Case 19- Upper GI Dosorders Flashcards
Barrett’s oesophagus investigations
FBC- anaemia
Upper GI endoscopy with biopsy- gold standard
Barrett’s oesophagus differentials
Oesophagitis, GORD, gastritis, oesophageal carcinoma
Oesophageal cancer Sx
Progressive dysphagia (solids then liquids), odynophagia, weight loss, post prandial cough, haematemesis, melaena, anorexia, vomiting
Oesophageal carcinoma differentials
Benign oesophageal stricture, achalasia, Barrett’s oesophagus
Oesophageal cancer management
If unable to eat and drink properly now- admit to hospital so that enteral nutrition can be initiated eg. NG tube inserted etc.
Plummer-Vinson syndrome
Difficulty swallowing, iron deficiency anaemia, glossitis, cheilosis, oesophageal webs
Achalasia
Failure of oesophageal peristalsis and of relaxation of lower oesophageal sphincter due to degenerative loss of ganglia from Auerbachs plexus
Achalasia Sx
Progressive dysphagia of BOTH solids and liquids, retrosternal pressure, posturing to aid swallowing, regurgitation, gradual weight loss, cough
Achalasia differentials
Oesophageal carcinoma, oesophagitis, oesophageal spasm
AAA/ allgrove syndrome
Achalasia, addisonianism, alacrima
Oesophagitis
Hx of heartburn
Odynophagia but no weight loss
Systemically well
Oesophageal candidiasis
History of HIV/ steroid use
Dysphagia
Dysphagia investigations
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.)
PUD risk factors
H pylori, NSAID use (aspirin, ibuprofen, naproxen, diclofenac, mefenamic acid), smoking, personal/ family history, spicy food, stress, alcohol, caffeine, SSRI, Zolliger Ellison syndrome
PUD Sx
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
PUD differentials
Oesophageal cancer, stomach cancer, GORD, acute pancreatitis, IBS, coeliac disease, pericarditis
Epigastric pain investigations
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
GORD differentials
ACS, stable angina, oesophageal stricture, Barrett’s oesophagus, oesophageal carcinoma
GORD Investigations
Without nausea vomiting/ weight loss, can organise a non urgent OGD but oesophageal pH monitoring will be the gold standard
Dyspepsia
Indigestion- pain in upper abdomen
Patients with evidence of a bleed (coffee ground vomit)
Admit to hospital- if actively bleeding need clinical support on the wards
Dysphagia causes
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)
Water brash
Excess saliva regurgitated due to excessive acid
GORD management
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
Barrets oesophagus pathophysiology
Squamous epithelium replaced by columnar epithelia
Leads to oesophageal adenocarcinoma
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
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
Achalasia investigations
Oesophageal manometry- LOS doesn’t relax (most important)
Barium swallow- birds beak
Upper GI endoscopy
Achalasia management
Pneumatic dilation (first line)
Hellers Myotomy
Or
Botulinum toxin injection or calcium channel blocker if not surgically fit
Investigations for PUD
FBC UE LFT Bone profile
H pylori stool antigen and urea breath test
Upper GI endoscopy
H pylori management
PPI + 2 antibiotics eg. Omeprazole + clarithromycin and amoxicillin (metronidazole if allergy)
PUD Management
PPI until ulcer is healed if no H pylori or H pylori eradication of present
Gastric cancer Sx
Epigastric pain, nausea, dysphagia, early satiety, malaena, anorexia and weight loss
High urea
Upper GI bleed
Glasgow Blatchford score
Suspected upper GI bleed based on presentation (pre endoscopy)
A score of 0 may warrant early discharge
Rockfall score
Identifies patients at risk of adverse outcome following acute upper GI bleed
NB- “fall on a rock”- adverse outcome
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
Bloods needed if upper GI suspected
FBC UE LFT coagulation profile
Crossmatch 2 units of blood
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)
Management of Barrett’s oesophagus
Endoscopy surveillance with biopsies
High dose PPI
Endoscopic surveillance of Barrett’s
Metaplasia- every 3-5 years
If dysplasia found- endoscopic mucosal resection, radio frequency ablation
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
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.)
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
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)
Gastric cancer associations
H pylori infection
Blood group A
Adenomatous polyps
Pernicious anameia
Smoking
Salty, spicy, nitrates
Investigations for suspected gastric cancer
2 week wait referral for upper GI endoscopy with biopsy
Staging CT
NB- full exam, bloods, etc.
Management of gastric cancer
Gastroenterology, upper GI, and oncology MDT
Cheotherapy
Surgical resection
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)
H pylori associations
PUD (duodenal)- most important
Gastric cancer
B cell lymphoma of MALT tissue
Atrophic Gastritis
NB- no relationship with GORD
Urea breath test for h pylori
Can’t be performed within 4 weeks of an ABX or within 2 weeks of a PPI
Management of H pylori
7 day course of PPI + amoxicillin (+clarithromycin or metronidazole)
If penicillin allergic- PPI + clarithromycin + metronidazole
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
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
Perforated peptic ulcer
Sudden epigastric pain, becomes more generalised
Syncope
Clinical diagnosis, but erect chest x ray will show free air under diaphragm
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
Features of pernicious anaemia
Features of anaemia, neuropathy, subacute combined degeneration of the cord, neuropsychiatric features, mild jaundice (lemon tinge), glossitis
Investigations for pernicious anaemia
FBC, vitamin B12 and folate
Antibodies- anti intrinsic factor antibodies
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
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)
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
Gastric MALT lymphoma
Low grade- most responds to H pylori eradication
Paraproteinaemia may be present
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
Benign oesophageal stricture
Children with tracheo-oesophageal fistulas will commonly develop oesophageal strictures following repair. These may require regular dilations throughout childhood.
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)
Grading of hepatic encephalopathy
Grade I: Irritability
Grade II: Confusion, inappropriate behaviour
Grade III: Incoherent, restless
Grade IV: Coma
Grading of hepatic encephalopathy
Grade I: Irritability
Grade II: Confusion, inappropriate behaviour
Grade III: Incoherent, restless
Grade IV: Coma
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)
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
Features of GORD (dyspepsia/indigestion)
Heartburn
Acid regurgitation
Retrosternal or epigastric pain
Bloating
Nocturnal cough
Hoarse voice
PPI and endoscopy
stop 2 weeks before
