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  1. 1. GI Lecture #2 Monday, 2/17/03, 9AM Dr. Troutman Sherif Rizkalla Page 1 of 4 Four Common Complaints of the GI Tract Dr. Troutman’s lecture basically followed the power points, and he added a few specific details on several of the symptoms. This lecture was approached from a clinical correlation standpoint, and is therefore not heavy on the details. I. Dysphagia A. Defined clinically as difficulty in swallowing. B. Patients may complain of food being hung up or getting stuck or it is slow going down. C. Race can be an important factor in some types of diseases that involve dysphagia. It should only be listed when relevant. II. Odynophagia A. Defined as a painful sensation that accompanies swallowing, but is not the same as difficulty in swallowing. B. Patient may complain that food gets stuck in their throat, and then it hurts, or that it is painful as the food is going down. C. These are signs of inflammation of the esophagus that can be caused by acid reflux. D. It is important to get the patient to differentiate between painful swallowing and difficulty in swallowing. III. Associated Symptoms A. Water Brash/Hypersalivation is the bitter taste one experiences caused by increased salivation prior to vomiting. B. It is important to ask the patient if there is any regurgitation that takes place. C. Other symptoms associated with dysphagia include heartburn, bloating, belching, and early satiety. D. Dr. Troutman also discussed the importance of using a method for history-taking (like OPQRST) in order to get as much out of the patient as possible. What they consider to be pain may be very different from what the physician considers. E. Weight loss is an important symptom associated with dysphagia, and can be a marker of the severity of the disorder. F. Hematemesis is the vomiting of blood and should be further described as being bright red or resembling coffee grounds. 1. Bright red hematemesis is a sign of a more aggressive, acute bleeding that’s faster in its progression and involves a more serious bleed. 2. Coffee-ground hematemesis is partially digested blood that is indicative of a slower bleed where the stomach releases gastric juices to digest the blood. The stomach becomes irritated and the result is vomiting.
  2. 2. GI Lecture #2 Monday, 2/17/03, 9AM Dr. Troutman Sherif Rizkalla Page 2 of 4 G. Black (melanotic) stool is blood in the stool that gives it a pitch- black coloration and a profound odor. Excess iron and Pepto- Bismol also produce a similar black stool. IV. Pulmonary Symptoms A. Because of the proximity of the trachea and primary bronchi to the esophagus, it is important to consider symptoms involving the pulmonary tree as relating to dysphagia. B. If something gets stuck in the esophagus, it can cause accumulation of saliva and sputum, leading to aspiration, coughing, and wheezing. C. Globus is a lump-like sensation in the throat. D. Nasal regurgitation involves “spitting up” liquid through the nose. V. Chest Pain A. Chest pain should always be considered a cardiac problem until proven otherwise. B. Once cardiac problems have been disproved, then one can examine pulmonary, musculoskeletal, and esophageal possibilities. C. Food stuck in the esophagus can also create chest pain. If it remains there for a long time it can result in esophageal spasm. This pain is described as being very similar to angina because of similar neurologic pathways. VI. Medications/Alcohol A. Knowing which medications the patient uses are essential to an accurate history. B. Patients do not often consider over-the-counter drugs as being medications. C. Aspirin and NSAID use can produce Esophagitis, so Dr. Troutman recommends that you ask the patient what they take for their pain. D. Excessive alcohol consumption can lead to liver disease, so getting an accurate account of amount and duration of use is helpful in determining the extent of damage. VII. Neuromuscular Symptoms A. Since the esophagus is a muscular tube, it is necessary to inquire about any muscle weakness and resultant dysphagia. B. Transfer Dysphagia- neurologic or musculoskeletal problems that affect swallowing and the transfer of a food bolus down the esophagus. C. It involves the voluntary muscles of swallowing, and the patient cannot get the food to be swallowed; in other words the food does not want to go from the mouth down to the esophagus. D. The food often will go down the trachea instead of the esophagus. E. Liquids will often be regurgitated through the nose. F. An in-depth neurologic exam should be able to determine the cause.
  3. 3. GI Lecture #2 Monday, 2/17/03, 9AM Dr. Troutman Sherif Rizkalla Page 3 of 4 G. Transfer dysphagia can be a sign of several neurologic/neuromuscular diseases such as Parkinson’s, Polio, dermatomyocitis (a disease of muscle and skin), stroke, ALS, and myasthenia gravis. VIII. Esophageal Symptoms A. Most common situation resulting in esophageal symptoms is a mechanical obstruction that keeps the food from going down. B. Food is “milked down” by way of peristalsis. 1. Primary peristalsis is initiated by swallowing the food. 2. Secondary peristalsis involves the milking down of food caused by distention of the esophagus. 3. Tertiary peristalsis is non-progressive contractions that resemble little ripples in the muscle movement. C. Webs/rings are attached pieces of tissue found in the esophagus that can obstruct solid foods. IX. Cancer of the Esophagus A. Squamous cell carcinomas are the most common and have significant risk factors including males, over 40, African American individuals, and people who drink and smoke. B. Adenocarcinomas are among the fastest rising cancers in the U.S. X. Other Causes of Dysphagia A. Peptic strictures are the scar tissue that results from the healing of esophageal ulcers (usually caused by chronic acid reflux disease). B. Motility Disorders can result in food being stuck in the esophagus without any mechanical obstruction. C. This situation would look normal with an x-ray or endoscopy. D. Specific Motility Disorders 1. Achalasia, a neurologic disease, is caused by the degeneration of myenteric ganglion cells in the wall of the esophagus that causes aperistalsis 2. Aperistalsis is caused by any disorder that results in neurogenic disruption to esophageal function or disorders that decrease muscular function of the esophagus. 3. Other causes such as lower esophageal sphincter failure. 4. The specifics are not important, just appreciate that there are different types of motility disorders that are not related to a mechanical obstruction. E. Dysphagia can be a secondary symptom of other diseases, such as diabetes, alcoholism, and thyroid disorders. XI. Diagnostic Workup A. It is most important to get an accurate history and physical exam to rule out several of the diagnoses and then order a diagnostic test to support your more specific diagnosis. B. Most common tests used are x-rays and endoscopy.
  4. 4. GI Lecture #2 Monday, 2/17/03, 9AM Dr. Troutman Sherif Rizkalla Page 4 of 4 C. Dysphagia in somebody 40 years old or older is considered to be cancer until proven otherwise. This can be easily determined through the use of endoscopy. D. Dr. Troutman announced that he does endoscopies all day every Wednesday, and those who are interested should call in advance and let him know that you are interested in seeing an endoscopy. He will be unavailable this Wednesday, however.