Disorders of the Upper GI tract Flashcards
What is the normal function of the oesophagus?
- Deglutition - striated muscle
- UOS (upper oesophageal sphincter) relaxes
- Food enters oesophagus
- Primary peristaltic wave triggered
- LOS relaxes as soon as swallow initiated
- Food into stomach
What are the common oesophageal disorders?
-GORD ( gastro-oesophageal reflux disease)
=Oesophagitis (inflammation)
=Barrett’s oesophagus
=Benign oesophageal stricture
-Oesophageal Motility disorders ( e.g. Achalasia)
-Eosinophilic oesophagitis
-Oesophageal cancer
What are the common symptoms of oesophageal disease?
- Dysphagia (difficulty swallowing, late-stage cancer)
- Odynophagia (painful swallowing)
- Heartburn (acid refluxing often retro sternally)
- Acid regurgitation (in mouth)
- Waterbrash (increased salivation due to discomfort)
What are the less common symptoms of oesophageal disease?
- Chest pain
- Food regurgitation
- Food bolus obstruction
- Globus (sensation that something at back of throat)
- Cough (acid in respiratory system)
- Dysphonia ( altered voice, irritated vocal chords)
What is dysphagia?
- Difficulty in swallowing solids or liquids
- Alarm symptom for immediate evaluation to define the exact cause and initiate appropriate therapy
- Classified as either Oropharyngeal or Oesophageal
Describe Oropharyngeal causes of dysphagia
-Neuromuscular
-Skeletal Muscular Disorders
-Mechanical obstruction (narrowing/ blockage)
-Miscellaneous
=Decreased saliva (medications, radiation, Sjogren syndrome= reduced salivation)
=Alzheimer Disease
=Depression
Describe Oesophageal causes of dysphagia
-Mechanical obstruction
-Motility Disorders
-Miscellaneous
=Diabetes
=Alcoholism
=Gastro-oesophageal reflux
What are the clinical signs of oesophageal disease?
- Dental erosion in GORD
- Weight loss
- Anaemia
- Lymphadenopathy
Describe reflux with transient lower oesophageal relaxations
- More common
- Daytime reflux
- Small or no HH (hiatus hernia, where upper part of stomach slides through diaphragm in chest)
- Often no oesophagitis
Describe reflux with low lower oesophageal sphincter pressures
- Less common (20%) but most severe
- Nocturnal reflux
- Often large hiatus hernia (inflammation)
- More severe oesophagitis
- Barrett’s
What are the typical symptoms of GORD?
- Heartburn (burning discomfort behind the breast bone spreading upwards/ pyrosis)
- Acid regurgitation (effortless, often meal related, postural)
- Waterbrash (hypersalivation secondary to gastro-oesophageal reflux)
How do we investigate oesophageal disease?
-Endoscopy and biopsy
-Barium swallow
-Oesophageal function tests (Manometry, pH and Impedence monitoring= detect material refluxing into oesophagus that isn’t acidic)
=for motility pattern
=measure exposure of acid over 24hrs
What investigations are used if suspicion of cancer?
- Urgent upper GI endoscopy
- CT
- CT-PET (spread)
- Endoscopic ultrasound (staging)
What is reflux oesophagitis?
- Result of gastro oesophageal reflux
- If acid stays in oesophagus for long enough= linear erosions
- Grade A to D (depending on circumference and severity)
Describe Barrett’s Oesophagus
-Specialised Intestinal metaplasia in the lower oesophagus
-Commonest in obese men >50
-Often asymptomatic
-Premalignant
=low grade dysplasia
=high grade dysplasia
=adenocarcinoma
-Approx. 0.3% p.a (ie 1/300pt years)
-Surveillance vs. Ablation
-Long term Tx with proton pump inhibitors (omeprazole)
What are the complications of GORD?
- (Oesophagitis)
- Peptic stricture (benign narrowing of oesophagus)
- Barrett’s oesophagus
- Adenocarcinoma
What is the treatment for GORD?
