Gastroenterology

Mount Sinai Expert Guides: Gastroenterology will provide physicians with an extremely clinical and accessible handbook covering the major GI diseases and symptoms, their diagnosis and clinical management.  

Perfect as a point-of-care resource on the hospital wards and also as a refresher for board exam preparation, the focus throughout is on providing rapid reference, essential information on each disease to allow for quick, easy browsing and assimilation of the must-know information.  All chapters follow a consistent template including the following features:

- An opening bottom-line/key points section
- Classification, pathogenesis and prevention of disease
- Evidence-based diagnosis, including relevant algorithms, laboratory and imaging tests, and potential pitfalls when diagnosing a patient
- Disease management including commonly used medications with dosages, when to perform surgery, management algorithms and how to prevent complications
- How to manage special populations, ie, in pregnancy, children and the elderly
- The very latest evidence-based results, major society guidelines (ASG/ACG/UEGW) and key external sources to consult

In addition, the book comes with a companion website housing extra features such as case studies with related questions for self-assessment, key patient advice and ICD codes.  Each guide also has its own mobile app available for purchase, allowing you rapid access to the key features wherever you may be.

If you specialise in gastroenterology and require a concise, practical guide to the clinical management of GI disease, bought to you by one of world's leading hospitals, then this is the perfect book for you.

This title is also available as a mobile App from MedHand Mobile Libraries. Buy it now from iTunes, Google Play or the MedHand Store.

• Language: English
• Publisher: Wiley
• Release date: Nov 13, 2014
• ISBN: 9781118932735

Book preview

List of Contributors

James Aisenberg MD

Clinical Professor of Medicine

Dr. Henry D. Janowitz Division of Gastroenterology

Icahn School of Medicine at Mount Sinai

New York, NY, USA

Sharmila Anandasabapathy MD

Director of Endoscopy

Mount Sinai Medical Center

Icahn School of Medicine at Mount Sinai

New York, NY, USA

Hanumantha R. Ancha MD

Gastroenterology Fellow

University of Oklahoma Health Sciences Center

Oklahoma City, OK, USA

Neville D. Bamji MD

Clinical Instructor of Medicine

Dr. Henry D. Janowitz Division of Gastroenterology

Icahn School of Medicine at Mount Sinai

New York, NY, USA

Joel J. Bauer MD

Clinical Professor of Surgery

Division of Colon and Rectal Surgery

Icahn School of Medicine at Mount Sinai

New York, NY, USA

Ariel A. Benson MD

Resident

Department of Medicine

Icahn School of Medicine at Mount Sinai

New York, NY, USA

Sita S. Chokhavatia MD FACP FACG AGAF FASGE

Professor of Medicine

Division of Gastroenterology

Rutgers Robert Wood Johnson Medical School

New Brunswick, NJ, USA

Benjamin L. Cohen MD MAS

Assistant Professor of Medicine

Dr. Henry D. Janowitz

Division of Gastroenterology

Icahn School of Medicine at Mount Sinai

New York, NY, USA

Lawrence B. Cohen MD

Clinical Professor of Medicine

Dr. Henry D. Janowitz Division of Gastroenterology

Icahn School of Medicine at Mount Sinai

New York, NY, USA

Jean-Frédéric Colombel MD PhD

Professor of Medicine

Director of The Leona M. and Harry B. Helmsley Charitable Trust Inflammatory Bowel Disease Center

