Case 17: Swallowing difficulties Flashcards
does the LOS contain muscle
no it is a physiological (functional) sphincter so does not have any specific sphincteric muscle
which cells line the lower oesophagus
stratified squamous epithelium
which cells line the stomach
columnar epithelium
what do surface mucous cells do
secrete a protective coat of alkaline mucus
line gastric glands
prevents stomach from digesting itself
what do tight junctions do in the stomach
they are between epithelial cells and they prevent gastric juice from penetrating the underlying tissue
what do parietal cells do
what do parietal cells do
produce HCl and intrinsic factor (needed for B12 absorption)
what do chief cells do
secrete pepsinogen
HCl cleaves pepsinogen into its active form- pepsin
what do eneteroendocrine cells do
secrete various hormones into the interstitial fluid of the lamina propria
one of these hormones is gastrin
what do stem cells in the stomach do
they are located where the gastric glands join the gastric pits
they quickly replace damaged epithelial mucosal cells
how often is the surface epithelium of the stomach replaced
every 3-6 days
differentials for dysphagia
gastrooesophageal reflux
hiatus hernia
oesophageal cancer
oesophageal candidiasis
achalasia
muscle tension dysphagia
diffuse oesophageal spasm
pharyngitis
what does dysphagia to solids suggest
structural lesion
what does dysphagia to liquids and solids suggest
liquids and solids suggest
myomotility/neurological disorder
which type of oesophageal cancer is more common with alcohol and smoking
squamous cell carcinoma
which type of oesophageal cancer is more associated with barrett’s
adenocarcinoma
which type of oesophageal cancer is more common
squamous cell carcinoma
what may predispose/trigger GORD
alcohol
smoking
coffee
mints
citrus
fats
most common type of gastric cancer
adenocarcinoma
what type of gastric cancer may present with dysphagia
tumour of the gastro-oesophageal junction
is gastric cancer more common in men or women
twice as common in men
what is barrets
metaplasia change of the distal oesophagus from stratified squamous to columnar epithelium
is barrets malignant
no it is premalignant
increases risk of oesophageal cancer by 50 fold
when would you consider referral for barrets rather than surveillance
if there is dysplasia
when would those with barrets get endoscopes
every 3-5 years
what type of cancer is related to virchows node
gastric
when would you do 2 week endoscopy wait
dysphagia
or
55 or over with weight loss and any of following- upper abdominal pain, reflux, dyspepsia
what is first line investigation for dysphagia
ODG (oesophago-gastro duodenoscopy) with biopsy
what abnormal bloods may be seen in oesophageal cancer
hypokalaemia due to the inability to swallow potassium rich saliva
iron deficiency anaemia/ anaemia of chronic disease
LFTs deranged in liver metastases
CRP raised in malignancy
bone profile (including ALP) may be raised in bone metastases
what investigation would you do to identify a stricture
barium swallow
why would you use a PET scan for oesophageal cancer
used for staging
used before initiating therapy to identify primary tumour sight, locoregional disease and metastases
pain with peptic ulcer disease is usually associated with what
hunger
2 most common causes of peptic ulcer disease
NSAIDs
H.pylori
age and sex most commonly affected by peptic ulcer disease
50-70
men= women
when does a mallory weiss tear typically occur
after a period of recurrent wrenching, vomiting, coughing or straining
treatment for mallory weiss tear
usually self limiting so treatment is supportive
do more men or women get malllory weiss tear
more men
most common cause of mallory weiss tear in women of childbearing age
hyperemesis gravidarum
causes of peptic ulcer disease in order of importance
h.pylori
drugs- NSAIDs, bisphosphonates, corticosteroids, potassium supplements, SSRIss, recreational drugs
smoking, alcohol consumption and stress
zollinger-ellison syndrome
how is h.pylori able to survive in the stomach
it migrates to less acidic regions
it uses urease enzyme to convert urea to CO2 and ammonia
this ammonia neutralises the stomach acid and protects h.pylori
what cancers is h.pylori linked with
gastric
malt lymphoma
criteria for h.pylori testing work
must stop PPI within 14 days of treatment
must not of had antibiotics in past 4 weeks
retesting is only needed in those with associated peptic ulcer or persistent symptoms despite treatment
what is the glasgow blatchford score
screening tool used to assess the likelihood that someone with an upper GI bleed with need to have medical intervention such as a blood transfusion/endoscopic intervention
which medication would you give specific for variceal bleeding
terlipressin
how does terlipressin work
it acts on the splanchnic circulation to reduce pressure in the portal vein which will help slow or stop bleeding varices
two methods of endoscopic treatment for variceal bleeding
banding (cuts off blood supply)
trans-jugular intrahepatic portosystemic shunt (TIPS)
how does TIPS procedure work
radiologist inserts a stent to connect portal vein to hepatic vein
this allows blood to be brought back from the bowel to the heart whilst bypassing the liver
this reduces the pressure in the portal vein
what are the endoscopic treatments for a peptic ulcer bleed
clips (mechanical)
thermal coagulation (heat probe)
fibrin and thrombin (haemostatic adjuncts)
injection of vasoconstrictors (adrenaline)
what does the rockhall score estimate
estimates the risk of rebleeding and overall mortality with upper GI bleeds
what factors affect the rockhall score
age
shock
comorbidities
diagnosis
major stigmata of recent haemorrhage
what drug must be given following peptic ulcer bleed
omeprazole (or other PPI)
what artery is the cause for most bleeding due to duodenal ulcers
posterior duodenal ulcers cause bleeding from the gastroduodenal artery most commonly
secondary prevention for peptic ulcer bleeding
stop NSAIDs
stop smoking
stop drinking
which symptom indicated gastric cancer rather than any other upper GI cancer
stomach pains (constant burning sensation)
what criteria does the glasgow blatchford scale take into account
Hb
BUN (urea nitrogen)
initial systolic BP
sex
heart rate over 100
melena present
recent syncope
hepatic disease
cardiac failure
what score is considered high risk GI bleed which is likely to require medical intervention on glasgow blatchford
score above 0
