2
NURS 5461 GI Exam with verified detailed answers || || || || || || ||
dysphagia - ✔✔Subjective sebsation of difficulty swallowing
|| May be due to
|| || || || || || || || || || || ||
physiological or anatomical abnormalities along any portion of the esophagus, including the
|| || || || || || || || || || ||
upper and lower sphincters
|| || An alarm symptom that must prompt evaluation and
|| || || || || || || || || || || || || ||
should never be attributed to normal aging without an appropriate evaluation
|| || || || || || || || || ||
Dysphagia Types - ✔✔oropharyngeal (above the esophagus) and esophageal-->most
|| || || || || || || || ||
common is achalasia-disorder of esophageal nerves preventing food movement.
|| || || || || || || ||
Structural starts with solids r/o malignancy (adenocarcinoma distal esophagus)
|| || || || || || || ||
infection involves PAINFUL swallowing, viral (CMV usually immunosuppressed) or fungal
|| || || || || || || || || ||
(candida-inhaled asteroid) ||
Chewing [mastication] - ✔✔involves CNV [trigeminal], CNVII [facial], CNIX
|| || || || || || || || ||
[glossopharyngeal], and CNXII [hypoglossal], in addition to muscles of jaw, cheeks, tongue || || || || || || || || || || || ||
and palate ||
Clinical characteristics of Dysphagia - ✔✔Problems in the oral phase include - Poor bolus
|| || || || || || || || || || || || || ||
control - Spillage from lips or into pharynx - Dry oral membranes (xerostomia) - Pocketing
|| || || || || || || || || || || || || || ||
of oral residue - Difficulty with chewing
|| || || || || ||
Pharyngeal dysphagia results from || || || ||
weakness or poor coordination of pharyngeal || || || || || ||
muscles, which can cause→ || || ||
- Delayed swallowing
|| ||
- Failure of airway protection
|| || || ||
- Nasal or oral regurgitation
|| || || ||
- Residue remaining in pharynx after swallowing
|| || || || || || ||
manifested as coughing, choking or gurgling || || || || ||
,2
Clinical Presentation - ✔✔- Short duration with weight loss suggests malignancy - Abrupt
|| || || || || || || || || || || || ||
onset associated with neuro changes suggests CVA ⚫¼ - ½ of new stoke patients will have
|| || || || || || || || || || || || || || || ||
dysphagia
gradual progressive onset-PD, ALS, MG|| || || ||
medications that can contribute to Dysphagia - ✔✔Antidepressants, Antihistamines,
|| || || || || || || || ||
Fosamax, NSAIDS, K, Fe, Nitates, BB, CCB || || || || || ||
diagnostics for dysphagia - ✔✔ Cineesophagram (video swallow study or videofluoroscpy)
|| || || || || || || || || || || || ||
|| Modified barium swallow, endoscopy NOT helpful, alone but may need to r/o other
|| || || || || || || || || || || || || || ||
causes
DDx dysphagia - ✔✔Acute inflammation [infection; bone and mucosal disorders] Stroke
|| || || || || || || || || || ||
syndromes and vascular disorders Myasthenia Gravis Dementias Chemical agents
|| || || || || || || || ||
Parkinson's disease Neuromuscular esophageal disorders Multiple Sclerosis Medications
|| || || || || || || ||
Huntington's disease Scleroderma Tuberculosis Muscle anomalies Tetanus Achalasia
|| || || || || || || ||
Syphilis Pharyngoesophageal diverticulum ALS Diffuse spasm NeoplasmsCarcinoma
|| || || || || || ||
Recurrent laryngeal neuropathies Degenerative disorders Irradiation Guillain-Barre'
|| || || || || || ||
syndrome Psychopathology Esophageal stenosis Diabetes Feeding phobias Esophageal
|| || || || || || || ||
webs, rings or stricture Cerebral palsy Sensory deficits
|| || || || || || ||
Management of Dysphagia - ✔✔Medication review, particularly focusing on anticholinergic
|| || || || || || || || ||
drugs
|| Oropharyngeal dysphagia: Swallowing rehabilitation, dietary modifications such
|| || || || || || || || || ||
as thickening liquids, or careful hand feeding
|| || Achalasia: Surgical or endoscopic || || || || || || || || || || || || ||
myotomy (SOE=A); injection of the lower esophageal sphincter with botulinum toxin may
|| || || || || || || || || || || ||
provide months of symptomatic relief in patients who are not surgical candidates
|| || || || || || || || || || || || || || ||
Spastic motility disorders: Calcium channel blockers or phosphodiesterase inhibitors may
|| || || || || || || || || ||
provide relief (SOE=B) Strictures: Endoscopic dilation has a very high success rate,
|| || || || || || || || || || || || || || ||