Dr. Henry D. Janowitz Division of Gastroenterology

Icahn School of Medicine at Mount Sinai

New York, NY, USA

Vera Kandror Denmark MD

Fellow in Gastroenterology

Dr. Henry D. Janowitz Division of Gastroenterology

Icahn School of Medicine at Mount Sinai New York, NY, USA

Christopher J. DiMaio MD

Director of Therapeutic Endoscopy

Assistant Professor of Medicine

Dr. Henry D. Janowitz Division of Gastroenterology

Icahn School of Medicine at Mount Sinai

New York, NY, USA

Stuart I. Finkel MD

Assistant Clinical Professor of Medicine

Dr. Henry D. Janowitz Division of Gastroenterology

Icahn School of Medicine at Mount Sinai

New York, NY, USA

Gerald Friedman MD PhD FACP MACG AGAF

Clinical Professor of Medicine

Dr. Henry D. Janowitz Division of Gastroenterology

Icahn School of Medicine at Mount Sinai

New York, NY, USA

James George MD

Clinical Instructor of Medicine

Dr. Henry D. Janowitz Division of Gastroenterology

Mount Sinai Medical Center

New York, NY, USA

Charles D. Gerson MD

Clinical Professor of Medicine

Dr. Henry D. Janowitz Division of Gastroenterology

Mount Sinai School of Medicine

New York, NY, USA

Eric S. Goldstein MD

Clinical Instructor of Medicine

Dr. Henry D. Janowitz Division of Gastroenterology

Icahn School of Medicine at Mount Sinai

New York, NY, USA

Stephen R. Gorfine MD

Clinical Professor of Surgery

Division of Colon and Rectal Surgery

Icahn School of Medicine at Mount Sinai

New York, NY, USA

Alexander J. Greenstein MD, MPH, FACS

Assistant Professor of Surgery

Icahn School of Medicine at Mount Sinai

New York, NY, USA

Ari Grinspan MD

Assistant Professor of Medicine

Dr. Henry D. Janowitz Division of Gastroenterology

Icahn School of Medicine at Mount Sinai

New York, NY, USA

Steven H. Itzkowitz MD FACP FACG AGAF

Professor of Medicine

Dr. Henry D. Janowitz Division of Gastroenterology

Icahn School of Medicine at Mount Sinai

New York, NY, USA

Barry W. Jaffin MD

Assistant Clinical Professor of Medicine

Dr. Henry D. Janowitz Division of Gastroenterology

Icahn School of Medicine at Mount Sinai

New York, NY, USA

Miriam Kaminski MD

Resident

Department of Neurology

Klinikum rechts der Isar

Technische Universität München, Germany

Prashant Kedia MD

New York Presbyterian Hospital, Weill Cornell Medical Center

New York, NY, USA

Sergey Khaitov MD FACS

Assistant Professor of Surgery

Icahn School of Medicine at Mount Sinai

New York, NY, USA

Michelle Kang Kim MD MSc

Associate Director of Endoscopy

Associate Professor of Medicine

Dr. Henry D. Janowitz Division of Gastroenterology

Icahn School of Medicine at Mount Sinai

New York, NY, USA

Asher Kornbluth MD

Clinical Professor of Medicine

Dr. Henry D. Janowitz Division of Gastroenterology

Icahn School of Medicine at Mount Sinai

New York, NY, USA

Mark A. Korsten MD

Professor of Medicine

Icahn School of Medicine at Mount Sinai

New York, NY, USA;

Chief of Gastroenterology

James J. Peters VA Medical Center

Bronx, NY, USA

Peter E. Legnani MD

Clinical Instructor of Medicine

Dr. Henry D. Janowitz Division of Gastroenterology

Icahn School of Medicine at Mount Sinai

New York, NY, USA

Blair S. Lewis MD

Clinical Professor of Medicine

Dr. Henry D. Janowitz Division of Gastroenterology

Icahn School of Medicine at Mount Sinai

New York, NY, USA

Jeffrey R. Lewis MD

Clinical Instructor of Medicine

Division of Digestive Diseases

David Geffen School of Medicine at UCLA

Los Angeles, CA, USA;

