.g., reflux into respiratory tract, adult-onset asthma, cough, dyspnea).
  • Damage to tooth enamel.

• GERD Treatment:

  • Weight loss.
  • Dietary modification (avoiding triggers like fatty foods, caffeine, chocolate, spicy foods, carbonated beverages, and peppermint).
  • Refractory GERD: Nissen fundoplication (surgical procedure).
  • Histamine (H2) blockers (e.g., famotidine, ranitidine, nizatidine, cimetidine).
  • Proton pump inhibitors (e.g., omeprazole, pantoprazole, lansoprazole, esomeprazole).

• Potential Consequences of GERD:

  • Ulcers: acid destroys the mucosa.
  • Fibrosis: tissue replacement with scar tissue.
  • Strictures: constrictions that cause dysphagia (difficulty swallowing).

• Ingestion of Lye:

  • Alkali substances (sodium or potassium hydroxide) found in household cleaners.
  • Rapid tissue damage (liquefactive necrosis) through the esophagus' mucosa, often requiring surgical repair.
  • Usually neutralized in the stomach, allowing for recovery in most cases.

• Barrett's Esophagus:

  • A result of long-standing GERD.
  • Metaplasia of the esophageal epithelium (turning into intestinal-like epithelium).
  • Squamous epithelium changes to intestinal epithelium.

• Barrett's Esophagus Diagnosis and Management:

  • Endoscopy often performed for GERD patients.
  • If Barrett's is seen, regular surveillance endoscopy is needed.
  • Biopsy samples are essential to check for dysplasia and carcinoma.

• Esophageal Cancer

  • Squamous cell carcinoma or adenocarcinoma are types.
  • Smoking increases the risk of both types.
  • Often diagnosed late, resulting in advanced disease.
  • "Progressive" dysphagia is a prevalent symptom.
  • Commonly presents with other symptoms such as weight loss, hematemesis, etc.

• Adenocarcinoma is most frequent in US.

  • Usually arises from the lower one-third of the esophagus.

• Additional forms of esophageal cancer, depending on location.

• Esophageal Cancer Lymph Node Involvement:

  • Upper esophagus: cervical lymph nodes.
  • Middle esophagus: mediastinal and tracheobronchial nodes.
  • Lower esophagus: celiac and gastric nodes.

• Esophagitis (Infectious Causes):

  • Candida: white membranes, pseudohyphae seen on biopsy
  • HSV-1 (Herpes Simplex): often oral herpes, may affect esophagus, punched-out ulcers
  • CMV (Cytomegalovirus): linear ulcers
  • AIDS (CD4<50): linear ulcers

• Eosinophilic Esophagitis:

  • Allergic or immune-mediated reaction (unknown antigens).
  • Esophageal dysfunctions (e.g., dysphagia).
  • Predominant eosinophils observed on biopsy.
  • Diagnosed by exclusion after ruling out other potential causes (e.g., GERD).

• Achalasia:

  • Inability to relax the lower esophageal sphincter.
  • Due to a loss in Auerbach's plexus ganglion cells in the esophageal muscular layer.
  • Often idiopathic.

• Achalasia Symptoms:

  • Dysphagia (solids and liquids).
  • "Closed” lower esophageal sphincter (only for solids).
  • Contrast obstruction (solids).
  • Bad breath
  • Accumulation of food in esophagus

• Achalasia Diagnostic Testing:

  • Esophagus dilation ("bird's beak") on barium swallow.
  • Esophageal manometry to measure pressure changes during contraction.

• Esophageal Varices:

  • Dilated submucosal veins, often in the lower one-third of the esophagus.
  • Usually due to portal hypertension (often from cirrhosis).
  • Can lead to upper gastrointestinal bleeding (variceal rupture).
  • Frequently a cause of death from liver-related conditions
  • Treated with emergent endoscopy for banding/ligation.

• Malloy-Weiss Syndrome: damage to esophagus at gastroesophageal junction.

• Boerhaave Syndrome: transmural rupture of esophagus due to severe/chronic vomiting or retching.

