Deck 9 Flashcards
odynophagia
painful swallow.
Can be infections but also malignancy
Dyspepsia definition
Abdo pain/heartburn/acid reflux for 4+ weeks
Causes of dysphagia
Physical (malignancy, obstruction, pharyngeal pouch, tonsilitis, stricture, oesophagitis, eosinophilic/allergic oesophagitis, proximal gastric cancer, lymph node enlargement, retrosternal goitre, bronchial carcinoma)
Can be functional (CNS (MS/stroke, demential, parkinsons), PNS (MG/MND), muscle (CREST), achalasia, globus
CREST
Autoimmune CT disorder with calcinosis, Raynaud’s, oesophageal dysmotility, sclerodactyli, telangectasia
Oropharyngeal vs oesophogeal dysphagia
Oropharyngeal is difficulty initiating swallow (can have choking/aspiration) - often neurological. (neuro exam + videofluoroscopic swallow)
OEsophageal dysphagia is food sticking after swallow. Can be achalasia, stricture, oesophagitis, pharyngeal pouch. Investigate with barium swallow, OGD (unless pouch) and biopsy
Plummer vinson syndrome
dysphagia, koilonycia, glossitis (IDA)
Premalignant, as oesophagus becomes hyperkeratinised in oesophageal web formation
Tx with iron and OGD
Sudden dysphagia
? stroke
Rapidly progressive dysphagia
? cancer
insidious dysphagia
?MND/MG
Longstanding dysphagia
likely spasm/achalasia
Solids only dysphagia
? mechanical
Pain and dysphagia
cancer, oesophageal ulcer, candida or spasm
Liquid dysphagia
consider motility
PMHx and dysphagia
GORD predisposes to oesophageal adenocarcinoma and strictures
Peptic ulcers cause scarring and strictures
Strokes and parkinsons cause functional issues
DHx and dysphagia
NSAIDs have ulcer risk, CCB/nitrates relax smooth muscle and make reflux worse. Steroids and bisphosphonates increase ulcer risk
2ww for upper GI endoscopy
Any patient with dysphagia
OR
Aged 55+ with wt loss and either upper abdo pain/reflux/dyspepsia
OR
Upper abdo mass consistent with stomach cancer (may only be palpable in thin patients)
O/E, O/I for dysphagia
Check fluid balance, palpate neck for large pharyngeal pouch/goitre, anaemia signs, virchow’s node, palpate abdomen for mass, CN/PNS exam
Bloods (IDA, infection, platelets (raised in gastric malignancy), U&E (AKI/dehydration), LFTs (common met for gastric ca)
Imaging - limited role for CXR but may see dilatation in achalasia.
Specialist imaging:
OGD +/- biopsy, manometry, barium swallow (pharyngeal pouch), Staging CT if malignancy
oesophageal malignancy symptoms
Progressive dysphagia (solids to liquid - liquid is late sign), weight loss, odynophagia (esp retrosternal), globus, hoarse voice, cough
squamous oesophageal cancer
More common worldwide.
Middle and upper 1/3.
RF smoking, alcohol, nitrate rich food, chronic inflammation (hot drinks and achalasia)
oesophageal adenocarcinoma
More common in UK
lower 1/3
Overlap with GORD (obesity, alcohol, sphincter relaxing drugs, smoking). Barrett’s oesophagus allows metaplasia to columnar epithelium. Dysplasia leads to adenocarcinoma and endoscopic surveillance required
OEsophageal malignancy diagnosis
OGD
Staging CT/PETCT
Tx is surgical, chemo, radio. Poor prognosis
Gastric malignancy RF
55+, Males 4x, hypochloria (alkaline stomach - H pylori), pernicious anaemia against parietal cells (atrophic gastritis), post gasterectomy, (stump malgnancy), smoking, blood group A, adenomatous polyps, BNPAA, japanese heritage, nitrate preservatices
Gastric cancer symptoms and signs
Dyspepsia, dysphagia (proximal malignancy), early satiety (distal malginanct), vomiting, melaena, anorexia, weight loss, anaemia
May also have jaundice, hepatomegaly, virchow’s node, acanthosis nigricans , palpable epigastric mass
Dyspepsia alarm features
New onset, unresponsive to Tx
Anaemia, weight loss, anorexia, melaena, age over 55, haematemesis
Transcoelomic gastric cancer spread
Krukenberg tumours (secondary ovarian, may be bilateral) Can also get leiomyomas, meiomyosarcomas from interstitial cells of cajal
Achalasia
Lower oesophageal sphincter fails to relax during peristalsis (loss of ganglion cells) and food bolus retained in oesophagus.
