Case 19 - Upper GI Diseases Flashcards
What is Barrett’s Oesophagus?
A pre-malignant condition where there is a change of the normal epithelium of the esophagus
Not all cases will go on to become malignant, but gives a higher risk (x50) of oesophageal cancer
What is the pathophysiology of Barrett’s Oesophagus?
Normal oesophageal epithelium is squamous epithelium
Barrett’s is a change to glandular epithelium, like that of the stomach
Dysplasia is when there are abnormal cell types present - when dysplasia is present, this leads to a very high risk of cancer
RFs for Barrett’s Oesophagus
Male Smoker Increasing age GORD Hiatus hernia Central obesity
Diagnosis and screening for Barrett’s Oesophagus?
Should screen anyone with persistent GORD (>5y) or that affects ADL with any 3 of:
- Over 50
- White
- Male
- Smoker
- Obese
Then, OGD done to assess the oesophageal lining - will see pink streaks of different cells in the normal epithelium
Can then biopsy to determine if there’s any evidence of dysplasia - stain for p53 overexpression
When should Barrett’s be monitored?
When there are streaks of Barrett’s more than 3cm, should have 3-5 yearly OGD to monitor and treat the GORD Sx
What is the management for Barrett’s Oesophagus?
When there is any evidence of dysplasia, treat
Otherwise surveillance and PPIs/H2 receptor antagonists to treat the GORD
Endoscopic resection of the mucosa - nodular areas, can stage Ca. Can cause strictures
Radiofrequency ablation - for flat areas. Can cause post-op chest pain and strictures
Cryotherapy - for those who have had failed ablation. May have post-op chest pain and strictures
Surgery - when the neoplasia involves the submucosa the risk of lymph node involvement becomes greater than surgery
What is dysphagia?
Inability to swallow food and/or liquids comfortably
Can be due to a variety of causes:
Neuromuscular - neuro=stroke, Parkinsons
Muscular=myaesthenia gravis, muscular dystrophy
Weakened muscles = in elderly
Narrowing - Mass of any kind - oesophageal, throat etc
Scars or rings formed in oesophagus e.g. from GORD
Symptoms of dysphagia and their likely aetiologies
When there is a struggle with solids and foods, suggests a neuromuscular aetiology/achalsia
When liquids can pass easily, progressive dysphagia for solids, suggests some kind of obstructive cause/stricture
History for dysphagia?
Weight loss Vomiting/haematemesis Change in bowels/malaena Any pain Sx of anaemia
PMHx - any previous upper GI investigations
Medications, why, when
NSAIDs
Previous abdo surgery
FHx of strokes etc
SHx - smoker/drinker
Examination for dysphagia
Note body habitus, jaundice, pallor etc Abdo exam oral inspection for candida/dry mouth Should see if there is a lump on swallowing or sticking tongue out Any lymphadenopathy
Investigations for dysphagia?
BTs - anaemia, U and E, LFTs
OGD +/- biopsy
Prep - No food 6 hours before, only clear liquids, NBM 2 hours before. stop anticoagulants
During - telescope test, use numbing spray at the back of the throat and potentially a sedative. If anything is found, we will take a biopsy
After - must be accompanied for 24hrs if had the sedative
Risks - pain, infection, bleeding, perforation
Alternatives - can do swallow studies, but none will give us as good a view of the tract as OGD
Treatment for dysphagia
Proper sitting position when eating can help
Physiotherapy to re-train the swallowing muscles
Soft/liquid only diet can be helpful
Surgery
Tube feeding
Complications of dysphagia
Aspiration - aspiration pneumonia etc
Choking
Malnutrition
What is odynophagia?
Pain on swallowing- can be associated with masses, ulcers, GORD etc.
What is the epidemiology of oesophageal cancer?
Often only found when symptomatic and therefore in its later stages
On the increase, and increasing in younger people
Smoking and alcohol have a syndergistic effect
Most are squamous cell/adenoarcinoma
RFs for oesophageal cancer
Smoker Excess alcohol GORD Poor diet Folate deficiency High BMI and reflux
2WW guidelines for oesophageal cancer
Should refer for an urgent OGD- Anyone with dysphagia >55y with: -upper abdo pain -reflux -dyspepsia
Non-urgent OGD for others
Investigations for oesophageal cancer
FBC - WCC, Hb U and E for contrast tolerance and chemo tolerance LFTs CRP OGD +/- biopsy Staging CT/PET
Staging of oesophageal cancer
T1 - in the submucosa
T2 - in the muscularis
T3 - in the adventitia
T4 - in the adventitia, potentially spreading to adventitia of other organs (T4b) or into other organs (T4b)
Treatment of oesophageal cancer
Should determine if resectable by using endoscopic USS
No, lymph node involvement and a small tumour can be operated on straight away
In larger tumours or if there are nodes - chemo first then re-evaluate
T4 straight to palliative
What are the types of hernia?
Named after location - inguinal, umbilical etc.
Direct inguinal is when there is a weakness in the abdominal wall and the contents spill out into the inguinal canal
Indirect is when there is no rupture of the abdominal wall, but the abdominal contents enter the inguinal canal through deep inguinal ring, and can extend down to the scrotum in men
Strangulation is when the blood supply to the hernia is cut off - surgical emergency
How are hernias treated?
Open or laparoscopic surgery
Try laparoscopic for a small hernia in an otherwise fit and healthy person - fewer risks, smaller scar and less healing time
Use open if it’s a large hernia of if there’s likely to be adhesions, or if closed has been unsuccessful
Haematemesis history
Duration and Frequency ie. quantity Volume Colour of blood Clots Sx of shock Any retching Hx of GI bleed or ulcers NSAID use Anticoagulants/antiplatelets Weight loss Alcohol/smoking Contact with ill people?
What is a Mallory-Weiss tear?
A small tear in the oesophageal lining usually after extended period of sickness or retching
More common in younger people
Often self-resolves, but need scope and clipping if GBS above 1
Due to:
-Self-enforced vomiting
-Pregnancy
-Alcoholic binge
