1. Integrative Lecture: Esophagus, Stomach & Duodenum RALPH LEE, MMED(DIST), MD, FRCPC GASTROENTEROLOGIST, ASSISTANT PROFESSOR AND MEDICAL EDUCATOR UNIVERSITY OF OTTAWA

2. Case I

3. Case 1  A 55 year old male presents to your office with complaints of ‘heartburn’  Past Medical history  Hypertension, hypercholesterolemia, cholecystectomy  Medications: TUMS  Allergies: None  What questions would you ask?

4. Case 1  Characterize the symptom:  Onset?  Usually after meals and with lying down  Position? Retrosternal  Quality? Burning  Radiation? To neck  Severity? 4/10  Timing? 1x every 2 weeks, for the last 6 months  Aggravating factors? Spicy foods, lying down at night  Relieving factors? Better with TUMS  Associated symptoms?  Regurgitation? 1x every 2 weeks  AM sore throat, hoarse voice? None.

5. Case 1  Alarm symptoms?  Dysphagia, odynophagia, vomiting, chest pain, weight loss, hematemesis, melena  Patient denies any of these symptoms  Risk behaviours?  Intake: Caffeine, chocolates, spicy foods, citrus foods, carbonated beverages, alcohol, peppermints  Habits: Smoking, alcohol  Patient incidentally reports that his father died of esophageal cancer  What would you do next?

6. Case 1  Physical exam:  Obese male, but otherwise unremarkable.  What do you believe is the diagnosis?  What would you do next?

7. Case 1  What would you do next? a. Empirically treat him with a proton pump inhibitor b. Counsel him on lifestyle measures and suggest over the counter antacids c. Order laboratory investigations d. Order an ECG e. Order a barium swallow f. Consult GI for an esophagastroduodenoscopy g. Order a CT scan of the chest h. Order a 24 hour pH study

8. Case 1  What would you do next? a. Empirically treat him with a proton pump inhibitor b. Counsel him on lifestyle measures and suggest over the counter antacids c. Order laboratory investigations d. Order an ECG e. Order a barium swallow f. Consult GI for an esophagastroduodenoscopy g. Order a CT scan of the chest h. Order a 24 hour pH study

9. Case 1 – Follow-up  You recommend some lifestyle measures for GERD and over-the-counter antacids  The patient’s symptoms resolve with weight loss and dietary modification

10. Case 2

11.  27 year old female with presents to your office with severe ‘stomach’ pain  Past Medical History:  Left rotator cuff tear  Hypothyroidism  Appendectomy  What would you ask?

12. Case 2  Characterize the symptom  Onset? Usually 30 minutes after meals.  Position? Epigastric.  Quality? Burning.  Radiation? To mid-back.  Severity? 8/10.  Timing?  Started 1 month ago @ 1x/week, but increased in frequency to daily. Lasts for 30-45 minutes.  Aggravating factors?  Worse with eating and with alcohol.  Relieving factors?  Better with TUMS and milk.  Associated symptoms? Nausea.

13. Case 2  Alarm Features?  Vomiting, hematemesis, melena, dysphagia, odynophagia, early satiety, unexplained weight loss, jaundice, family history of gastric CA  The patient reports that she has been having black, ‘tar-like’ stools 3x/day for the last 2 days  Medications?  NSAIDs? Patient reports she has been taking 6-8 tablets of Ibuprofen per day for the past 2 weeks  Habits? Non-smoker. EtOH: Social  Family History?  No family history of gastric CA, PUD  What is the differential diagnosis?

14. Case 2 - DDx  Peptic ulcer disease  H. Pylori gastritis  Functional dyspepsia  Pancreatitis  Biliary cause (biliary colic, choledocholithiasis)  Cholecystitis  Gastroparesis  Gastroenteritis  Malignancy  Pregnancy  Hepatitis  Pulmonary cause  Cardiac cause  Muskuloskeletal cause  What would you do next?