Proximal dilatation and inflammation. Muscle hypertrophy.
Can give malignancy risk (squamous).
Relatively rare
40s, 50s. Equal sex
Progressive, VARIABLE dysphagia on liquids and solids (early liquid involvement, suggests not malignancy), nocturnal cough, weight loss, regurgitation
Investigate with OGD (rule out cancer) but mannometry is GSTD (high resting pressure in lower sphincter).
Barium swalloq can also be used (bird beak dilated tapering)
Slow eating may help, botox injection, endoscopic balloon dilatation (risks perforation), myotomy (definitive, good success)
Pharyngeal pouch
Midling pharyngeal wall outpouching
C5/C6
Rare
60s-80s, 5x male
Dysphagia (S+L), regurgitation, crhonic cough, gurgling on drinking, halitosis, globus, infections (asp neu)
Barium swallow for diagnosis (OGD can perforate)
Can have carcinoma/inflammation association
Surgical management
Gold standard diagnostic for achalasia
mannometry
Protection of oesophagus from stomach contents
Anatomical (angle of His) sphincter, and physiological sphincter
GORD RF
obesity, hiatus hernia, pregnancy, CT disorder (scleroderma), delayed gastric emptying, smoking, large/late meal, fried/fatty food, alcohol, coffee, aspirin
Gord symptoms
heartburn, acid reflux, oesophagitis (with odynophagia), water brash, halitosis, bloating/belching, N&V, dysphagia
hiatus hernia
sliding (whole stomach moves up) or rolling (paraoesophageal - hernia outpouching.
Forms via increased pressure
May see on CXR as gastric bubble above diaphragm
Rolling is more concerning. Needs investigation.
hiatus hernia rolling symptoms
pain, gastric obstruction, bloating, volvulus
GORD complications
Oesophageal ulcer (bleeding, pain odynopagia), strictures (dysphagia/odynophagia), Barett’s oesophagus (epithelial metaplasia), oesophageal cancer (dysphagia, wt loss, persistent indigestion, hoarseness, persistent cough, haemoptysis, vomiting)
GORD referrals
ALARM Anaemia Loss of Weight Anorexia Recent onset/progressive Melaena/haematesis Dysphagis and 55+
Don’t scope everyone but if dyspepsia and signicant acute GI bleed then same day referral
Gord diagnosis/tx
clincally, treated empirally (PPI for 8 weeks - continue as maintenance if severe) unless ALARM
Specialist GORD investigations
Oesophageal pH monitoring (24h) and oesophageal mannometry (assess sphincter competence) and barium swallow (exclude stricture, hiatus hernia or motility disorder)
Duodenal ulcer
may improve with food as delayed gastric emptying, may present with bleeding if posterior, or perforation if anterior). 4x more common. Often have pain at night. Alcohol intake is risk factor.
Gastric ulcer
More painful immediately after food. May present with small or large bleed. Tends to occur in 55+ patients. Can be relieved by antacids.