• Esophageal Webs and Rings: tissue protrusion in esophagus, causing food obstruction

• Schatzki Ring: Ring at the squamocolumnar junction frequently causes food obstruction

• Plummer-Vinson Syndrome: Triad of iron deficiency anemia, beefy red tongue, and esophageal web, often in middle-aged and white females

• Zenker's Diverticulum: Hernias of the pharynx/esophagus, often due to malfunctioning cricopharyngeal muscle.

• Zenker's Diverticulum symptoms include dysphagia, as well as halitosis (bad breath) because of trapped food inside.

• Video Swallowing Study: Diagnosis of esophageal and other swallowing issues

• Liver Disease: General information on liver disease and conditions.

• Liver Tests and Function: Details of different liver enzymes, including AST, ALT, alkaline phosphatase, and GGT

• Alcoholic Liver Disease, three stages:

  • Fatty liver disease
  • Acute hepatitis
  • Cirrhosis

• Non-Alcoholic Fatty Liver Disease (NAFLD)

  • Fatty infiltration of liver not due to alcohol
  • NAFL (Fatty liver).
  • NASH (Steatohepatitis) - fat and inflammation

• Alcoholic Hepatitis

  • Classically results from heavy, binge drinking on top of long history of alcohol consumption
  • Symptoms may include fever, jaundice, and RUQ pain/tenderness

• Mallory bodies are cytoplasmic inclusions found in cells of the liver

• Budd-Chiari Syndrome

  • Venous thrombosis of the hepatic veins
  • Usually related to several other medical conditions

• Right Heart Failure

  • Rare event causing nutmeg liver with edema
  • Mottled liver, like a nutmeg
  • Common in association with Budd Chiari syndrome

• Reyes Syndrome (rare): Liver failure/encephalopathy from viral infections (e.g., chickenpox) with aspirin use.

• a1-antitrypsin Deficiency causes lung disease.

• a1-antitrypsin Deficiency also causes cirrhosis.

• Liver Abscess: infection in liver tissue.

• Viral Hepatitis A, B, C, D, E: Infections characterized by elevated liver enzymes and jaundice. Severity may vary.

• Autoimmune Hepatitis: Autoimmune diseases of liver and bile ducts

  • More common in females in 40s, 50s

• Anti-nuclear antibodies (ANAs).

• Anti-smooth muscle antibodies (ASMA).

• Tylenol Overdose: Acute liver failure due to acetaminophen overdose.

• Shock Liver (Ischemic Hepatitis): Liver damage due to lack of blood perfusion caused by various causes

• Cirrhosis: End-stage, irreversible liver disease due to chronic liver injury.

• Characteristic features, like shrunken liver, are observed in this condition.

• Clinical features include hyperammonemia (elevated ammonia levels), causing confusion and coma.

• Treatment options include a low protein diet and the use of lactulose (a synthetic disaccharide) to lower colonic pH and reduce ammonia absorption, as well as addressing other associated conditions.

• Clinical features include jaundice, hypoglycemia, coagulopathy/bleeding problems, and hypoalbuminemia.

• Portal Hypertension: High pressure in portal vein due to obstructed flow, often caused by cirrhosis

  • Blood flows → portal vein → liver → hepatic vein

• Ascites and Edema: Conditions where excess fluid accumulates in peritoneal cavity due to underlying liver conditions

• Venous Collaterals: Secondary blood vessels/veins develop to help blood flow by detour when main blood vessel is blocked or damaged, often seen in conditions such as portal hypertension.

• Gastric Varices: Gastric varices are dilated veins located in the stomach, occurring frequently in patients with portal hypertension.

• Caput Medusa: Observable engorgement of veins around the umbilical region

• Internal Hemorrhoids: Dilated blood vessels near anus.

• Hypersplenism: Spleen swells and consumes blood components (e.g., platelets)

  • Engorgement of spleen can cause a decrease in platelets in portal hypertension

• Portal Vein Thrombosis

  • Usually from causes such as other medical conditions
  • Splenomegaly and gastric varices can result

• SAAG (Serum Ascites Albumin Gradient) is a helpful diagnostic tool for determining the causes of ascites (fluid in the abdominal cavity)

• TIPS (Transjugular Intrahepatic Portosystemic Shunt) is a surgical procedure performed in portal hypertension cases.