15. Case 2  Physical exam:  HR 110, BP 120/80, RR 16, T 37.5  H&N: Moist mucous membranes  Abdomen: Tender epigastric area, no rebound, no masses, no HSM  Laboratory  Patient found to be anemic (Hgb 102 g/L).  What would you do next?

16. Case 2  What would you do next?  Start her empirically on a PPI and arrange follow-up in 2 weeks.  Counsel her on lifestyle measures and suggest over- the-counter antacids.  Arrange a barium swallow.  Send her directly to the emergency department for an urgent GI consult and EGD  Start her on a PPI and consult an outpatient gastroenterologist for a non-urgent EGD.  Arrange a CT scan.

17. Case 2  What would you do next?  Start her empirically on a PPI and arrange follow-up in 2 weeks.  Counsel her on lifestyle measures and suggest over- the-counter antacids.  Arrange a barium swallow.  Send her directly to the emergency department for an urgent GI consult and EGD  Start her on a PPI and consult an outpatient gastroenterologist for a non-urgent EGD.  Arrange a CT scan.

18. Case 2 - EGD  What would you do next?

19. Case 2 - Pathology

20. Case 2  What would you do?  Treat for H. Pylori  Amoxicilin 1g po BID, Clarithromycin 500mg po BID, PPI po BID x 14 days.  Proton pump inhibitors  Treat for 8 weeks, then consider trial off.  Stop the NSAIDs  If unable to stop, ensure patient is on a PPI for gastroduodenal protection  Repeat Endoscopy within 3 months  To confirm healing of ulcer  Small percentage of gastric ulcers can be malignant.  Repeat H. Pylori biopsies to confirm eradication  Other methods: H. Pylori Breath test

21. Case 2 – Follow-up  You prescribe a course of triple therapy for 14 days and she continues with omeprazole 20 mg po bid for a total 8 weeks  A repeat EGD in 3 months confirms healing of the ulcer and gastric biopsies are negative for H. Pylori  Her pain has resolved at 3 months of follow-up

22. Case 3

23.  A 42 year old male presents to your office complaining of trouble swallowing.  Past medical history:  Obesity  EtOH Abuse  What do you want to ask?

24. Case 3  Characterize the symptom  Food sticking? Where?  Difficulty initiating swallow? Choking? Nasal regurgitation  Patient reports a feeling of food sticking in his retrosternal area.  Solids and liquids or solids alone?  Patient reports it is only solid food, but he can tolerate intake of liquids. There have been occasions that solid food became stuck and he could not swallow any liquids including his own saliva.

25. Case 3 - DDx  Malignancy  Peptic stricture  Eosinophilic esophagitis  What would you do next?

26. Case 3  Is it intermittent or progressive?  Patient reports it started intermittently, but has been progressively worse. He is afraid to eat any type of solid for fear it will become stuck.  Is there any associated weight loss?  Patient reports a 20lb weight loss over the last 3 months.  Is there any associated heartburn?  Patient denies any history of heartburn.  What is your differential diagnosis?

27. Case 3  What would you do next?  Arrange a barium swallow  Consult GI for an upper endoscopy  Counsel the patient on lifestyle measures for GERD and prescribe over the counter medications  Empirically start the patient on a PPI and arrange a follow-up visit in 2 months  Order a CT Chest  Tell the patient to chew their food more carefully and ‘man up’.

28. Case 3  What would you do next?  Arrange a barium swallow  Consult GI for an upper endoscopy  Counsel the patient on lifestyle measures for GERD and prescribe over the counter medications  Empirically start the patient on a PPI and arrange a follow-up visit in 2 months  Order a CT Chest  Tell the patient to chew their food more carefully and ‘man up’.

29. Case 3 - EGD

30. Case 3 – Follow-up  Biopsies confirm esophageal adenocarcinoma  CT Abdomen/Chest reveals multiple pulmonary and liver metastases (Stage IV)  The patient is referred to radiation oncology for palliative radiotherapy and back to GI for esophageal stent placement.

31. Questions?