Diseases Of The Upper GI Tract Flashcards
What questions would you ask someone with dysphagia?
Symptoms:
Has he lost any weight? If so how much and over what timescale? Was it deliberate weight loss?
Has he been vomiting and has he noticed any bleeding?
Any change in bowel habit (thinking of melaena)?
Has he had any pain? If so where?
Has he any symptoms of anaemia?
Background:
Has he had any previous investigations, in particular upper GI endoscopies?
Ask for more information about omeprazole: When and why was he started on it?
Has he taken any NSAIDs recently? Any other medications, including OTC drugs?
Has he had any previous abdominal surgery?
Is there a relevant family history?
Lifestyle – smoking and drinking? If so how much and for how long?
What is Barrett’s esophagus?
Barrett’s is a pre-malignant condition and increases the risk of oesophageal adenocarcinoma by about 50 times compared to the general population. The risk of developing cancer is still relatively low (3 per 1000 per year) but increases significantly if dysplasia is present.
Barrett’s metaplasia is a change from the normal squamous epithelium of the oesophagus to columnar epithelium, similar to that normally found in the stomach.
Esophagitis -> metaplasia -> dysplasia -> neoplasia (adenocarcinoma)
Endoscopic surveillance should be performed every 3-5 years
If dysplasia or neoplasia is confirmed then endoscopic mucosal resection or radiofrequency ablation is needed for treatment.
What are you looking for on clinical examination in someone with Barrett’s esophagus?
General observation - Evidence of weight loss, jaundice or pallor
Abdominal examination - Scaphoid abdomen, abdominal tenderness, hepatomegaly, previous scars
Oral inspection - Dry mouth, candida
Neck palpation - Lymphadenopathy, left SCF node = Virchow’s node
What is dysphagia? What are some causes? What are the complications? What is the treatment?
Difficulty swallowing
- Neuromuscular
- Muscular (myasthenia gravies, muscular dystrophy)
- Neurological (PD, multiple sclerosis, stroke)
- Weakened muscles
- Impaired coordination (in elderly) - Narrowing of throat/esophagus
- Throat/esophageal cancer
- Rings/sacs in esophagus
- GORD
Complications:
- Pulmonary aspiration
- Choking
Treatment:
- Muscle exercises
- Change position of neck when eating
- Change diet
- Surgery (if narrowed)
- Tube feeding
What are the differentials for progressive dysphagia? Difficulties swallowing liquids?
Progressive dysphagia for solids is suggestive of a mechanical obstruction or stricture. Causes include oesophageal cancer, peptic strictures or extrinsic compression of the oesophagus.
Neurological causes and achalasia are less likely as Mr Cunliffe has no difficulties swallowing liquids.
What investigations would you request for dysphagia?
The main investigation will be an upper gastrointestinal endoscopy (often referred to as an OGD or simply a gastroscopy). You will also ask for some blood tests.
The upper GI endoscopy is the most important test for making the diagnosis as this will give you direct vision of the oesophagus and stomach and allows a biopsy to be taken of any areas of concern.
He will also need blood tests to look for anaemia, to check his renal function (important for the contrast enhanced CT scan and possible treatments) and liver function tests as a screen for metastases.
While a barium swallow could show the site of a stricture it does not allow biopsy. You expect he will also need cross sectional imaging, most likely a CT scan, for staging.
When would you refer for urgent upper GI endoscopy (gastroscopy)? Non-urgent?
To be performed within 2 weeks if the following are present:
- Dysphagia
- Over 55y of age with weight loss AND any of the following:
- upper abdominal pain
- reflux
- dyspepsia
Non-urgent:
- Hematemesis
What are the components of patient consent for a procedure?
You need to explain the procedure in terms that the patient can understand. Explain the purpose of the procedure and what it will involve, for example where you are examining with the endoscope, and what you might do if you find an abnormality, eg take a biopsy.
You will need to advise him of risks of the procedure including bleeding and perforation, and give him some idea of how common and how serious these risks are.
If he is not confident to go ahead, you will need to advise of any alternatives to undergoing this procedure. You might also need to advise what would happen if he declined to undergo the procedure you are recommending.
Although not part of the consent process you may also ask about sedation (he has come alone) and particular contraindications – for instance: is he on anti-coagulants that have not been stopped, has he starved for the required time period, if he is diabetic has he taken or omitted his usual medication.
You should have mentioned assessment of capacity. It is good practice to confirm the patient’s understanding of the reason for the test. You will read more on the assessment of capacity later.
If Barrett’s metaplasia and a stricture/tumour is found on endoscopy, what is the next investigation?
Contrast CT of chest, abdomen, and pelvis Blood tests (hematology, biochemistry) Biopsy of tumour (analysed by pathologist)
What investigations should be done for someone with new dysphagia?
- Upper GI endoscopy
- Bloods
- ECG
- PFT
- Chest X-ray
- CT thorax/abdo/pelvis
- esophageal ultrasound
- PET
- Laparoscopy
- Cardiopulmonary exercise
What are the treatment options for esophageal cancer?
- Surgery (open, laparoscopic)
- Chemotherapy (neoadjuvant/definitive/palliative)
- Radiotherapy (small cell carcinoma)
- Endoscopic (EMR/ESD)
- Combination
- Palliative (stenting/PEG/PEJ/jejunal feeding/surgical bypass/paracentesis/drugs)
What is the presentation of esophageal cancer?
Dysphagia combined with 1+ alarming symptoms:
- Weight loss
- Anemia
- Anorexia
- Persistent vomiting
What type of muscle is found in the esophagus?
Upper 1/3 = striated muscle
Lower 1/3 = smooth muscle
Middle 1/3 = mixture of smooth + striated muscle
What is odynophagia and when does this symptom present?
Painful swallowing
- Esophageal ulcers
- Tumours
- Fungal infections of the esophagus I.e. esophageal candidiasis (immunocompromised pts- steroids, anti-rejection drugs, HIV) -> tx with oral anti-fungal agents
Describe the storage capacity of the stomach and what enzymes are secreted here and by which cells
Stomach stores 2-4L in the form of chyme (after bolus is churned and undergoes hydrolysis)
Chief cells -> pepsinogen
Parietal cells -> HCl
Mucous cells -> mucin (gastric surfactant)
Pepsinogen + HCl = pepsin (active form) which breaks down proteins