although patients often require ongoing medical treatment of the underlying cause as well
|| || || || || || || || || || || || ||
|| Aspiration and Nonoral Feeding in Dysphagia of Functional Origin - Patients with severe
|| || || || || || || || || || || || ||
aspiration, which is not treatable with dietary or positional modifications, should receive
|| || || || || || || || || || || || ||
nonoral feedings to prevent aspiration|| Head positioning, swallowing maneuvers and || || || || || || || || || || || ||
,2
dietary textural modifications seem to demonstrate clear evidence of benefit in treating
|| || || || || || || || || || || ||
functional dysphagia - Refer to speech pathologist for evaluation
|| || || || || || || ||
Indications for Hospitalization/Referral - ✔✔Dietary consultation GI consult Will need
|| || || || || || || || || ||
intervention if patient has structural problem Speech therapy Neurology may be needed
|| || || || || || || || || || ||
Dyspepsia (heartburn) - ✔✔ Most commonly associated with peptic ulcer disease, GERD,
|| || || || || || || || || || || || || ||
biliary colic, or medication-induced discomfort
|| Whether gastritis due to Helicobacter
|| || || || || || || || || || || ||
pylori can cause symptoms of dyspepsia is debated
|| Consider prompt endoscopy in
|| || || || || || || || || || || || || ||
older adults because of the increased rate of organic disease, including malignancy ➢
|| || || || || || || || || || || || ||
Associated with significant reduction in PPI use and improved qualify of life (SOE=B) ➢
|| || || || || || || || || || || || || ||
Safe for older adults who are otherwise healthy ➢
|| || || || || || || ||
Differential Diagnoses Dyspepsia - ✔✔ Heartburn is occasionally described as extreme—
|| || || || || || || || || || || ||
and may make if difficult to differentiate from angina or MI
|| || These folks describe pain || || || || || || || || || || || || || || || ||
as radiating to the back, arms or jaw—which further complicates the diagnosis
|| || || || || || || || || || || || || ||
Medication induced gastritis - Alcohol; salicylates; corticosteroids; NSAIDs; erythromycin;
|| || || || || || || || ||
theophylline Giardiasis - This patient will have occasional bouts of diarrhea || || || || || || || || || || || || || || || || ||
Nonulcer Dyspepsia [NURD or NERD] - From H. pylori || Gastric Cancer - Dyspepsia, || || || || || || || || || || || || || || ||
anorexia, weight loss || ||
Dyspepsia presentation - ✔✔Heartburn is common (7% w/qd complaints-usually GERD),
|| || || || || || || || || ||
Dyspepsia usually presents with epigastric discomfort, postprandial fullness, early satiety,
|| || || || || || || || || ||
anorexia, belching, nausea, vomiting, indigestion, bloating, borborygmi, dysphagia and
|| || || || || || || || ||
abdominal bloating These symptoms can have a functional or organic cause—organic
|| || || || || || || || || || ||
causes increase with age, if endocopy rules out structural dx=functional dyspepsia
|| || || || || || || || || ||
Managing Dyspepsia - ✔✔ Perform H pylori testing in all patients, with a 13C-urea breath
|| || || || || || || || || || || || || || || || ||
test or fecal antigen test along with biopsies at the time of endoscopy ➢ Treatment for H
|| || || || || || || || || || || || || || || || ||
pylori in patients with ulcers will result in healing and elimination of symptoms in a large
|| || || || || || || || || || || || || || || ||
majority of patients Patients with large or nonhealing ulcers: biopsy to exclude
|| || || || || || || || || || || || || || ||
malignancy Patients negative for H pylori: 2-month empiric trial of PPI (SOE=B)
|| || || || || || || || || || || || || || || || || ||
Patients with a normal upper endoscopy: consider further testing, including abdominal
|| || || || || || || || || || ||
, 2
imaging and a gastric emptying study Patients with functional dyspepsia (no identified
|| || || || || || || || || || || || || || ||
organic disease): trial of PPI, although the rate of symptom improvement is low
|| || || || || || || || || || || ||
**off label TCA (nortriptyline) functional dyspepsia whith poor response to other Rx-avoid
|| || || || || || || || || || || ||
in elderly
||
GERD - ✔✔most common upper GI condition, decrease pain perception in older adults
|| || || || || || || || || || || ||