- Lifestyle measures (smoking, alcohol, diet, weight reduction)
- Mechanical (posture, clothing, elevate bed-head)
- Antacids
- Acid suppression (PPIs-omeprazole , H2RA-ranitidine)
- Surgical- fundoplication
Describe Achalasia
- Failure of the LOS relaxation
- Absence of peristalsis
- Hypertonic LOS
- Rat-tailed effect
- Incidence 1/100,000
- Degenerative lesion of oesophageal innervation
- Presents with dysphagia to liquids and solids, weight loss, chest pain
- Endoscopic appearances usually normal (sometimes dilation, absent peristalsis and pooling of fluid)
- Can progress to oesophageal dilatation and respiratory complications
- BoTox (paralyse), Endoscopic Dilatation (risk of perforation), Surgical myotomy (cut sphincter), POEM (knife through layers, clips in incision)
Describe Eosinophilic oesophagitis
-Common presentation with Food bolus obstruction, dysphagia
-Younger age, M>F, prevalence 50/100,000
-History of atopy (asthma, hay fever, food allergies)
-Endoscopy - furrows, rings, exudates, strictures
-Biopsy for diagnosis ( >15 eosinophils /pof)
-Treatment
=Diet – elimination (egg, wheat, milk, nuts, soya, fish)
=Drugs – PPI, topical steroids ( budesonide fluticazone)
=Dilatation – for strictures
-Natural history/course uncertain
=first described1993, 15X rise in prevalence since
What is an oesophageal stricture and what are the causes?
-Narrowing of the gullet
-Benign
=GORD up to 10%
=Barrett’s
=Extrinsic compression (mediastinum/ lung)
=Post-radiotherapy
=Anastomotic ( following surgery / oesophagectomy)
=Rings and webs
=Corrosive ( accidental or suicidal ingestion)
-Malignant
=Oesophageal cancer
How do we treat benign strictures?
-Proton pump inhibitors (e.g. omeprazole) if not severe and due to inflammation
-Dilatation
–Push dilators
=Celestin gradual dilators up to 18mm
=Savary-Gillard polyvinyl dilators
Describe oesophageal adenocarcinoma
- Lower third oesophagus
- Younger
- Reflux (Barrett’s)
- Obesity
- More common
- Increasing
Describe oesophageal squamous cell carcinoma
- Mid/upper oesophagus
- Older
- Smoking
- Alcohol
- Less common
- Declining
Describe staging and treatment of oesophageal cancer
- TNM system of staging ( T=tumour N=Nodes M= metastases)
- Patient deemed fit for surgery and had preoperative chemotherapy followed by surgery.
- Confirmed T3N1 on excised specimen.
- 5-y survival 5-10% increased to 20-30% after chemotherapy /surgery
What are the palliation aims for malignant strictures?
- 2/3rds of tumours
- To relieve the symptoms without necessarily altering the course of the disease or prolonging life if curative treatment not possible.
- The emphasis is to improve quality of life.
- Stents
How may a motility problem present?
- Intermittent dysphagia but progressive
- Normal endoscopy
How do you treat eosinophilic oesophagitis?
Topical steroids= orodispersible Budesonide (Jorvesa)
What are the main hints in the diagnosis of dysphagia?
- In the elderly think of neurological causes particularly if intermittent / long standing or sinister causes (oesophageal Ca) if new, progressive with regurgitation and weight loss.
- Oesophageal Ca presents with progressive dysphagia for solids first then liquids.
- In the younger think of dysmotility (achalasia, or 2ndary to acid reflux,).
- In dysmotility syndromes dysphagia for liquids is as bad as for solids.
- Young patients with food bolus obstruction: think of eosinophilic oesophagitis.
- If hoarse voice think of ENT causes, advanced tumour
- If regurgitation of food or previous days think of pharyngeal pouch (fills up with food= compression, empties pouch)
What bacteria causes gastric ulcers?
- Helicobacter pylori
- Gastric pits, interferes with acid secretion, inflammatory cell recruitment
- Alters balance between hyper acidity and mucosal defence
Describe diagnosis of H.pylori
-Non-invasive =Breath test (C-13 labelled urea, bicarbonate formed and breathed out) =Antibody measurement (serology) =Stool antigen test -Invasive =Culture =Histology =CLO test (petri dish with pH indicator with urea, split to ammonia so yellow to red)
What is the first line therapy for H.pylori?
90% efficacy
Lansoprazole 30mg twice daily (or omeprazole 20 mg BD)
Clarithromycin 500mg twice dailyMetronidazole 400mg twice daily all three for 1 week only
What is the second line therapy for H.pylori?
85-90%
Lansoprazole 30mg twice daily(or omeprazole 20 mg BD)
Clarithromycin 500mg twice dailyAmoxycillin 1g twice daily all three for 1 week only
Note: For patients allergic to penicillin, repeat 1st line regimen as 2nd line Eradication is confirmed by a C13 breath test 6-12 weeks later
