Case 8: Dyspepsia Flashcards
What were Mr Muller symptoms?
- Heart Burn uncomfortable
- Dull pain and worse after meals
How long is the oesophagus?
25cm
Where does the oesophagus start and end?
- inferior border of thecricoid cartilage(C6)
2. cardiac orifice of the stomach (T11)
When does the oesophagus enter the abdomen?
T10
What are the two layers of the oesophagus?
- adventia (outer layer of connective tissue)
- muscle layer
- submucosa
- mucosa
What are the two layers of the muscle layer?
- external layer of longitudinal muscle
- inner layer of circular muscle
What are the different layers in the external layer and their type of muscle?
- Superior third – voluntary striated muscle
- . Middle third – voluntary striated and smooth muscle
- Inferior third – smooth muscle
What is the mucosa made of?
non-keratinised stratified squamous epithelium (contiguous with columnar epithelium of the stomach)
What is the upper oesophageal sphincter?
- Normally, it is constricted to prevent the entrance of air into the oesophagus
- junction between pharynx and oesophagus
What is the upper oesophageal sphincter made of?
- striated muscle sphincter
- produced by thecricopharyngeusmuscle
Where is the lower oesophageal sphincter?
in thegastro-oesophageal junction
Where is the GO junction?
eft of theT11 vertebra, and is marked by the change from oesophageal to gastric mucosa
How is the sphincter characterised by?
- The oesophagus enters the stomach at anacute angle
- The walls of the intra-abdominal section of the oesophagus arecompressedwhen there is a positive intra-abdominal pressure.
- Thefolds of mucosapresent aid in occluding the lumen at the gastro-oesophageal junction.
- The right crus of the diaphragm has a“pinch-cock”effect.
- During oesophageal peristalsis, the sphincter is relaxed to allow food to enter the stomach. Otherwise at rest, the function of this sphincter is to prevent the reflux of acidic gastric contents into the oesophagus.
What are the anterior cervical and thoracic anatomical relations of the oesophagus?
- Trachea
2 Left recurrent laryngeal nerve - Pericardium
What are the posterior cervical and thoracic anatomical relations of the oesophagus?
- Thoracic vertebral bodies
- Thoracic duct
- Azygous veins
- Descending aorta
What are the right cervical and thoracic anatomical relations of the oesophagus?
- Pleura
2. Terminal part of azygous vein
What are the left cervical and thoracic anatomical relations of the oesophagus?
- Subclavian artery
- Aortic arch
- Thoracic duct
- Pleura
What are the anterior abdominal anatomical relations of the oesophagus?
- Left vagus nerve
2. Posterior surface of the heart
What are the posterior abdominal relations of the oesophagus?
- Right vagus nerve
2. Left crus of the diaphragm
Where are foreign objects most likely to become impacted?
- arch of aorta
- Bronchus (left main stem)
- Cricoid cartilage
- Diaphragmatic hiatus
What is Barretts oesophagus?
themetaplasia(reversible change from one differentiated cell type to another) of lower oesophageal squamous epithelium to gastric columnar epithelium
What is the most common symptoms of BO?
long-term burning sensation of indigestion
What are the clinical features of oesophageal carcinoma?
- Dysphagia
2. Weight loss
What are the two major types of oesophageal carcinomas?
- Squamous cell carcinoma– the most common subtype of oesophagus cancer
- can occur at any level of the oesophagus. - Adenocarcinoma
- only occurs in the inferiorthird of the oesophagus and is associated with Barrett’s oesophagus
- It usually originates in the metaplastic epithelium of Barrett’s oesophagus.
How does the abdominal oesophagus drain?
into both thesystemicandportalcirculation, forming an anastomosis between the two
What are oesophageal varices?
abnormally dilatedsub-mucosal veins(in the wall of the oesophagus) that lie within this anastomosis
When are oesophageal varices produced?
when the pressure in the portal system increases beyond normal, a state known asportal hypertension
When does portal hypertension occur?
