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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
Barrets oesophagus pathophysiology
Squamous epithelium replaced by columnar epithelia Leads to oesophageal adenocarcinoma
26
Oesophageal cancer investigations
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
27
Squamous carcinoma of oesophagus
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
28
Achalasia investigations
Oesophageal manometry- LOS doesn’t relax (most important) Barium swallow- birds beak Upper GI endoscopy
29
Achalasia management
Pneumatic dilation (first line) Hellers Myotomy Or Botulinum toxin injection or calcium channel blocker if not surgically fit
30
Investigations for PUD
FBC UE LFT Bone profile H pylori stool antigen and urea breath test Upper GI endoscopy
31
H pylori management
PPI + 2 antibiotics eg. Omeprazole + clarithromycin and amoxicillin (metronidazole if allergy)
32
PUD Management
PPI until ulcer is healed if no H pylori or H pylori eradication of present
33
Gastric cancer Sx
Epigastric pain, nausea, dysphagia, early satiety, malaena, anorexia and weight loss
34
High urea
Upper GI bleed
35
Glasgow Blatchford score
Suspected upper GI bleed based on presentation (pre endoscopy) A score of 0 may warrant early discharge
36
Rockfall score
Identifies patients at risk of adverse outcome following acute upper GI bleed NB- "fall on a rock"- adverse outcome
37
Management of an upper GI bleed
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
Bloods needed if upper GI suspected
FBC UE LFT coagulation profile Crossmatch 2 units of blood
39
Specific management of ruptured oesophageal varices
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
Management of Barrett’s oesophagus
Endoscopy surveillance with biopsies High dose PPI
41
Endoscopic surveillance of Barrett’s
Metaplasia- every 3-5 years If dysplasia found- endoscopic mucosal resection, radio frequency ablation
42
Dyspepsia criteria for urgent 2ww referral for endoscopy
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
Dyspepsia criteria for non urgent 2ww referral for endoscopy
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
Managing patients with dyspepsia who don’t meet referral criteria for an endoscopy
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
Testing for H pylori
Stool antigen test No need to re test when symptoms have reduced (but if want to, use a carbon 13 breath test)
46
Gastric cancer associations
H pylori infection Blood group A Adenomatous polyps Pernicious anameia Smoking Salty, spicy, nitrates
47
Investigations for suspected gastric cancer
2 week wait referral for upper GI endoscopy with biopsy Staging CT NB- full exam, bloods, etc.
48
Management of gastric cancer
Gastroenterology, upper GI, and oncology MDT Cheotherapy Surgical resection
49
What is the gold standard investigation for GORD
24 hour oesophageal pH monitoring (although endoscopy usually done first- use this test if endoscopy is negative)
50
H pylori associations
PUD (duodenal)- most important Gastric cancer B cell lymphoma of MALT tissue Atrophic Gastritis NB- no relationship with GORD
51
Urea breath test for h pylori
Can’t be performed within 4 weeks of an ABX or within 2 weeks of a PPI
52
Management of H pylori
7 day course of PPI + amoxicillin (+clarithromycin or metronidazole) If penicillin allergic- PPI + clarithromycin + metronidazole
53
Boerhaave syndrome
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
Acute bleeding peptic ulcer
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
Perforated peptic ulcer
Sudden epigastric pain, becomes more generalised Syncope Clinical diagnosis, but erect chest x ray will show free air under diaphragm
56
What is pernicious anaemia ?
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
Features of pernicious anaemia
Features of anaemia, neuropathy, subacute combined degeneration of the cord, neuropsychiatric features, mild jaundice (lemon tinge), glossitis
58
Investigations for pernicious anaemia
FBC, vitamin B12 and folate Antibodies- anti intrinsic factor antibodies
59
Management of pernicious anaemia
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
Cholangiocarcinoma
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
Gastrectomy complications
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
Gastric MALT lymphoma
Low grade- most responds to H pylori eradication Paraproteinaemia may be present
63
Perforated peptic ulcer
Infected material can migrate to right parabolic gutter mimicking appendicitis (central abdominal pain radiating to right hand side) NB- history very important
64
Benign oesophageal stricture
Children with tracheo-oesophageal fistulas will commonly develop oesophageal strictures following repair. These may require regular dilations throughout childhood.
65
Features of hepatic encepahlopathy
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
Grading of hepatic encephalopathy
Grade I: Irritability Grade II: Confusion, inappropriate behaviour Grade III: Incoherent, restless Grade IV: Coma
67
Grading of hepatic encephalopathy
Grade I: Irritability Grade II: Confusion, inappropriate behaviour Grade III: Incoherent, restless Grade IV: Coma
68
Causes of hepatic encephalopathy
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
Management of hepatic encephalopathy
treat any underlying precipitating cause NICE recommend lactulose first-line, with the addition of rifaximin for the secondary prophylaxis of hepatic encephalopathy
70
Features of GORD (dyspepsia/indigestion)
Heartburn Acid regurgitation Retrosternal or epigastric pain Bloating Nocturnal cough Hoarse voice
71
PPI and endoscopy
stop 2 weeks before

Year 3 OSCE (61 decks)

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