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Year 3 OSCE > Case 19- Upper GI Dosorders > Flashcards

Case 19- Upper GI Dosorders Flashcards

1
Q

Barrett’s oesophagus investigations

A

FBC- anaemia
Upper GI endoscopy with biopsy- gold standard

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2
Q

Barrett’s oesophagus differentials

A

Oesophagitis, GORD, gastritis, oesophageal carcinoma

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3
Q

Oesophageal cancer Sx

A

Progressive dysphagia (solids then liquids), odynophagia, weight loss, post prandial cough, haematemesis, melaena, anorexia, vomiting

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4
Q

Oesophageal carcinoma differentials

A

Benign oesophageal stricture, achalasia, Barrett’s oesophagus

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5
Q

Oesophageal cancer management

A

If unable to eat and drink properly now- admit to hospital so that enteral nutrition can be initiated eg. NG tube inserted etc.

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6
Q

Plummer-Vinson syndrome

A

Difficulty swallowing, iron deficiency anaemia, glossitis, cheilosis, oesophageal webs

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7
Q

Achalasia

A

Failure of oesophageal peristalsis and of relaxation of lower oesophageal sphincter due to degenerative loss of ganglia from Auerbachs plexus

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8
Q

Achalasia Sx

A

Progressive dysphagia of BOTH solids and liquids, retrosternal pressure, posturing to aid swallowing, regurgitation, gradual weight loss, cough

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9
Q

Achalasia differentials

A

Oesophageal carcinoma, oesophagitis, oesophageal spasm

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10
Q

AAA/ allgrove syndrome

A

Achalasia, addisonianism, alacrima

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11
Q

Oesophagitis

A

Hx of heartburn
Odynophagia but no weight loss
Systemically well

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12
Q

Oesophageal candidiasis

A

History of HIV/ steroid use
Dysphagia

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13
Q

Dysphagia investigations

A

2 week wait for an OGD/ biopsy
Bloods- FBC, UE, LFT
Imaging- nothing on biopsy do fluoroscopic swallowing studies, oesophageal manometry and a CXR- widened mediastinum
Cancer found- staging scan eg. Transoesophageal endoscopic USS, PET or CT chest/ abdomen

NB- always consider enteral feeding (NG tube eg.)

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14
Q

PUD risk factors

A

H pylori, NSAID use (aspirin, ibuprofen, naproxen, diclofenac, mefenamic acid), smoking, personal/ family history, spicy food, stress, alcohol, caffeine, SSRI, Zolliger Ellison syndrome

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15
Q

PUD Sx

A

Dyspepsia, early satiety, burning epigastric pain, signs of anaemia (melaena, haematemesis)

Gastric- weight loss, post prandial pain
Duodenal (more common)- pain relieved by eating, then increases 2-5 hours after food, some weight gain, nocturnal pain

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16
Q

PUD differentials

A

Oesophageal cancer, stomach cancer, GORD, acute pancreatitis, IBS, coeliac disease, pericarditis

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17
Q

Epigastric pain investigations

A

2 week wait for OGD & biopsy
Full abdominal and reticuloendothelial examination- lymphadenopathy
FBC- anaemia, UE- malnutrition and contrast
Urea breath test for H pylori, staging scan if cancer suspected CT thorax/ abdomen

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18
Q

GORD differentials

A

ACS, stable angina, oesophageal stricture, Barrett’s oesophagus, oesophageal carcinoma

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19
Q

GORD Investigations

A

Without nausea vomiting/ weight loss, can organise a non urgent OGD but oesophageal pH monitoring will be the gold standard

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20
Q

Dyspepsia

A

Indigestion- pain in upper abdomen

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21
Q

Patients with evidence of a bleed (coffee ground vomit)

A

Admit to hospital- if actively bleeding need clinical support on the wards

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22
Q

Dysphagia causes

A

Extrinsic- mediastinal mass, cervical spondylosis

Intrinsic- tumour (systemic Sx), stricture, oesophageal web, pharyngeal pouch (halitosis, lump, gurgle, cough, regurgitation, aspiration)

Oesophageal wall- achalasia (liquids and solids), diffuse oesophageal spasm, oesophagitis (pain), candidiasis (risk factor eg. HIV)

Neurological- CVA, Parkinson’s, MS, MG, globus hystericus (history of MH, intermittent, relived by swallowing)

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23
Q

Water brash

A

Excess saliva regurgitated due to excessive acid

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24
Q

GORD management

A

lifestyle advice- reduce tea, coffee, alcohol, smaller meals, remain upright after meals (don’t lie down)

Endoscopically proven oesophagitis- full dose PPI for 1-2 months (no response, double for a month, if response, low dose)

Endoscopically negative- full dose PPI for 1 month, if response, keep on that, no response, histamine antagonist

NB- when this has failed, and they have no urgent referral criteria, they should be tested and treated for H. pylori