Former Fellow in Gastroenterology

Icahn School of Medicine at Mount Sinai

New York, NY, USA

Aimee L. Lucas MD MS

Assistant Professor of Medicine

Dr. Henry D. Janowitz Division of Gastroenterology

Icahn School of Medicine at Mount Sinai

New York, NY, USA

Laura Manning RD CDN

Clinical Nutrition Coordinator

Dr. Henry D. Janowitz Division of Gastroenterology

Icahn School of Medicine at Mount Sinai

New York, NY, USA

James F. Marion MD AGAF

Associate Clinical Professor of Medicine

Dr. Henry D. Janowitz Division of Gastroenterology

Icahn School of Medicine at Mount Sinai

New York, NY, USA

Elana A. Maser MD FRCPC

Assistant Professor of Medicine

Dr. Henry D. Janowitz Division of Gastroenterology

Icahn School of Medicine at Mount Sinai

New York, NY, USA

Saurabh Mehandru MD

Assistant Professor of Medicine

Dr. Henry D. Janowitz Division of Gastroenterology

The Immunology Institute

Icahn School of Medicine at Mount Sinai

New York, NY, USA

Ron Palmon MD

Clinical Instructor of Medicine

Dr. Henry D. Janowitz Division of Gastroenterology

Icahn School of Medicine at Mount Sinai

New York, NY, USA

Kalpesh K. Patel MD

Assistant Professor of Medicine

Baylor College of Medicine Medical Center

Houston, TX, USA

Jonathan Z. Potack MD

Assistant Professor of Medicine

Dr. Henry D. Janowitz Division of Gastroenterology

Icahn School of Medicine at Mount Sinai

New York, NY, USA

Daniel H. Present MD

Clinical Professor of Medicine

Dr. Henry D. Janowitz Division of Gastroenterology

Icahn School of Medicine at Mount Sinai

New York, NY, USA

Jose Romeu MD

Assistant Clinical Professor of Medicine

Dr. Henry D. Janowitz Division of Gastroenterology

Icahn School of Medicine at Mount Sinai

Attending Physician

Mount Sinai Hospital

New York, NY, USA

Peter H. Rubin MD

Associate Clinical Professor of Medicine

Dr. Henry D. Janowitz Division of Gastroenterology

Icahn School of Medicine at Mount Sinai

New York, NY, USA

David B. Sachar MD FACP MACG AGAF

Clinical Professor of Medicine

Master Educator, Institute for Medical Education

Director Emeritus of the Dr. Henry D. Janowitz Division of Gastroenterology

Icahn School of Medicine at Mount Sinai

New York, NY, USA

Gina R. Sam MD

Director, Mount Sinai Gastrointestinal Motility Center

Assistant Professor of Medicine

Dr. Henry D. Janowitz Division of Gastroenterology

Icahn School of Medicine at Mount Sinai

New York, NY, USA

Jenny Sauk MD

Instructor in Medicine

Harvard Medical School

Massachusetts General Hospital

Boston, MA, USA

Lauren K. Schwartz MD

Assistant Professor of Medicine

Dr. Henry D. Janowitz Division of Gastroenterology

Icahn School of Medicine at Mount Sinai

New York, NY, USA

Brijen J. Shah MD

Assistant Professor of Medicine

Dr. Henry D. Janowitz Division of Gastroenterology

Icahn School of Medicine at Mount Sinai

New York, NY, USA

Adam F. Steinlauf MD

New York Presbyterian Hospital Weill Cornell Medical Center

New York, NY, USA

Christina A. Tennyson MD

Associate Physician

Mount Sinai Doctors Brooklyn Heights

Dr. Henry D. Janowitz Division of Gastroenterology

Brooklyn, NY, USA

Joana Torres MD

Gastroenterologist

Surgical Department

Gastroenterology Division

Hospital Beatriz Ângelo

Loures, Portugal

Thomas A. Ullman MD

Chief Medical Officer

Mount Sinai Doctors Faculty Practice

Associate Professor of Medicine

Dr. Henry D. Janowitz Division of Gastroenterology

Icahn School of Medicine at Mount Sinai

New York, NY, USA

Richard R.P. Warner MD

Professor of Medicine

Director, Center for Carcinoid and Neuroendocrine Tumors

Dr. Henry D. Janowitz Division of Gastroenterology

Icahn School of Medicine at Mount Sinai

New York, NY, USA

Jerome D. Waye MD

Director, Endoscopic Education

Mount Sinai Hospital

Clinical Professor of Medicine

Dr. Henry D. Janowitz Division of Gastroenterology

Icahn School of Medicine at Mount Sinai

New York, NY, USA

Anthony A. Weiss MD

Assistant Clinical Professor of Medicine

Dr. Henry D. Janowitz Division of Gastroenterology

Icahn School of Medicine at Mount Sinai

New York, NY, USA

Yuki Young MD

Assistant Professor of Medicine

Dr. Henry D. Janowitz Division of Gastroenterology

Icahn School of Medicine at Mount Sinai

New York, NY, USA

Series Foreword

Now more than ever, immediacy in obtaining accurate and practical information is the coin of the realm in providing high quality patient care. The Mount Sinai Expert Guides series addresses this vital need by providing accurate, up-to-date guidance, written by experts in formats that are accessible in the patient care setting: websites, smartphone apps and portable books. The Icahn School of Medicine, which was chartered in 1963, embodies a deep tradition of pre-eminence in clinical care and scholarship that was first shaped by the founding of the Mount Sinai Hospital in 1855. Today, the Mount Sinai Health System, comprised of seven hospitals anchored by the Icahn School of Medicine, is one of the largest health care systems in the United States, and is revolutionizing medicine through its embracing of transformative technologies for clinical diagnosis and treatment. The Mount Sinai Expert Guides series builds upon both this historical renown and contemporary excellence. Leading experts across a range of disciplines provide practical yet sage advice in a digestible format that is ideal for trainees, mid-level providers and practicing physicians. Few medical centers in the United States could offer this type of breadth while relying exclusively on its own physicians, yet here no compromises were required in offering a truly unique series that is sure to become embedded within the key resources of busy providers. In producing this series, the editors and authors are fortunate to have an equally dynamic and forward-viewing partner in Wiley Blackwell, which together ensures that health care professionals will benefit from a unique, first-class effort that will advance the care of their patients.

Scott Friedman MD

Series Editor

Dean for Therapeutic Discovery

Fishberg Professor and Chief, Division of Liver Diseases

Icahn School of Medicine at Mount Sinai

New York, NY, USA

Preface

As in many areas of medicine, gastroenterology has seen an acceleration of change, driven by evolving technology, new therapies and better understanding of the basic mechanisms of disease. Particularly in a specialty that has been driven by advancing the boundaries of endoscopic and imaging techniques, it can prove challenging for the clinician to provide the most up-to-date and optimal care.

Recognizing these challenges, this book, and its associated online resources, is intended to provide a concise resource for the clinician. The book draws upon the broad and historic expertise in gastrointestinal diseases found at Mount Sinai, and offers evidence-based approaches to diagnosis and treatment that are tempered by the real-world experience of talented clinicians. The book is divided into two parts. The first provides a series of approaches to the major presentations of gastrointestinal disease, while the second part offers detailed information about specific conditions. Chapters include information about disease pathogenesis in brief detail, as an underpinning to understand approaches to prevention, diagnosis and management. Further detail is provided to guide efficient testing strategies, and algorithms for treatment, as well as more detailed information on specific therapies. A succinct reading list and a compendium of society guidelines, where available, round out the presentation, allowing inquisitive readers to review the details for themselves. The case histories and multiple-choice questions provided at the end of each chapter will be helpful for students of gastroenterology at all levels of training. In the future, access to a web-based resource and smartphone app will allow handy accessibility to the facts, and frequent updating as knowledge and practice change.

Sincere thanks go to Jennifer Seward and Oliver Walter at Wiley, who patiently guided this publication. I am especially indebted to my talented, dedicated colleagues in the Dr. Henry D. Janowitz Division of Gastroenterology, and in the Departments of Surgery, Radiology and Pathology. Their passion for our discipline, their zeal for innovation and their absolute dedication to our patients makes Mount Sinai a vibrant, exciting place to work. Their commitment to education – of each other in daily interactions over patients, and of the next generation of trainees – is palpable every day, and shines through in this work.

Bruce E. Sands MD, MS, AGAF, FACG, FACP

Chief of the Dr. Henry D. Janowitz Division of Gastroenterology

Mount Sinai Medical Center and Mount Sinai Health System

Dr. Burrill B. Crohn Professor of Medicine

Icahn School of Medicine at Mount Sinai

New York, NY, USA

Abbreviation List

About the Companion Website

This series is accompanied by a companion website:

flast02-fig-5001 www.mountsinaiexpertguides.com

The website includes:

Cases with multiple choice questions (MCQs)

ICD codes

Patient advice

Video clips

PART 1

Approach to Specific Complaints

CHAPTER 1

Approach to Dysphagia

Gina R. Sam

Mount Sinai Gastrointestinal Motility Center; Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA

Overall Bottom Line

Dysphagia occurs when a patient has difficulty transferring solid or liquid bolus from the oral cavity to the esophagus.

There are two types of dysphagia: oropharyngeal dysphagia and esophageal dysphagia.

Oropharyngeal dysphagia occurs when there is difficulty initiating the swallow.

Esophageal dysphagia occurs when swallowing food or liquid has the sensation of getting stuck in the throat or chest.