- secondary to chronic liver disease, such as cirrhosis or an obstruction in the portal vein
- alcoholics high risk of developing OV
What are the varices like?
predisposed to bleeding, with most patients presenting withhaematemesis(vomiting of blood)
What is the initial treatment for GORD/reflux?
- PPI 4-8 weeks
- If come back PPI at lowest dose, take when needed
- If not work H2 blocker
What is the treatment for severe oesophagitis?
- PPI 8 weeks
- Come back high dose or diff PPI
- If PPI doesn’t work lifestyle
What surgery are possible for severe GORD?
- Side effects, or no med LT
- laparoscopic fundoplication
- keyhole surgery techniquesurgeon stitches and folds the top of the stomach, just below where the oesophagus meets the stomach, to create a smaller opening
- The aim is to reduce the amount of stomach contents re-entering the oesophagus
What could be causing his dyspepsia?
- Coeliac disease
- Inflammatory bowel disease
- Upper GI malignancy
- GORD
- Gastritis
- Pancreatitis
- Medication side effects
- Functional dyspepsia
- Gallbladder disease
- Gastroentertitis
- Stress
- Peptic ulcer disease
- Coronary heart disease
What are the five most likely?
- Gastritis
- Stress
- Peptic ulcer disease
- GORD (lying down and after eating bad)
- Functional dyspepsia
What would be a red flag of back pain?
spinal cord compression, malignancy, infection
What is a red flag for Mr muller?
- Dysphagia
- Anemia
- Sudden weight loss
What action is appropriate for Mr muller?
- FBC
- LFTS
- Alcohol history
- Medication history
- ECG
- Test for H pylori
- Weight
Why is mentoring his weight a good idea?
- Simple and free
- Good to monitor and calculate BMI
Why should you do an ECG?
- Quick and non-invasive
- Ideally during pain
- Might highlight abnormalities
Why should you check alcohol history?
- See if above limit
- To offer support and see clinical consequences
Why is it important to take medication history?
- Include over the counter
- Those the relic the oesophageal sphincter
- Those that affect gastric mucosa
Why test for H.pylori?
- Common in dyspepsia
- Gastritis peptic ulcer disease (PUD), gastric malignancies
- Highly prevalent
Why take FBC?
- Anemia
- High platelets (thrombocytosis)
- Think red flags
Why do LFT?
- Biliary disease
- Alcohol induced changes
- Opportunistic
What does H pylori secrete?
an enzyme urease converts chemical urea to ammonia which neutralises HCL and goes into mcusu by flagella
How does H pylori adheres to host? And what toxins?
- LPS/BabA for adhesion to host
- VacA and CagA
What are the advantages of Carbon-13 urea breath test?
- non-invasive, simple and safe
- high sensitivity and specificity
- can be sued for diagnosis and as a test of cure
What are the disadvantages of Carbon-13 urea breath test?
- requires specialist analysing equipment and samples may need sending away
- If patient on PPIs or antibiotics the results may be falser negative
- requires fasting conditions
What are the advantages of the stool antigen test?
- Non-invasive simple and safe
- High sensitivity and specificity
- Can be used for diagnosis and theoretically as test of cure
What are the disadvantages of the stool antigen test?
- Patients might prefer other tests
- Samples need refrigeration
- If patient on antibiotics or PPIs, results may be negative
- Sufficient evidence lacking for use as a test of cure
What are the advantages of serum serology test?
- Cheap and widely available
2. Maybe useful for diagnosing a patient that is newly infected
What are the disadvantages of serum serology test?
- IgM poorly sensitive for new infection
- IgG does not tell you if infection is current (as will remind positive after infection cleared)
- Cannot test for cure
What are the advantages of CLO test?
- High sensitivity and specificity
- Instantneous result
What are the diadvantages of CLO test?
- If patient is on antibiotics or PPis result might be falsely negative
- Invasive
Why is the serum different?
- Serum probes for human protein (check for presence of specific human antibodies), doesn’t necessarily mean current
- The rest for H pylori protein and stool one is for antigen (h pylori catalase) carbon-13 needs specialist so stool over carbon-13 and the other one is invasive