GERD prevalence - ✔✔ It is COMMON
|| Higher rates are seen in overweight or obese || || || || || || || || || || || || || || || || || || ||
and those with a BMI >25
|| Prevalence in the US is near 20 percent - 10% of the adult
|| || || || || || || || || || || || || || || || || || || || ||
population complain daily || ||
Epidemiology and Causes - ✔✔Primary cause—inappropriate, spontaneous relaxation of || || || || || || || || ||
the LES, An incompetent LES allows free reflux during abdominal straining, lifting,
|| || || || || || || || || || || ||
bending and recumbency; severe disease, the LES is incompetent—resting pressure of <10
|| || || || || || || || || || || ||
mm Hg ||
Pathophysiology GERD - ✔✔ 4 probable factors - Transient LES relaxation - Low resting || || || || || || || || || || || || || || || ||
pressure of LES - Decreased ability of esophagus to clear itself of material - Decreased
|| || || || || || || || || || || || || || ||
gastric emptying (fxn disorder most common cause
|| || || || || ||
**In pregnancy, 25-58% prevalence of reflux
|| || || || ||
Clinical Presentation GERD - ✔✔A "burning" sensation in the chest, behind sternum is
|| || || || || || || || || || || || ||
characteristic Symptoms often occur or are worse after a meal; better w/ antacid, and
|| || || || || || || || || || || || || ||
patients may note certain food triggers Older patients may present with atypical or
|| || || || || || || || || || || || ||
extraesophageal manifestations, sometimes without accompanying heartburn: dyspepsia, || || || || || || ||
epigastric pain, nausea, bloating, belching, asthma, chronic cough, and laryngitis or voice
|| || || || || || || || || || || ||
changes Many older adults with longstanding atypical symptoms delay in seeking care and
|| || || || || || || || || || || || ||
first present with alarm symptoms such as dysphagia, odynophagia, or vomiting
|| || || || || || || || || ||
|| If delayed gastric emptying is the cause of GERD, patient may also have - Abdominal
|| || || || || || || || || || || || || || || || ||
fullness; nausea; early satiety || || || ||
|| || || Dysphagia and odynophagia (painful swallowing) are **alarm symptoms || || || || || || ||
NURS 5461 GI Exam with verified detailed answers || || || || || || ||
dysphagia - ✔✔Subjective sebsation of difficulty swallowing
|| May be due to
|| || || || || || || || || || || ||
physiological or anatomical abnormalities along any portion of the esophagus, including the
|| || || || || || || || || || ||
upper and lower sphincters
|| || An alarm symptom that must prompt evaluation and
|| || || || || || || || || || || || || ||
should never be attributed to normal aging without an appropriate evaluation
|| || || || || || || || || ||
Dysphagia Types - ✔✔oropharyngeal (above the esophagus) and esophageal-->most
|| || || || || || || || ||
common is achalasia-disorder of esophageal nerves preventing food movement.
|| || || || || || || ||
Structural starts with solids r/o malignancy (adenocarcinoma distal esophagus)
|| || || || || || || ||
infection involves PAINFUL swallowing, viral (CMV usually immunosuppressed) or fungal
|| || || || || || || || || ||
(candida-inhaled asteroid) ||
Chewing [mastication] - ✔✔involves CNV [trigeminal], CNVII [facial], CNIX
|| || || || || || || || ||
[glossopharyngeal], and CNXII [hypoglossal], in addition to muscles of jaw, cheeks, tongue || || || || || || || || || || || ||
and palate ||
Clinical characteristics of Dysphagia - ✔✔Problems in the oral phase include - Poor bolus
|| || || || || || || || || || || || || ||
control - Spillage from lips or into pharynx - Dry oral membranes (xerostomia) - Pocketing
|| || || || || || || || || || || || || || ||
of oral residue - Difficulty with chewing
|| || || || || ||
Pharyngeal dysphagia results from || || || ||
weakness or poor coordination of pharyngeal || || || || || ||
muscles, which can cause→ || || ||
- Delayed swallowing
|| ||
- Failure of airway protection
|| || || ||
- Nasal or oral regurgitation
|| || || ||
- Residue remaining in pharynx after swallowing
|| || || || || || ||
manifested as coughing, choking or gurgling || || || || ||
,2
Clinical Presentation - ✔✔- Short duration with weight loss suggests malignancy - Abrupt
|| || || || || || || || || || || || ||
onset associated with neuro changes suggests CVA ⚫¼ - ½ of new stoke patients will have
