2025 – PAGE 238 – GASTROENTEROLOGY

ACHALASIA

Achalasia is a motor disorder of the esophagus with three components: 1) loss of esophageal paristalsis, 2) increased LES pressure and 3) absent or incomplete LES relaxation with swallows. This results in forceful emesis and eventual esophageal dilatation. Look for forceful vomiting, difficulty swallowing (dysphagia), and weight loss or FTT. To diagnose, first start with an upper GI barium series to look for a “bird’s beak” appearance. Then do an EGD to look for masses, or other abnormalities, that could cause the same appearance. Finally, the esophageal manometry (the gold standard test) is done to look for an absence of contraction and a high tone within the esophageal sphincter while the patient is asked to swallow.

VOLVULUS

A volvulus can cause bilious emesis, abdominal distension, and possibly even bloody stools (from ischemia and necrosis of bowel). This occurs due to a rotational defect during embryology resulting in poorly-fixed bowel (the rotational defect is called a MALROTATION). This leads to the bowel wrapping around the su­pe­rior mesenteric artery (SMA) and causing bowel ischemia, and therefore requires emergent surgery. A double bubble may be seen on imaging.

PEARLS: An upper GI series is the preferred and gold-standard study, though a barium enema can be helpful when the UGI is inconclusive. There may be a “corkscrew” appearance of the duodenum. On barium enema, the cecum may be in the wrong place (abnormally high). An abdominal X-ray may be shown with a “double bubble” sign.

IMAGE: www.pbrlinks.com/VOLVULUS1 (corkscrew)
IMAGE: www.pbrlinks.com/VOLVULUS2 (corkscrew)
IMAGE: www.pbrlinks.com/VOLVULUS3

ANNULAR PANCREAS

Look for a history of polyhydramnios and then vomiting in a neonate. The annular pancreas forms a ring around the intestine. This causes poor swallowing in utero, resulting in polyhydramnios, and then vomiting in the neonatal period.

IMAGE: www.pbrlinks.com/ANNULARPANCREAS1

CYCLIC VOMITING

Cyclic vomiting is associated with intermittent episodes of repeated vomiting with periods of complete normalcy. There is likely to be an emotional component to the question, either in the patient or the family, and there may also be a history of migraines or IBS. Treatment may include hydration and/or prophylactic medi­cations similar to those used in migraine patients: Amitriptyline (or similar tricyclic antidepressant/TCA), cypro­heptadine, or propranolol.

PEARL: This is a diagnosis of exclusion, so make sure somewhat of a workup has been done before choosing this answer.