Which upper GI ulcer more likely to bleed
Gastric, then posterior duodenal, then anterior
Peptic ulcer RF
H pylori (most common cause), long term NSAID/aspirin (COX-1 inhibition prevents protective PGs), steroids (also inhibit protective prostaglandins) , increased acid (Zollinger ellison syndrome - gastrin producing tumour), increased IC pressure (crushing ulcers), post severe burns (Curling ulcer) Worsening factors are smoking (disrupts mucous renewal, nicotine increasing acid secretion), stress, spicy food, alcohol
Peptic ulcer symptoms
Burning epigastric pain, fullness/bloating/belching, fatty food intolerance, heartburn, waterbrash, nausea. Severe signs of vomiting, haematemesis, melaena, dyspnoea, syncope, weight loss, appetite change and severe abdo pain can suggest perforation
H pylori
gram negative helical rod
Makes urease, produces ammonia
Infection can give chronic gastritis, gastric cancer and MALT lymphoma
H pylori investigation
C13 breath test
Stool antigen (Hp)
IgG serology to Hp
If low pre test probability then urea and stool
If no alarm fatures and high pretest probability then IgG
If alarm features, antral mucosa biopsy (rapid urease test, histology, culutre)
2WW referral in upper GI
Anyone with dysphagia
Over 55 with upper abdo pain, reflux or dyspepsia
Non urgent upper GI assessment
55+ and Tx resistant dyspepsia, OR upper abdo pain with low Hb, OR leukocytosis with N&V, wt loss, reflux, dyspepsia or epigastric pain OR N&V with wt loss, reflux, dyspepsia and upper abdo pain
Gastric ulcer FU
endoscopy at 6-8wks.
FU carbon 13 breath test (will become negative)
Tx of peptic ulcer
Amoxicillin, clarythromycin or metronidazole with PPI
If not resolved then surgical fundoplication (risk of bleed, obstruction, perforation or malignancy)
Malaria types
Parasite
Falciparum (most common in subsaharan africa)
Ovale
Vivax
Malariae
All via female anopheles (night bite) misquito
Initially liver cells infected, replication then blood stream
Malaria reservoir
Ovale, vivax, malariae all move from liver to RBCs to replicate
Falciparum replicates in organs (kidneys/brain) and is more difficult for the spleen to remove - severe
Malaria symptoms
Cyclical fevers (occur during RBC rupture) - every 48-72h (species dependent)
Often non specific features
Mild is fever, rigors, malaise, headache, GI upset
Severe malaria has reduced GCS (hypoglycaemia/cerebral malaria), seizures, ARDS, shock, jaundice, oliguria (AKI), severe anaemia (<50hb), intravascular haemolysis (haemoglobinuria - black urine), acidosis, DIC, thrombocytopoeania (spontaneous bleed)
Diagnosis of malaria
Blood film (parasites - gives load and indicates severity)
Rapid diagnostic test
Basic obs, FBC (Hb/platelets), U&E, LFT (pre-hepatic jaundice), BM (hypoglycaemia), ABG, blood culutre
Malaria Tx
Artemisinin, quinine. Primaquine in vivax, ovale for liver stage
Bloody diarrhoea
Dysentery - fever and tenesmus are common
E coli? Campylobacter? Shigella? Amoebiasis?
Mucous suggests large bowel
C diff diarrhoea
green tinge
Cholera diarrhoea
rice water
stool sample for returning traveller diarrhoeaa
may need 3
Culture, microscopy (ova/cysts/parasites)
Blood culture/films in traveller diarrhoea
Typhoid (enteric fever) diagnosed by blood culture
Malaria needs blood film
Bacterial causes of diarrhoea with short incubation
Bacilus cereus (rice?) and staphylococcus aureus symptomatic within hours due to toxins
Shigellosis
Gram negative
3 day incubation
Inflammation, ulceration, microabscesses, bleeding
Mild is watery diarrhoea, severe is mucous and dysentery. May have HUS. May have shock.
Diagnosis is redcurrant jelly stool., MC&S, rectal swab
Supportive management, ciprofloxacin, ?zinc/vit A in kids
Camylobacter
Common in UK plus abroad.
Flu prodrome, abdo pain, fever, diarrhoea +/- blood
Supportive management and ciproloxacin if severe
E Coli (GI infection)
Less common UK diarrhoea cause
Initially watery diarrhoea, then bloody. nausea, abdo cramps. Can give HUS (Esp in children)
Supportive management
Enteric fever/typhoid
Salmonella subtypes
Week 1 is headache, cough, sore throat, anorexia, fever, and abdo discomfort
Week 2 is toxic (fever, rose spots, abdo pain, hepatosplenomegaly, diarrhoea/constipation)
Week 3: fever breaks. Either settles or complications (perforation, GI haemorrhage, severe toxaemia, shock)
Diagnosis by stool culture, blood culture, serology
Fluroquinolones and supportive
Giardia
Parasite.
7-10 day incubation (sometimes months).