|| || || || || || || || || || || || || || || ||
dysphagia
gradual progressive onset-PD, ALS, MG|| || || ||
medications that can contribute to Dysphagia - ✔✔Antidepressants, Antihistamines,
|| || || || || || || || ||
Fosamax, NSAIDS, K, Fe, Nitates, BB, CCB || || || || || ||
diagnostics for dysphagia - ✔✔ Cineesophagram (video swallow study or videofluoroscpy)
|| || || || || || || || || || || || ||
|| Modified barium swallow, endoscopy NOT helpful, alone but may need to r/o other
|| || || || || || || || || || || || || || ||
causes
DDx dysphagia - ✔✔Acute inflammation [infection; bone and mucosal disorders] Stroke
|| || || || || || || || || || ||
syndromes and vascular disorders Myasthenia Gravis Dementias Chemical agents
|| || || || || || || || ||
Parkinson's disease Neuromuscular esophageal disorders Multiple Sclerosis Medications
|| || || || || || || ||
Huntington's disease Scleroderma Tuberculosis Muscle anomalies Tetanus Achalasia
|| || || || || || || ||
Syphilis Pharyngoesophageal diverticulum ALS Diffuse spasm NeoplasmsCarcinoma
|| || || || || || ||
Recurrent laryngeal neuropathies Degenerative disorders Irradiation Guillain-Barre'
|| || || || || || ||
syndrome Psychopathology Esophageal stenosis Diabetes Feeding phobias Esophageal
|| || || || || || || ||
webs, rings or stricture Cerebral palsy Sensory deficits
|| || || || || || ||
Management of Dysphagia - ✔✔Medication review, particularly focusing on anticholinergic
|| || || || || || || || ||
drugs
|| Oropharyngeal dysphagia: Swallowing rehabilitation, dietary modifications such
|| || || || || || || || || ||
as thickening liquids, or careful hand feeding
|| || Achalasia: Surgical or endoscopic || || || || || || || || || || || || ||
myotomy (SOE=A); injection of the lower esophageal sphincter with botulinum toxin may
|| || || || || || || || || || || ||
provide months of symptomatic relief in patients who are not surgical candidates
|| || || || || || || || || || || || || || ||
Spastic motility disorders: Calcium channel blockers or phosphodiesterase inhibitors may
|| || || || || || || || || ||
provide relief (SOE=B) Strictures: Endoscopic dilation has a very high success rate,
|| || || || || || || || || || || || || || ||
although patients often require ongoing medical treatment of the underlying cause as well
|| || || || || || || || || || || || ||
|| Aspiration and Nonoral Feeding in Dysphagia of Functional Origin - Patients with severe
|| || || || || || || || || || || || ||
aspiration, which is not treatable with dietary or positional modifications, should receive
|| || || || || || || || || || || || ||
nonoral feedings to prevent aspiration|| Head positioning, swallowing maneuvers and || || || || || || || || || || || ||
,2
dietary textural modifications seem to demonstrate clear evidence of benefit in treating
|| || || || || || || || || || || ||
functional dysphagia - Refer to speech pathologist for evaluation
|| || || || || || || ||
Indications for Hospitalization/Referral - ✔✔Dietary consultation GI consult Will need
|| || || || || || || || || ||
intervention if patient has structural problem Speech therapy Neurology may be needed
|| || || || || || || || || || ||
Dyspepsia (heartburn) - ✔✔ Most commonly associated with peptic ulcer disease, GERD,
|| || || || || || || || || || || || || ||
biliary colic, or medication-induced discomfort
|| Whether gastritis due to Helicobacter
|| || || || || || || || || || || ||
pylori can cause symptoms of dyspepsia is debated
|| Consider prompt endoscopy in
|| || || || || || || || || || || || || ||
older adults because of the increased rate of organic disease, including malignancy ➢
|| || || || || || || || || || || || ||
Associated with significant reduction in PPI use and improved qualify of life (SOE=B) ➢
|| || || || || || || || || || || || || ||
Safe for older adults who are otherwise healthy ➢
|| || || || || || || ||
Differential Diagnoses Dyspepsia - ✔✔ Heartburn is occasionally described as extreme—
|| || || || || || || || || || || ||
and may make if difficult to differentiate from angina or MI
|| || These folks describe pain || || || || || || || || || || || || || || || ||
as radiating to the back, arms or jaw—which further complicates the diagnosis
|| || || || || || || || || || || || || ||
Medication induced gastritis - Alcohol; salicylates; corticosteroids; NSAIDs; erythromycin;
|| || || || || || || || ||