Surgery- laparoscopic fundoplication is last resort

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25
Q

Barrets oesophagus pathophysiology

A

Squamous epithelium replaced by columnar epithelia
Leads to oesophageal adenocarcinoma

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26
Q

Oesophageal cancer investigations

A

2 week wait pathway
FBC UE LFT bone profile
Upper GI endoscopy with biopsy
Staging CT scan thorax abdomen pelvis (local stage can be investigated using endoscopic USS)
SALT assessment

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27
Q

Squamous carcinoma of oesophagus

A

Upper 2/3 (smoking, alcohol, achalasia, Plummer Vinson syndrome, nitrosamine diet)
Adenocarcinoma is bottom 1/3 (GORD, Barrett’s, smoking, achalasia, obesity)

NB- adenocarcinoma is the most common in the UK, squamous is the most common worldwide

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28
Q

Achalasia investigations

A

Oesophageal manometry- LOS doesn’t relax (most important)
Barium swallow- birds beak
Upper GI endoscopy

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29
Q

Achalasia management

A

Pneumatic dilation (first line)
Hellers Myotomy
Or
Botulinum toxin injection or calcium channel blocker if not surgically fit

30
Q

Investigations for PUD

A

FBC UE LFT Bone profile
H pylori stool antigen and urea breath test
Upper GI endoscopy

31
Q

H pylori management

A

PPI + 2 antibiotics eg. Omeprazole + clarithromycin and amoxicillin (metronidazole if allergy)

32
Q

PUD Management

A

PPI until ulcer is healed if no H pylori or H pylori eradication of present

33
Q

Gastric cancer Sx

A

Epigastric pain, nausea, dysphagia, early satiety, malaena, anorexia and weight loss

34
Q

High urea

A

Upper GI bleed

35
Q

Glasgow Blatchford score

A

Suspected upper GI bleed based on presentation (pre endoscopy)

A score of 0 may warrant early discharge

36
Q

Rockfall score

A

Identifies patients at risk of adverse outcome following acute upper GI bleed

NB- “fall on a rock”- adverse outcome

37
Q

Management of an upper GI bleed

A

ABATED

ABCDE
Bloods
Access (2 large bore cannulae)
Transfuse (platelets if actively bleeding and count less than 50)
Endoscopy (within 24 hours)
Drugs (stop anticoagulants and NSAIDS)

NB- for oesophageal varices and PUD

38
Q

Bloods needed if upper GI suspected

A

FBC UE LFT coagulation profile
Crossmatch 2 units of blood

39
Q

Specific management of ruptured oesophageal varices

A

ABATED, then;

Terlipressin and prophylactic IV ABX (if cirrhosis) before endoscopy
During endoscopy- endoscopic variceal band ligation
Sengstaken-Blakemore tube if uncontrolled haemorrhage
TIPSS if above fail- may exacerbate encephalopathy

Propranolol can be used as prophylaxis of variceal haemorrhage (also elective EVBL with PPI, but not sclerotherapy)

40
Q

Management of Barrett’s oesophagus

A

Endoscopy surveillance with biopsies
High dose PPI

41
Q

Endoscopic surveillance of Barrett’s

A

Metaplasia- every 3-5 years
If dysplasia found- endoscopic mucosal resection, radio frequency ablation

42
Q

Dyspepsia criteria for urgent 2ww referral for endoscopy

A

Anyone with dysphagia
Anyone with an upper GI mass
People over 55 with weight loss and any of the following;
Upper abdominal pain
Reflux
Dyspepsia

43
Q

Dyspepsia criteria for non urgent 2ww referral for endoscopy

A

Patients with haematemesis

Patients aged 55 with any of the following

Treatment resistant dyspepsia
Upper abdominal pain with low Hb
Raised platelets (with associated GI symptoms eg, weight loss, pain, reflux etc.)
Nausea and vomiting (with associated GI symptoms eg, weight loss, pain, reflux etc.)

44
Q

Managing patients with dyspepsia who don’t meet referral criteria for an endoscopy

A

Review medications
Lifestyle advice (reduce hot drinks, smoking, sit up after meals, plenty water exercise etc,)
1 month PPI, if that fails, test and treat regime for H pylori

45
Q

Testing for H pylori

A

Stool antigen test
No need to re test when symptoms have reduced (but if want to, use a carbon 13 breath test)

46
Q

Gastric cancer associations

A

H pylori infection
Blood group A
Adenomatous polyps
Pernicious anameia
Smoking
Salty, spicy, nitrates

47
Q

Investigations for suspected gastric cancer

A

2 week wait referral for upper GI endoscopy with biopsy
Staging CT

NB- full exam, bloods, etc.