  • Creation of channel in liver to connect portal vein to hepatic vein to divert blood flow

• Spontaneous Bacterial Peritonitis (SBP): Bacterial infections in ascitic fluid.

• MELD Score: Scoring system to evaluate and predict mortality among individuals with chronic liver conditions

  • Points system for bilirubin, creatinine, and INR are evaluated.

• Child-Pugh classification

  • Scoring system to evaluate and predict mortality among individuals with chronic liver conditions
  • Points system for encephalopathy, ascites, bilirubin, albumin, and prothrombin time are evaluated.

• Liver Biopsy is the gold standard for liver condition diagnosis

• Stellate Cells are cells that are important to liver structure and function.

• Liver Tumors: Descriptions of different liver tumors, including hepatocellular carcinoma (HCC) and types that are rarer

• Aspergillus: A fungus that produces the toxin aflatoxin, which is associated with a rare type of liver cancer (HCC)

  • Can contaminate foods like corn, soybeans, peanuts

• Hepatocellular Carcinoma (HCC)

  • Most common primary liver cancer.
  • Often a consequence of chronic liver disease such as hepatitis B & C, alcoholic liver disease, Wilson’s disease, hemochromatosis, and α 1-antitrypsin

• Hepatic Adenoma: Benign tumor of the liver.

  • Often detected by chance.
  • Associated with usage of certain drugs (e.g., oral contraceptives, anabolic steroids).

• Hepatic Hemangioma: Benign tumor of the liver

  • Most common benign liver tumor.
  • Composed of vascular spaces often containing blood clots.

• Hepatic Angiosarcoma: Rare, malignant liver tumor

  • Often associated with certain toxic exposures (e.g., vinyl chloride, arsenic).

• Metastasis to liver is a common finding in several types of cancers.

• Wilson's Disease is an inherited disorder of copper metabolism in which copper can build up in the liver.

• Clinical features including various neurological issues are associated with this disease

• Hemochromatosis is a hereditary disease involving iron overload in the body which can also cause liver damage.

• Gallstones: Stones can form in the gallbladder made of cholesterol and/or bilirubin

• Cholelithiasis (gallstones) are solid masses that form within the gallbladder. -Components are bilirubin, bile salts, and cholesterol .

  • If the balance of these components is upset, stones can form and precipitate

• Several Conditions can cause acute cholecystitis such as gallstone disease.

• Choledocolithiasis involves obstructing stones in the common bile duct

  • Clinical features like Jaundice might be present

• Chronic Cholecystitis

  • Chronic inflammation of the gallbladder.
  • Can cause a porcelain gallbladder.

• Acalculous cholecystitis results from ischemia or inflammation of gallbladder without gallstones.

• AIDS Cholangiopathy

  • Rare disorder of biliary tree seen in individuals with end-stage HIV disease (infection or disorder in biliary tract).

• Ascending cholangitis : Infection of biliary tree through ascending infection

  • Charcot's triad (fever, right upper quadrant pain, jaundice)

• ERCP (Endoscopic retrograde cholangiopancreatography) is an imaging procedure used in biliary tree assessments

• Gallstone Ileus result from the perforation of a gallstone through the biliary tract wall

  • Causes intestinal obstruction

• Gallstone Pancreatitis is a condition in which gallstones cause acute inflammation in the pancreas.

• Gallbladder Carcinoma: Adenocarcinoma resulting from chronic inflammation processes

  • Rare malignancy involving gall bladder.

• Biliary Atresia : Biliary atresia occurs when the bile ducts of the liver do not develop properly or become blocked.

• In neonates, and key findings include jaundice, dark urine, and pale stool

• Biliary Cirrhosis is an older term for liver damage due to chronic biliary obstructions involving several conditions

• Primary Biliary Cirrhosis (PBC) is a chronic, cholestatic liver disease

  • Autoimmune response targeting the interlobular biliary ducts

• Clinical features include itching (pruritus), fatigue, and ultimately cirrhosis.