theophylline Giardiasis - This patient will have occasional bouts of diarrhea || || || || || || || || || || || || || || || || ||
Nonulcer Dyspepsia [NURD or NERD] - From H. pylori || Gastric Cancer - Dyspepsia, || || || || || || || || || || || || || || ||
anorexia, weight loss || ||
Dyspepsia presentation - ✔✔Heartburn is common (7% w/qd complaints-usually GERD),
|| || || || || || || || || ||
Dyspepsia usually presents with epigastric discomfort, postprandial fullness, early satiety,
|| || || || || || || || || ||
anorexia, belching, nausea, vomiting, indigestion, bloating, borborygmi, dysphagia and
|| || || || || || || || ||
abdominal bloating These symptoms can have a functional or organic cause—organic
|| || || || || || || || || || ||
causes increase with age, if endocopy rules out structural dx=functional dyspepsia
|| || || || || || || || || ||
Managing Dyspepsia - ✔✔ Perform H pylori testing in all patients, with a 13C-urea breath
|| || || || || || || || || || || || || || || || ||
test or fecal antigen test along with biopsies at the time of endoscopy ➢ Treatment for H
|| || || || || || || || || || || || || || || || ||
pylori in patients with ulcers will result in healing and elimination of symptoms in a large
|| || || || || || || || || || || || || || || ||
majority of patients Patients with large or nonhealing ulcers: biopsy to exclude
|| || || || || || || || || || || || || || ||
malignancy Patients negative for H pylori: 2-month empiric trial of PPI (SOE=B)
|| || || || || || || || || || || || || || || || || ||
Patients with a normal upper endoscopy: consider further testing, including abdominal
|| || || || || || || || || || ||
, 2
imaging and a gastric emptying study Patients with functional dyspepsia (no identified
|| || || || || || || || || || || || || || ||
organic disease): trial of PPI, although the rate of symptom improvement is low
|| || || || || || || || || || || ||
**off label TCA (nortriptyline) functional dyspepsia whith poor response to other Rx-avoid
|| || || || || || || || || || || ||
in elderly
||
GERD - ✔✔most common upper GI condition, decrease pain perception in older adults
|| || || || || || || || || || || ||
GERD prevalence - ✔✔ It is COMMON
|| Higher rates are seen in overweight or obese || || || || || || || || || || || || || || || || || || ||
and those with a BMI >25
|| Prevalence in the US is near 20 percent - 10% of the adult
|| || || || || || || || || || || || || || || || || || || || ||
population complain daily || ||
Epidemiology and Causes - ✔✔Primary cause—inappropriate, spontaneous relaxation of || || || || || || || || ||
the LES, An incompetent LES allows free reflux during abdominal straining, lifting,
|| || || || || || || || || || || ||
bending and recumbency; severe disease, the LES is incompetent—resting pressure of <10
|| || || || || || || || || || || ||
mm Hg ||
Pathophysiology GERD - ✔✔ 4 probable factors - Transient LES relaxation - Low resting || || || || || || || || || || || || || || || ||
pressure of LES - Decreased ability of esophagus to clear itself of material - Decreased
|| || || || || || || || || || || || || || ||
gastric emptying (fxn disorder most common cause
|| || || || || ||
**In pregnancy, 25-58% prevalence of reflux
|| || || || ||
Clinical Presentation GERD - ✔✔A "burning" sensation in the chest, behind sternum is
|| || || || || || || || || || || || ||
characteristic Symptoms often occur or are worse after a meal; better w/ antacid, and
|| || || || || || || || || || || || || ||
patients may note certain food triggers Older patients may present with atypical or
|| || || || || || || || || || || || ||
extraesophageal manifestations, sometimes without accompanying heartburn: dyspepsia, || || || || || || ||
epigastric pain, nausea, bloating, belching, asthma, chronic cough, and laryngitis or voice
|| || || || || || || || || || || ||
changes Many older adults with longstanding atypical symptoms delay in seeking care and
|| || || || || || || || || || || || ||
first present with alarm symptoms such as dysphagia, odynophagia, or vomiting
|| || || || || || || || || ||
|| If delayed gastric emptying is the cause of GERD, patient may also have - Abdominal
|| || || || || || || || || || || || || || || || ||
fullness; nausea; early satiety || || || ||
|| || || Dysphagia and odynophagia (painful swallowing) are **alarm symptoms || || || || || || ||