Depending on the cause of the dysphagia the treatment is tailored to the underlying disorder.

Section 1: Background

Definition of Disease

Dysphagia is defined as trouble or a delay in transferring or preparing solid or liquid from the oral cavity to the esophagus and difficulty in the passage of food from the esophagus to the stomach.

Disease Classification

Oropharyngeal dysphagia occurs when there is impaired initiation of the swallow.

Esophageal dysphagia occurs when food has the sensation of being caught up or feels stuck within the chest.

Incidence/Prevalence

The true prevalence of dysphagia is unknown but epidemiologic studies estimate that the overall prevalence of dysphagia is 16–22% in individuals over the age of 50 years.

Approximately 60% of nursing home occupants have difficulty feeding.

Nursing home occupants who have oropharyngeal dysphagia and aspiration have been estimated to have a 45% 12-month mortality.

It is estimated that dysphagia affects 16% of people in a lifetime based on a questionnaire of 672 random individuals.

The overall prevalence of dysphagia in patients above the age of 65 years has been estimated at 15%.

Economic Impact

The overall economic burden of dysphagia is unclear. Studies need to be carried out to evaluate the economic burden in the inpatient and outpatient setting.

Etiology

Dysphagia results from the following two mechanisms: (i) a mechanical obstruction or structural abnormality, or (ii) a neuromotor defect.

Pathology/Pathogenesis

The swallowing function comprises a coordinated sequence of events that move food or liquid from the mouth into the hypopharynx and then into the esophagus. Swallowing can be divided into three phases and, if any of these events are disrupted, dysphagia can occur.

The first phase in swallowing is the oral phase where food enters the oral cavity and is broken down by mastication to prepare the bolus. This phase is a voluntary process.

The second phase is the pharyngeal phase, where the tongue elevates and moves the bolus to the pharynx along with simultaneous closing of the nasopharynx to prevent nasopharyngeal regurgitation. A peristaltic wave then propels the bolus distally. In the oropharynx, the hyoid bone elevates and moves anteriorly while the larynx elevates and moves forward, tilts posteriorly, and this allows the bolus to move inward. The epiglottis then moves under the tongue, which overlaps the opening of the larynx to prevent aspiration of food.

The third phase of swallowing is the esophageal phase, whereby the pharynx contracts and the upper esophageal sphincter (UES) relaxes, allowing the bolus to enter into the esophagus.

The swallow causes primary peristalsis via efferent vagal nerves that arise in the medulla. During primary peristalsis, coordinated contractions from the proximal esophagus travel down to the distal esophagus and then result in lower esophageal sphincter (LES) relaxation. A primary peristaltic contraction travels down the esophagus at a rate of 2–4 cm/second and reaches the LES in about 9 seconds after the initiation of the swallow. Secondary peristaltic contraction is a local reflex that attempts to move any bolus left in the esophagus after the primary contraction is completed.

Oropharyngeal or esophageal dysphagia can be due to either mechanical obstruction and/or structural abnormality or a neuromotor defect.

Causes of Oropharyngeal Dysphagia

Causes of Esophageal Dysphagia

Predictive/Risk Factors

Cerebrovascular accident.

Scleroderma.

Esophageal reflux.

Parkinsons's disease.

Diabetes.

Section 2: Prevention

Bottom Line/Clinical Pearls

No interventions have been demonstrated to prevent the development of the disease.

Screening

Primary care physicians can enquire about dysphagia on routine history-taking, particularly in the elderly population.

Primary Prevention and Secondary Prevention

Depending on the cause of the dysphagia, primary and secondary prevention is directed at identifying dysphagia early on in the disease to prevent complications from aspiration pneumonia, worsening of an esophageal stricture from continuous reflux, or developing invasive esophageal cancer if the cause is a tumor.

Section 3: Diagnosis

Bottom Line

The first step in diagnosing the cause of dysphagia is to obtain a detailed history.

The key questions include the following:

Is there dysphagia to solids, liquids or both?

What is the location of the dysphagia?

What is the duration of symptoms and are they progressive or intermittent?

Is the dysphagia associated with other symptoms such as weight loss or changes in appetite?

What other medical conditions or surgeries does the patient have?

A complete physical examination should be performed including careful examination of the head, neck, lymph nodes, and thyroid and an extensive neurological examination.

Several imaging techniques are available including barium esophagram and videoflouroscopy.

An esophageal manometry test can be performed to measure the pressure changes and look for any motility disorders. An endoscopy can be performed to look for structural abnormalities.

Typical Presentation

A patient with oropharyngeal dysphagia usually presents with difficulty in getting food from the mouth to the esophagus. The patient may describe coughing, nasal regurgitation, choking, and halitosis. In addition, they may describe dysarthria, diplopia, or weakness in the extremities if resulting from a neurologic cause.

A patient with esophageal dysphagia will usually present with the complaint of something stuck in the chest and often with the need to drink liquids to get the food down. A patient may also report inducing vomiting to get the food out. Oftentimes, patients have tried restricting the diet to primarily soft foods or liquids.

Clinical Diagnosis

History

The history is very important and should include questions about dysphagia to solids, liquids, or both, the location of the dysphagia, when the dysphagia started, and if it is progressive or intermittent. Information on other medical conditions that the patient may have such as weight loss, history of antireflux surgery, any radiation, and any immunosuppressive diseases should also be obtained. If a patient describes odynophagia (pain with swallowing) and dysphagia, a list of medications should be obtained.

The localization of the dysphagia is not always reliable. If the patient describes that the bolus gets hung up in the cervical area or the mid-chest area, the cause is usually not at that location. On the other hand, if the patient describes that the dysphagia is primarily in the lower chest or subxiphoid region, 80% of the time it is accurate and the problem is in the distal esophagus.