48
Q

Management of gastric cancer

A

Gastroenterology, upper GI, and oncology MDT
Cheotherapy
Surgical resection

49
Q

What is the gold standard investigation for GORD

A

24 hour oesophageal pH monitoring (although endoscopy usually done first- use this test if endoscopy is negative)

50
Q

H pylori associations

A

PUD (duodenal)- most important
Gastric cancer
B cell lymphoma of MALT tissue
Atrophic Gastritis

NB- no relationship with GORD

51
Q

Urea breath test for h pylori

A

Can’t be performed within 4 weeks of an ABX or within 2 weeks of a PPI

52
Q

Management of H pylori

A

7 day course of PPI + amoxicillin (+clarithromycin or metronidazole)
If penicillin allergic- PPI + clarithromycin + metronidazole

53
Q

Boerhaave syndrome

A

Severe vomiting followed by severe chest pain and shock (hypotension)
Due to oesophageal rupture
May get subcutaneous emphysema
Investigation- CT contrast swallow
Primary repair if within 12 hours

54
Q

Acute bleeding peptic ulcer

A

Usually from gastroduodenal artery

Haematemesis, melaena, hypotension, tachycardia

ABCDE
IV PPI
Endoscopic intervention
Failure (twice) and still bleeding- interventional radiography with transarterial embolization or SURGERY ie. laparotomy

55
Q

Perforated peptic ulcer

A

Sudden epigastric pain, becomes more generalised
Syncope

Clinical diagnosis, but erect chest x ray will show free air under diaphragm

56
Q

What is pernicious anaemia ?

A

An autoimmune disorder affecting the gastric mucosa that results in vitamin B12 deficiency

Antibodies develop to intrinsic factor and or gastric parietal cells (can’t absorb B12- anameia and neuropathy)

Associated with other autoimmune disorders eg, thyroid, T1DM, Addisons, rheumatoid, vitiligo

57
Q

Features of pernicious anaemia

A

Features of anaemia, neuropathy, subacute combined degeneration of the cord, neuropsychiatric features, mild jaundice (lemon tinge), glossitis

58
Q

Investigations for pernicious anaemia

A

FBC, vitamin B12 and folate
Antibodies- anti intrinsic factor antibodies

59
Q

Management of pernicious anaemia

A

Vitamin B12 replacement (3 injections per week for 2 weeks followed by 3 monthly injections). More frequent doses if neurological features

Increased risk of gastric cancer

60
Q

Cholangiocarcinoma

A

PSC main risk factor

Persistent biliary colic
Anorexia, weight loss, jaundice
Palpable mass RUQ (courvoisier)
Peri umbilical lymphadenopathy (sister Mary Joseph nodules)
Left supraclavicular lymphadenopathy (Virchow node)

61
Q

Gastrectomy complications

A

Dumping syndrome- fluid shift into small intestine, rebound hypoglycaemia

Weight loss, early satiety

Iron deficiency anaemia

Osteoporosis

Vitamin B12 deficiency

Increased risk of gallstones and gastric cancer

62
Q

Gastric MALT lymphoma

A

Low grade- most responds to H pylori eradication

Paraproteinaemia may be present

63
Q

Perforated peptic ulcer

A

Infected material can migrate to right parabolic gutter mimicking appendicitis (central abdominal pain radiating to right hand side)

NB- history very important

64
Q

Benign oesophageal stricture

A

Children with tracheo-oesophageal fistulas will commonly develop oesophageal strictures following repair. These may require regular dilations throughout childhood.

65
Q

Features of hepatic encepahlopathy

A

confusion, altered GCS (see below)
asterix: ‘liver flap’, arrhythmic negative myoclonus with a frequency of 3-5 Hz
constructional apraxia: inability to draw a 5-pointed star
triphasic slow waves on EEG
raised ammonia level (not commonly measured anymore)

66
Q

Grading of hepatic encephalopathy

A

Grade I: Irritability
Grade II: Confusion, inappropriate behaviour
Grade III: Incoherent, restless
Grade IV: Coma

67
Q

Grading of hepatic encephalopathy

A

Grade I: Irritability
Grade II: Confusion, inappropriate behaviour
Grade III: Incoherent, restless
Grade IV: Coma

68
Q

Causes of hepatic encephalopathy

A

infection e.g. spontaneous bacterial peritonitis (SBP)
GI bleed
post transjugular intrahepatic portosystemic shunt (TIPS)
constipation
drugs: sedatives, diuretics
hypokalaemia
renal failure
increased dietary protein (uncommon)

69
Q

Management of hepatic encephalopathy

A

treat any underlying precipitating cause
NICE recommend lactulose first-line, with the addition of rifaximin for the secondary prophylaxis of hepatic encephalopathy

70
Q

Features of GORD (dyspepsia/indigestion)

A

Heartburn
Acid regurgitation
Retrosternal or epigastric pain
Bloating
Nocturnal cough
Hoarse voice

71
Q

PPI and endoscopy

A

stop 2 weeks before

Year 3 OSCE (61 decks)

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