Diagnostic Approaches And Management Of Common Upper GI Conditions - Part 2

Question 1

How can GI bleeding present?

Answer 1

Melena
Hematemesis
Coffee ground emesis
Hematochezia

Question 2

Peptic ulcer disease (PUD) vs. Erosion

Answer 2

Ulcer - break in the mucosa which extends through the muscularis mucosa

Erosion - break through the mucosa which does not penetrate the muscularis mucosa

Question 3

Causes of upper GI ulceration

Answer 3

Infections - H. Pylori
Medications - NSAIDs
Vascular - ischemia, stress ulceration
Zollinger-Ellison syndrome
Inflammatory - radiation, Chron’s
Neoplastic - Adenocarcinoma

Question 4

Zollinger-Ellison syndrome
- define
- epidemoiology
- presentation

Answer 4

Secretion of gastrin by duodenal or pancreatic neuroendocrine tumours (gastriomas)

• 20 to 50 year olds, higher incidence in men
• 20-30% occur in association with multiple endocrine neoplasia (MEN1)

Chronic diarrhea - failure of resabsorption of the increased gastric acid, inactivation of pancreatic enzymes, damage to intestinal epithelium and inhibition of the absorption of sodium and water

Abdominal pain, PUD

Question 5

H pylori

Answer 5

Spiral shaped, micro-aerophilic, gram-negative bacterium
- 2-7 unipolar sheathed flagella that enhance mobility through viscous solutions-urease positive

• prevalence of 90-95% in DU, 80-85% in GU
• most common chronic bacterial infection worldwide (30% in Canada)
• strains with VacA and CagA gene most likely to cause PUD
• less than 1/4 of patients with H. Pylori dyspepsia symptoms response to eradication therapy

Question 6

What can H. Pylori cause?

Answer 6

Gastric ulcer - infection more evenly speared throughout

Duodenal ulcer - antral predonimant H. Pylori

Question 7

Indications to test and treat HP infection

Answer 7

1) active PUD
2) confirmed Hx of PUD (not previously treated for HP)
3) gastric MALT lymphoma
4) following endoscopic resection of early gastric cancer
5) uninvestigated dyspepsia (in high prevalence population)

Question 8

H pylori diagnosis

Answer 8

Urea breath test (UBT)
Stool antigen assay
Histologically

Question 9

Serology for HP?
Should we use?
How does it work?

Answer 9

Is an ELISA test to detect IgG abs against H. Pylori
Should not be used in low prevalence populations as low accuracy would result in inappropriate treatment in a large number of patients
- low PPV in low prevalence propulsion, but high NPV
- does not reliable distinguish between active and past infection

Question 10

Most important factors in pathogenesis of PUD

Answer 10

HP infection
ASA/NSAIDs
Idiopathic

Question 11

Risk factors for serious GI event with NSAID use

Answer 11

• advanced age
• Hx of PUD or ulcer complication
• major illness (heart disease)
• concomitant anticoagulants
• use of steroids
• Hx of PUD
• high dose of NSAIDs
• presence of H. Pylori
• smoking and alcohol

Question 12

Complications of PUD?

Answer 12

Penetration/perforation
Bleeding
Obstruction

Question 13

Management of PUD

Answer 13

Correct the cause
Lifestyle modifications
PPI
Endoscopic measures
- injection, coagulation, clipping, hemp spray, biopsies

Question 14

PPIs for PUD

Answer 14

Generally considered safe
Can cause physiologic hypergastrinemia
- reduce stomach acid and therefore bioavailability of drugs reliant on intragastric acidity to maximize absorption (ketoconazole)
- anti-platelet action of clopidogrel maybe modestly reduced by PPIs

Question 15

Hemospray

Answer 15

Family of hemostatic powders
Consists of small mineral granules that achieve homeostasis
TC-325 binds to actively bleeding sites
Granules absorb all the water from blood or secretions and then swell or adhere to the bleeding - acts as a bandage

Question 16

Embolization for PPD

Answer 16

In case of ulcer bleeding refractory to medical/endoscopic therapy —> embolization