Very common
Bloating, flatulence, buping, prolonged watery/greasy diarrhoea
Entamoeba
Amoebiasis. Parasite). Days to years incubation.
Can be asymptomatic (fulminant colitis, flask ulcers on endoscopy). Liver abscesses can form.
May present insidious onset abdo discomofrt and diarrhoea +/- blood/mucous
Cryptosporidium/cyclospora
7-10 days incubation
Bloating, weight loss, fever, malaise
Watery diarrhoea and abdominal cramps
Type of diarrhoea indicating parasitic cause
14 days +
Yellow fever
Viral, haemorrhagic fever.
Mosquitos only, no human-human spread
Can be mild, severe is jaundice, fulminant hepatic failure, GI bleed.
Leptospirosis
Spirochete.
Rodent urine
RF are water activity and soil contact
May get vasculitis, sudden onset fever, headache, myalgia, conjuntival suffision (no exudate), muscle tenderness
Second phase has Weil’s diease (jaundice, thrombocytopoenia and AKI) or aseptic meningitis
Serological diagnosis
Weils disease
Second phase of leptospirosis.
Jaundice, thrombocytopoenia and AKI
Calorie needs normal
1.3kcal/kg/h
Calorie needs during exercise
8.5kcal/kg/hour extra
Fat needs
30% of calories (9kcal/gram)
Carbs needs
56% of calories (4ckal/gram)
Protein needs
13% calories (4ckal/gram)
MUST score
malnutrition universal screenin tool, looks at risk of malnutrition
NG tube uses
unsafe swallow, altered consciousness, supplementing oral intake, upper GI stricutre
NG tube precautions
protocols govern confirmation (imaging or pH of aspirate)
Long term uses can cause damage and ulceration so need to be removed ASAP
BMI limits
<18.5 is underweight
12.6-24.9 is normL
25-29.9 IS OVERWEIGHT
30+ is obese
Waist circumference for obesity
88+ female, 102+ male
Waist/hip for abdo obesity
1.0+ in male, 0.9+ female
pharma for weight loss
orlistat - lipase inhibitor (abdo pain, steorrhoea, anal leak)
Liraglutide (GLP-1 agonist in diabetes - injection only)
Bariatric surgery recommended
BMI >40, BMI>35 if complications.
FLT for BMI>50
Intestinal granulomas
IBD (esp CD) and colonic TB. Not likely in malignancy or gastroenteritis.
See inner giant cells, macrophages and then lymphocytes
Vitamin A deficiency
night blindness
vitamin A excess
terotogen, hepatotoxic
B1 deficiency
thiamine deficiency. Polyneuropathy
B3 deficiency
niacin.
Pellagra (dermatitis, diarrhoea, dementia)
Vitamin C deficiency
gingitivis, bleeding
Vitamin D deficiency
Osteomalacia/rickets
Vitamin D excess
hypercalcaemia
Autoimmune IBD
ulcerative colitis
Microbiome linked IBD
CD
Smoking and IBD
protective in UC, RF in CD
IBD and pANCA
more likely in UC, less likely in CD
Imaging difference in CD and UC
CD: fat wraps around bowel due to inflammation
colitis causes thumbprinting from oedema
Colonoscopy different in CD and UC
CD gets skip lesions, cobblestone appearance, apthous and serpentine ulcer
UC has pseudopolyps (islands of healing tissue)
Anti saccaromyces cerevisae antibodies
May be found in CD
Features of CD`
Granulomas, fistulas, strictures
Extra intestinal features of crohns disease
Mouth ulcer, stomatitis, abdominal tenderness, skin tags, uveitis, pyoderma gangrenosum, fatty liver, venous thrombosis, ankylosing spondylitis (HLA B27)
Extra intestinal features of UC
Fatty liver, venous thrombosis, pACNA, PSC, cholangiocarcinoma, colorectal carcinoma, erythema nodosum, pyoderma gangrenosum, uveitis, psoriasis, episcleritis
Erythema nodosum
Red patches on shins (can be seen in UC, but also TB, RA)
pyodermal gangrenosum
non healing leg ulcer
Toxic megacolon
persistant fever, tachycardia, loose blood stained stool
Hypoalbuminaeia, hypokalaemia, AXR with filated colon (>6cm) with mucosal islands