If there is only dysphagia to solids, this is more likely a result of a mechanical obstruction. With dysphagia to both solids and liquids, this suggests a motility disorder such as achalasia or diffuse esophageal spasm. If there is first dysphagia to solids then liquids, this can be caused by an obstruction such as a peptic stricture or a growing esophageal tumor. If there is intermittent dysphagia, particularly with certain foods, this is suggestive of a peptic stricture or a Schatzki's ring.

Patients may also have other symptoms in addition to dysphagia and these may be the result of an underlying systemic disease such as polymyositis, dermatomyositis, myasthenia gravis, Parkinson's disease, or rheumatoid arthritis. In addition, if there is a history of a head and neck cancer with radiation, post-radiation stricture is the likely cause of the dysphagia.

Medication history is also important. Some medications can cause central or peripheral impairment and hinder the neural, muscle, or salivary function and cause dysphagia. Several medications that are centrally active, such as dopamine antagonists like metoclopramide, are known to cause extrapyramidal symptoms that may lead to dysphagia.

Physical Examination

The physical examination of a patient complaining of dysphagia should include a complete examination of the oral cavity, head and neck, thyroid, lymph nodes, and the neurologic system. Other systemic diseases may be apparent on the physical examination. For example, a patient with dermatomyositis may report dysphagia and the classic heliotrophic (purple) rash over the upper eyelids is found on examination.

Laboratory Diagnosis

List of Diagnostic Tests

Esophageal manometry: a very important test to investigate both oropharyngeal and esophageal dysphagia. A catheter with electrodes that measures the pressure in the esophagus as a swallow occurs is inserted through the patient's nares and then into the esophagus. LES pressure and relaxation are measured after a swallow of liquid to assess peristaltic contractions of the esophagus. In addition, esophageal manometry can assess the pharyngeal contraction and the upper esophageal sphincter pressure during the swallow to determine if it relaxes appropriately.

Impedance: measurement of impedance registers the changes in resistance (in ohms) of alternating electrical current passing through pairs of metal rings on a catheter. If a liquid bolus passes through the metal rings there is a decrease in impedance because of increased conductivity. On the other hand, with air there is an increase in impedance or decreased conductivity in the esophagus. Impedance monitoring is also often combined with pH testing for gastroesophageal reflux disease. It has been reported that patients who had achalasia or scleroderma often had poor bolus clearance as opposed to those patients with diffuse esophageal spasm or ineffective esophageal motility disorders, who had normal bolus transit.

High resolution esophageal manometry (HREM): this technologic advance allows topographic measurement of esophageal persistalsis. The esophageal catheter has 32 circumferential pressure electrodes spaced 1 cm apart and allows examination of the esophageal pressure throughout the esophagus while keeping the catheter in one place. HREM is often combined with impedance testing.

Endoscopy: usually performed in patients who are suspected to have a structural or a mucosal cause of the dysphagia. In patients who report odynophagia, endoscopy is performed to look for esophageal ulcerations or pill-induced esophagitis. Eosinophilic esophagitis can be diagnosed with biopsies taken at the proximal, mid, and distal esophagus.

Fiberoptic endoscopic examination of swallowing (FEES): a small endoscope is inserted trans­nasally to visualize the larynx and the pharyngeal structures as the patient swallows liquid and solid bolus.

Lists of Imaging Techniques

Barium esophagram: a radiographic test in which the patient is given liquid barium or a barium tablet and swallows with X-rays taken. It is useful in evaluating patients with dysphagia and can detect hiatal hernias, strictures, rings and reflux. It may also provide an impression of disordered esophageal motility.

Videofluoroscopy: useful in evaluating patients who report oropharyngeal dysphagia. The patient is given foods of different consistencies to swallow, such as liquid or apple sauce, and the swallow is videotaped. Videofluoroscopy allows the visualization of any delays in initiation of the swallow, detects aspiration and nasopharyngeal regurgitation. It also detects residual barium in the pharynx after the swallow. The patient can be advised by a speech therapist on various maneuvers or postures to enhance swallowing using the information obtained from the videoflourosocopy.

Potential Pitfalls/Common Errors Made Regarding Diagnosis of Disease

One of the major pitfalls in the correct diagnosis of dysphagia is failing to distinguish between oropharyngeal and esophageal dysphagia.

Algorithm 1.1  Diagnosis of Dysphagia

c1-fig-5001

Section 4: Treatment

Treatment Rationale

The management of dysphagia depends primarily on whether the dysphagia is oropharyngeal or esophageal.

In patients who have oropharyngeal dysphagia, undergoing a videofluoroscopy will help to assess the risk of aspiration. If oropharyngeal dysphagia is noted, the patient can be taught various posturing techniques to avoid aspiration. If a patient has a benign stricture or a web, esophageal dilation can be performed safely with good results in up to 75% of cases. If a patient has a dysfunction of the UES or cricopharynageal bar, a dilation can be helpful in addition to a cricopharyngeal myotomy. If the patient has a Zenker's diverticulum, a cricopharyngeal myotomy with a diverticulectomy and/or endoscopic myotomy can be performed. The treatment options for a cervical osteophyte are limited.

If the oropharnyngeal dysphagia is due to a neuromuscular cause, treatment can be directed at the specific cause of dysfunction and the degree of impairment. In many cases, swallowing therapy with diet modifications and altering the swallowing posture may improve the symptoms and nutritional status of the patient. If a patient has a high risk of aspiration, endoscopically placed feeding tubes, including percutaneous endoscopic gastrostomy or nasogastric feeding tubes, may be needed for enteral nutrition.