Question 17

Surgical management of PUD

Answer 17

Ulcer-based management - ligation of bleeding vessels or placement and fixation of omentum within the ulcer bed to cover defect and promote healing (Graham patch)

Vagotomy - transects/removes a portion of vagus nerve/branches to decrease gastric acid secretion

Gastric draining - pyloroplastly, gastrojejunostomy

Gastrectomy and reconstruction
- partial gastrectomy removes portion of the stomach containing the ulcer, the gastrin producing and a number of parietal cells
- reconstruction: Billroth I, II and Roux-en-y

Question 18

Causes of oropharyngeal dysphagia

Answer 18

CNS disease - CVA (brainstem, pseudobulbar palsy)
PNS disease - head and neck neoplasms, past radical neck surgery
Muscle disease - muscular atrophy, polymyositis and dermatomyositis, myasthenia Travis
Local disorders - Zenker’s diverticulum
Idiopathic conditions - idiopathic oropharyngeal incoordination

Question 19

Zenker’s diverticulum (ZD)
What is it?
How does it present?
Diagnosis

Answer 19

A sac-like outpouching of mucosa and Submucosa through Killian’s triangle (area of muscular weakness b/w transverse fibres of cricopharyngeus muscle and oblique fibres of lower inferior constrictor muscle

Progressive oropharyngeal dysphagia, regurgitation of undirected food

Diagnosis done by barium swallow and an upper endoscopy under direct vision should be preformed to exclude cancer

Question 20

Dysphagia 2-esophageal

Answer 20

Esophageal:
Mechanical:
- progressive - adenocarcinoma
- chronic - esophageal web, Schatzki’s ring
Motility
- hypomotility - scleroderma
- hypermotility - diffuse esophageal spasms
- both - achalasia

Question 21

Esophageal rings and webs

Answer 21

Rings - concentric (2-5mm) diaphragm of tissue protruding into esophageal lumen, typically in distal, usually mucosal (e.g. Schatzki ring)

Webs - thin (<2mm) eccentric membrane that protrudes into the esophageal lumen, covered with squamous epithelium, anteriorly in the cervical esophagus, causing focal narrowing in postcricoid area

Question 22

Esophageal webs

Answer 22

thin (<2mm) eccentric membrane that protrudes into the esophageal lumen, covered with squamous epithelium, anteriorly in the cervical esophagus, causing focal narrowing in postcricoid area

Question 23

Esophageal rings

Answer 23

concentric (2-5mm) diaphragm of tissue protruding into esophageal lumen, typically in distal, usually mucosal (e.g. Schatzki ring)

Question 24

Types of dysphagia

Answer 24

Oropharyngeal - can’t swallow, coughing, hoarseness
- structural and neuromuscular
- test with Barium swallow evaluation

Esophageal - food gets stuck below eternal notch
- if solids more affected than liquids - structural and do EGD
- if both solids and liquids affected - neuromuscular motility and do monometry (can be primary (achalasia) or secondary)

Question 25

Investigations for dysphagia

Answer 25

Blood work
Radiology - X-rays, Barrie swallow, videofluoroscopy with modified barium swallow, CT, MRI
Esophagogastroduodenoscopy (EGD)
Endoscopic ultrasound (EUS)
Monometry

Question 26

Diffuse esophageal spasm (DES)

Answer 26

• shows normal peristalsis
• interspersed with frequent high pressure non-propagated or “tertiary” waves and multi peaked waves
• chest pain and dysphagia
• barium X-ray shows corkscrew pattern

Etiology - unknown, maybe changes in intrinsic and extrinsic esophageal nerves

Tx - nitrates, CCB, injection of botulinum toxin in LES or distal esophagus

Question 27

Achalasia on Manometry

Answer 27

Loss of peristalsis (no red waves)

Question 28

EUS for cancer

Answer 28

At this time, it is only useful in distinguishing T1 and T2 cancers

Question 29

Squamous Cell Carcinoma of the esophagus

Answer 29

Risk factors include smoking and alcohol consumption
Majority are located in mid-esophagus
Early lesions usually subtle and easily missed on endoscopy