• Primary Sclerosing Cholangitis (PSC)

  • Chronic cholestatic liver disease.
  • Associated with ulcerative colitis.
  • Characterized by inflammatory involvement and strictures.

• Cholangiocarcinoma is a rare cancer arising from the bile duct epithelium.

  • Key risk factors are primary sclerosing cholangitis and chronic inflammatory bowel disease (IBD)

• Gastritis is an inflammation of the stomach mucosa

  • Symptoms: nausea, vomiting, loss of appetite, abdominal pain
  • Acute gastritis is usually caused by too much acid or loss of protection to the stomach lining
  • Chronic gastritis: Lymphocytes, macroph ages, H. pylori infection, autoimmune response

• Pernicious Anemia is a chronic condition often resulting from autoimmune gastritis wherein the stomach's intrinsic factor isn't secreted in sufficient amounts.

• Peptic Ulcer Disease: Sores or ulcers in the lining of the stomach and/or duodenum (upper small intestine).

  • H. pylori infection, NSAIDs use, smoking are risk factors.

• Duodenal ulcers frequently lead to complications such as bleeding problems.

• Bruhners Gland Hypertrophy is an increase in thickness of glands of the duodenum (part of small intestine)

  • Protects the duodenum from excess acidity by producing alkaline fluids.

• Complications of ulcers include perforation and upper GI bleeding.

• Stress ulcers are ulcers that develop in the stomach due to conditions such as shock, sepsis or trauma situations.

  • Prophylactic therapy with proton pump inhibitors (PPIs) is frequently administered.

• Gastric Carcinoma: A rare cancer frequently developing through complications of chronic gastritis and ulcers

  • 2 major subtypes: Intestinal and diffuse tumors .

• Hypertrophic Gastropathy; Rare disorders that cause enlargment of the rugal folds (folds or wrinkles of tissue in inner lining of stomach).

• Caused by hyperplasia (not inflammatory conditions)

• Menetrier's Disease: A rare disorder involving hyperplasia of stomach mucous cells (excessive secretions).

• Frequently occurs with protein loss ("protein-losing enteropathy")

• Malabsorption: Impaired nutrient intake due to abnormalities within the gut.

• Symptoms: diarrhea, weight loss, vitamin/mineral deficiencies

• Common presentation symptoms include steatorrhea, fatty, and foul-smelling stools.

• Celiac Sprue (Celiac Disease): Autoimmune response triggering destruction of the villi lining small intestine when exposed to gluten

• Key conditions include bloating, flatulence, or chronic diarrhea, loss of several essential nutrients

• Whipple's Disease: Rare infection of small intestine, causing malabsorption

  • Common in European, white males, with average age of 49.
  • Four cardinal features: diarrhea, abdominal pain, weight loss, and joint pains.
  • Microscopic analysis shows PAS-positive foamy macrophages.
  • Treated with antibiotics

• Lactose Intolerance: A common condition where the small intestine loses or has insufficient production of the enzyme lactase, necessary for digesting milk products.

  • Symptoms frequently following lactose ingestion with diarrhea, abdominal pain, or bloating

• Pancreatic Insufficiency is a condition commonly seen in cystic fibrosis and chronic pancreatitis (inflammation of pancreas)

• Features include fat malabsorption and steatorrhea, resulting from the loss of essential pancreatic enzymes

• Bacterial Overgrowth occurs when excessive bacteria are present, causing fermentation /inflammation/ and malnutrition /malabsorption

• Acute Pancreatitis: Acute inflammation of the pancreas.

• Common causes: gallstones, alcohol

• Rare causes: idiopathic, trauma, infections, toxins, autoimmune diseases, and certain medical conditions

• Complications of acute pancreatitis include DIC (disseminated intravascular coagulation), ARDS, pseudocysts, abscess, fat necrosis, hypocalcemia, and multi-organ failure.

• Diagnostic tools such as CT scans and elevations in serum amylase and lipase levels are used.

• Ranson's criteria are used for assessing the severity of acute pancreatitis.

• Several conditions are included along with treatment options and complications