There are several treatment options available for esophageal dysphagia, depending on the cause.

When to Hospitalize

Patients who have poor nutritional status from their dysphagia should be hospitalized.

Algorithm 1.2  Evaluation and Management of Oropharyngeal Dysphagia

c1-fig-5002

Algorithm 1.3  Evaluation of Esophageal Dysphagia

c1-fig-5003

Section 5: Special Populations

Dysphagia is a major problem in the elderly population and can affect the quality of life.

In patients with dementia or those who are mentally handicapped, the risk from dysphagia includes dehydration, malnutrition, weight loss, and aspiration pneumonia.

In these special populations, dysphagia may be a result of behavioral, sensory, or motor problems (or a combination of these).

Section 6: Prognosis

The prognosis of dysphagia is good if diagnosed early and the correct cause has been found.

Prognosis is poor in those for whom dysphagia is the presenting symptom of invasive esophageal cancer.

Section 7: Reading List

Allen B, Baker M, Flak G. Role of barium esophagography in evaluating dysphagia. Cleve Clin J Med 2009;76:105–11

Altman KW, Yu GP, Schaefer SD. Consequence of dysphagia in the hospitalized patient: impact on prognosis and hospital resources. Arch Otolaryngol Head Neck Surg 2010;136:784–9

American Gastroenterological Association. An American Gastroenterological Association medical position statement on the clinical use of esophageal manometry. Gastroenterology 1994;107:1865

Bloem BR, Lagaay AM, van Beek W, Haan J, Roos RA, Wintzen AR. Prevalence of subjective dysphagia in community residents aged over 87. BMJ 1990;300:721–2

Chen P, Golub JS, Harpner ER. Prevalence of perceived dysphagia and quality-of-life impairment in a geriatric population. Dysphagia 2009;24:1–6

Cook IJ. Disorders causing oropharyngeal dysphagia. In Castell DO, Richter JE (eds) The Esophagus, 4th edition. New York: Lippincott Williams and Wilkins, 2004:1–36

Crohgan JE, Burke EM, Caplan S, Denman S. Pilot study of 12-month outcomes of nursing home patients with aspiration on videofluoroscopy. Dysphagia 1994;9:141–6

Eslick GD, Talley NJ. Dysphagia: Epidemiology, risk factors, and impact on quality of life – a population-based study. Aliment Pharmacol Ther 2008;27:971–9

Kjellén G, Tibbling L. Manometric oesophageal function, acid perfusion test and symptomatology in a 55-year-old general population. Clin Physiol 1981;1:405–15

Lind CD. Dysphagia: evaluation and treatment. Gastroenterol Clin Am 2003;32:553–75

Lindgreen S, Janzon L. Prevalence of swallowing complaints and clinical findings among 50–79-year-old men and women in an urban population. Dysphagia 1991;6:187–92

Malagelada FR, Bazzoli F, Elewaut A. Dysphagia. World Gastroenterology Organization Practice Guidelines: Dysphagia. World Gastroenterology Organization, 2007

Pandolfino J, Kahrilas P. AGA technical review on the clinical use of esophageal manometry. Gastroenterology 2005;128:209–24

Roeder BE, Murray JA, Diekhising RA. Patient localization of esophageal dysphagia. Dig Dis Sci 2004;49:697–701

Siebens H, Trupe E, Siebens A, et al. J Am Geriatr Soc 1986;34:192–8

Talley NJ, Weaver AL, Zinsmeister AR, Melton LJ 3rd. Onset and disappearance of gastrointestinal symptoms and functional gastrointestinal disorders. Am J Epidemiol 1992;136:165–77

Zavala S, Katz P. Dysphagia and odynophagia. In Hawkey CJ, Bosch J, Richter JE, Garcia-Tsao G (eds) Textbook of Clinical Gastroenterology and Hepatology, 2nd edition. Oxford: Wiley-Blackwell, 2012: 11–15

Section 8: Guidelines

Section 9: Evidence

Not applicable for this topic.

Section 10: Images

Not applicable for this topic.

Additional material for this chapter can be found online at:

c1-fig-5004 www.mountsinaiexpertguides.com

This includes advice for patients and ICD codes.

CHAPTER 2

Approach to Nausea and Vomiting

Aimee L. Lucas

Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA

Overall Bottom Line

The differential diagnosis of nausea and vomiting is extraordinarily broad, and includes:

Disorders of the abdominal viscera.

Drug, toxin or other exposures.

Infection.

Central nervous system disease.

Metabolic and endocrine disease.

Other miscellaneous causes.

There is a lack of controlled trials to guide a diagnostic algorithm for nausea and vomiting; current recommendations are largely based on expert opinion with an evidence rating of C. Often, the history and physical examination will lead to the etiology of nausea and vomiting. Initial evaluation should (i) help determine or confirm the etiology of the symptoms, and (ii) determine consequences of the symptoms, such as dehydration.

Management of nausea and vomiting should be directed at treating the underlying disease process.

Section 1: Background

Definition of the Presenting Complaint

Nausea is a subjective constellation of sensations that immediately herald vomiting, while vomiting is defined as the active retrograde expulsion of gastric contents through the mouth.

Vomiting should be differentiated from regurgitation, which involves passive retrograde movement of gastric contents, and rumination, or unforced retrograde expulsion of gastric contents and food into the mouth and subsequent rechewing or reswallowing of contents.

Incidence

The incidence of nausea and vomiting varies with the underlying etiology. For example, up to 70–80% of pregnant women experience nausea and vomiting, particularly in the first trimester, and 60–70% of patients receiving chemotherapy report nausea and vomiting.

A primary care physician will see several hundred patients per year complaining of nausea and vomiting. A typical obstetrician can expect that 50–90% of pregnant patients experience nausea at some point during pregnancy. Gastrointestinal (GI) infections, a common cause of nausea and vomiting, account for 725 000 ambulatory visits and 178 000 hospitalizations in the United States every year.

Economic Impact

The estimated economic impact of nausea and vomiting is staggering. Pharmacologic treatment of GI infections alone is estimated to cost upwards of $45 million annually in United States. Daily expenses for those with chemotherapy-induced nausea and vomiting are estimated at $1850 per day. Digestive diseases, many of which lead to symptoms of nausea and vomiting, cost an estimated $126 billion annually.

Social impact: most cases of nausea and vomiting are acute and self-limited; thus, an estimation of the true social burden of these symptoms is challenging. Nausea and vomiting are extremely common, and disruptive of regular daily activities including school, work, and home life.

Section 2: Prevention

Prevention of nausea and vomiting is dependent on the underlying etiology. If the etiology is known, amenable to therapy, and an episode of nausea and/or vomiting is expected, prophylactic administration of fluids (oral or intravenous) or medications may be given (see Section 4: Treatment).

Section 3: Diagnosis

Differential Diagnosis

Bottom Line

The differential diagnosis of nausea and vomiting is extensive. Full exploration of all diagnoses is beyond the scope of this text.

Brief Summary of Key Recommendations with SORT Ratings

The differential diagnoses may be simplified by dividing the underlying etiologies into anatomic location and/or exposures. Evidence rating = C.

Disorders of the abdominal viscera: disorders of the GI system can be divided into:

mechanical obstruction (i.e. bowel obstruction, gastric outlet obstruction)

functional GI disorders (i.e. irritable bowel syndrome, non-ulcer dyspepsia), and

other organic GI disorders (i.e. pancreatitis, hepatitis, peptic ulcer disease).

Drug, toxin or other exposure: a wide variety of drugs and toxins may lead to nausea and vomiting via a variety of different pathways. Notable causes of symptoms include cancer chemotherapeutics (including nitrogen mustards and cisplatin), analgesics and narcotics, radiation therapy and ethanol.

Infectious exposure: both viral and bacterial gastroenteritis may lead to nausea and vomiting, as can infections outside of the GI tract, such as otitis media and intracranial infections.

Central nervous system (CNS): the CNS causes of nausea and vomiting are also diverse, and can include increased intracranial pressure (i.e. mass, hemorrhage, infection), labyrinthine disorders (i.e. Ménière's disease, motion sickness, labyrinthitis), seizures, psychiatric disorders and migraines.

Metabolic and endocrine: pregnancy should always be considered in a woman with nausea and vomiting. Uremia, hypo- and hyperparathyroidism, hyperthyroidism and diabetic ketoacidosis are other notable metabolic etiologies for nausea and vomiting.

Miscellaneous: other significant causes of nausea and vomiting include postoperative nausea and vomiting, cardiac disease (myocardial infarction and congestive heart failure) and cyclic vomiting syndrome.

Clinical Diagnosis

Bottom Line

The history of nausea and vomiting should be directed at determining the time course of events, as well as possible organ systems and anatomic locations involved.

Acute nausea and vomiting is defined as symptoms of ≤1 week duration and may indicate a more urgent evaluation is required, while chronic nausea and vomiting has ≥1 month duration.

Brief Summary of Key Recommendations with SORT Ratings

There is a lack of controlled trials to guide a diagnostic algorithm for nausea and vomiting; current recommendations are largely based on expert opinion with an evidence rating of C.

Often, the history and physical examination will lead to the etiology of nausea and vomiting. Evidence rating = C.

Physical examination may be directed by clues in the clinical history. Initial evaluation should:

Help determine or confirm the etiology of the symptoms.

Determine consequences, such as dehydration, of the symptoms. Evidence rating = C.

Typical Presentation

Laboratory Diagnosis

Bottom Line

All diagnostic testing should be directed at findings in the clinical history and physical examination (evidence rating = C).

Laboratory investigations should be tailored to the findings in the history and physical examination, and should include routine chemistries. The complete blood count (CBC), basic metabolic panel (BMP) and erythrocyte sedimentation rate (ESR) may suggest dehydration, anemia, inflammation, hypokalemic metabolic acidosis from a loss of gastric secretions which may be worsened by dehydration, and activation of the renin–angiotensin system.

All women of childbearing age should have serum or urine human chorionic gonadotropin (HCG) levels.

Further laboratory testing should be directed at the underlying etiology, and may include hormone levels (e.g. TSH, PTH), drug levels (e.g. digoxin, salicylates, theophylline), urine toxicology, ethanol level as indicated by the clinical scenario.

Upright and recumbent plain films of the abdomen, including the diaphragm, should be performed if the history and physical examination suggest obstruction or perforation. However, approximately 20% of these studies may be indeterminate.

An upper GI study may identify structural lesions in the upper GI system. Barium may be the contrast agent of choice if a fistula or perforation into the thorax is considered, while gastrograffin may be preferred if a bowel perforation is suspected.

An upper GI series with small bowel follow-through may demonstrate high grade obstructions and larger mucosal lesions.

Enteroclysis may identify small mucosal lesions in the small bowel.

Cross-sectional imaging of the abdomen provides evaluation for intestinal obstruction, larger mucosal lesions, mass lesions, hepatobiliary, pancreatic and retroperitoneal pathology. High resolution CT scan and magnetic resonance imaging (MRI), including CT/MR enterography, can provide detailed bowel visualization.

Intracranial imaging for CNS disease can be accomplished through CT scan or MRI, although MRI may be preferable in some instances because of improved imaging of posterior fossa.

Endoscopy and biopsy of the esophagus, stomach and small bowel, while included in the diagnostic testing of nausea and vomiting, is often normal, and should be considered after other testing is normal or if mucosal lesions are strongly suspected.

A radiolabeled gastric emptying study involves ingestion of a γ-radiolabeled food. Solid meals are more sensitive than liquid, although it should be noted that these findings are relatively non-specific and do not predict response to therapy.

Other studies such as electrogastrography and antroduodenal manometry examine gastric motor function, but are not readily available at all institutions.

Brief Summary of Key Recommendations with SORT Ratings

Diagnostic investigations should be tailored to the findings in the history and physical examination. Evidence rating = C.

Electrolyte imbalances, metabolic derangements and nutritional deficiencies should be assessed and corrected. Evidence rating = C.

Pregnancy testing should be considered on all fertile women. Evidence rating = C.

Treatment should be directed at the underlying etiology. If no etiology is discovered, treatment should be aimed at symptomatic relief. Evidence rating = B.

Recommended Diagnostic Strategy

Bottom Line

The clinical history and physical examination will suggest an underlying etiology for the majority of cases of nausea and vomiting. When these clinical features do not identify a clear cause, further diagnostic testing may be pursued but should be guided by the clinical history.

Brief Summary of Key Recommendations with SORT Ratings

The first step in diagnosis is differentiation between acute and chronic presentations of nausea and vomiting, then deciphering which situations require emergent evaluation. Evidence rating = C.

Diagnostic strategy should first focus on evaluation and correction of serious complications or consequences of nausea and vomiting. Evidence rating = C.

Further evaluation should focus on elucidating the etiology of symptoms, followed by treatment of underlying disease. Evidence rating = C.

Algorithm 2.1  Approach to the Patient with Nausea and Vomiting

c2-fig-5001

Section 4: Treatment (Algorithm 2.1)

Treatment Rationale

The initial step in management of nausea and vomiting should always include an assessment for metabolic derangements and volume status, with repletion as needed.

Further treatment is dependent upon the underlying etiology. For example, if a patient presents with nausea and vomiting because of a small bowel obstruction, appropriate management may include gastric decompression with a nasogastric tube and a surgical consultation.

Management of chemotherapy-induced nausea includes 5-HT3 receptor antagonists, while management of nausea resulting from toxin exposure may require withdrawal and possible reversal of the inciting agent.

When to Hospitalize

Metabolic disarray, unable to correct as outpatient.

Dehydration and inability to maintain adequate oral intake.

Surgical emergency, including bowel obstruction.

Severe underlying disease leading to nausea and vomiting (e.g. pancreatitis requiring IV fluids and pain management, severe infection requiring hospitalization).

Managing the Hospitalized Patient

Initial management of the hospitalized patient should include volume repletion and correction of metabolic disarray, if applicable.

Supportive management of the hospitalized patient includes any of the therapies in the Table of treatment.

As always, management of the hospitalized patient should be directed at treatment of the underlying disease.

Table of Treatment

Section 5: Special Populations

Not applicable for this topic.

Section 6: Prognosis

Bottom Line/Clinical Pearls

Prognosis is based upon the prognosis for the underlying disease.

Section 7: Reading List

Apfel CC, Korttila K, Abdalla M, et al. A factorial trial of six interventions for the prevention of postoperative nausea and vomiting. N Engl J Med 2004;350:2441–51

Attard CL, Kohli MA, Coleman S, et al. The burden of illness of severe nausea and vomiting of pregnancy in the United States. Am J Obstet Gynecol 2002;186:S220–7

Craver C, Gayle J, Balu S, et al. Clinical and economic burden of chemotherapy-induced nausea and vomiting among patients with cancer in a hospital outpatient setting in the United States. J Med Econ 2011;14:87–98

Everhart JE, Ruhl CE. Burden of digestive diseases in the United States part I: overall and upper gastrointestinal diseases. Gastroenterology 2009;136:376–86

Haiderali A, Menditto L, Good M, et al. Impact on daily functioning and indirect/direct costs associated with chemotherapy-induced nausea and vomiting (CINV) in a US population. Support Care Cancer 2011;19:843–51

Jewell D, Young G. Interventions for nausea and vomiting in early pregnancy. Cochrane Database Syst Rev 2003:CD000145

Lacasse A, Rey E, Ferreira E, et al. Nausea and vomiting of pregnancy: what about quality of life? BJOG 2008;115:1484–93

Lee NM, Saha S. Nausea and vomiting of pregnancy. Gastroenterol Clin North Am 2011;40:309–34, vii

Quigley EM, Hasler WL, Parkman HP. AGA technical review on nausea and vomiting. Gastroenterology 2001;120:263–86

Useful Websites

http://patients.gi.org/topics/nausea-and-vomiting/

http://digestive.niddk.nih.gov/ddiseases/a-z.aspx

http://digestive.niddk.nih.gov/ddiseases/pubs/viralgastroenteritis

http://www.gastro.org/patient-center

Section 8: Guidelines

Not applicable for this topic.

Section 9: Evidence

Not applicable for this topic.

Section 10: Images

Not applicable for this topic.

Additional material for this chapter can be found online at:

c2-fig-5002 www.mountsinaiexpertguides.com

This includes a case study with multiple choice questions, advice for patients, and ICD codes

CHAPTER 3

Approach to Abdominal Pain

Jonathan Z. Potack

Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA

Overall Bottom Line

Acute abdominal pain is one of the most common presenting symptoms, especially in an emergency department setting.

The possible etiologies of acute abdominal pain range from benign to life-threatening causes; therefore it is essential that the initial evaluation differentiate these causes early in the presentation.

Chronic abdominal pain is one of the most