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Dyspepsia/Indigestion Flashcards

1
Q

Signet ring cells are associated with which type of cancer?

A

Gastric cancer

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2
Q

Erosion vs. ulcer?

A

Erosion is a superficial break within epithelium or mucosal surface. Whereas an ulcer is a deep break through the full thickness of epithelium or mucosal surface.

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3
Q

Is H.pylori gram positive or negative?

A

Gram negative.

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4
Q

Which type of ulcers do peptic ulcers include?

A

Gastric and duodenal.

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5
Q

Are gastric or duodenal ulcers more common?

A

Duodenal

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6
Q

What are the main risk factors for peptic ulcers?

A

H.pylori and NSAIDs

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7
Q

How do NSAIDs cause peptic ulcers?

A

Inhibition of COX-1 reduces protective prostaglandin secretion, causing breakdown of the mucosa.

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8
Q

How does H.pylori cause peptic ulcers?

A

Persistent low-grade inflammation causes breakdown of mucosa.

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9
Q

What are the symptoms of peptic ulcers?

A

Dyspepsia, epigastric pain, heart burn, nausea.

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10
Q

What are the symptoms/signs of a bleeding peptic ulcer?

A

Haematemesis, coffee ground vomit, melaena, iron deficiency anaemia.

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11
Q

What are the symptoms/signs of a perforated peptic ulcer?

A

Acute, severe abdominal pain, guarding and shock.

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12
Q

From the history, how can you distinguish between a gastric and duodenal ulcer?

A

Gastric ulcer pain worsens upon eating, whereas duodenal ulcer pain improves.

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13
Q

What is the main investigation for a peptic ulcer?

A

Upper GI endoscopy.

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14
Q

How would you test for H.pylori infection?

A

Rapid urease test (CLO test) —> presence of urease causes a pH colour change.

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15
Q

How would you treat a H.pylori infection?

A

Eradication therapy: PPI + amoxicillin + clarithromycin/metronidazole

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16
Q

How would you treat peptic ulcers that aren’t associated with H.pylori?

A

Full-dose PPI for 4-8 weeks.

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17
Q

What are the 3 complications of peptic ulcers?

A

Bleeding, perforation and pyloric stenosis.

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18
Q

What are the risk from a perforated peptic ulcer?

A

Peritonitis.

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19
Q

What causes pyloric stenosis?

A

Scarring and strictures of muscle and mucosa.

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20
Q

What are the symptoms of pyloric stenosis?

A

Upper abdominal pain, distension and N+V.

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21
Q

Define achalasia

A

Rare motility disorder affecting the oesophagus, characterised by failure to relax the lower oesophageal sphincter.

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22
Q

What are the types of achalasia?

A

Primary: idiopathic, loss of inhibitory neutrons.
Secondary: increased pressure at lower oesophageal sphincter, preventing relaxation.

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23
Q

What are the 2 main symptoms of achalasia?

A

Dysphasia (solids and liquids).
Regurgitation of undigested food.

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24
Q

What investigations would you do for a patient presenting with achalasia?

A

OGD endoscopy.
Barium swallow (dilated oesophagus and bird beak).
Manometry (sense pressure and constriction).

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25
What is the management for achalasia?
Pneumatic dilation: balloon insertion via endoscope. Peroral endoscopic myotomy (POEM): cutting oesophageal mucosa and dissecting down inner circular muscle layer towards cardia of stomach. Surgical myotomy: cutting muscle fibres of lower oesophageal sphincter without disturbing mucosa (laparoscopic Heller myotomy). Fundoplication also performed to prevent further reflux complication.
26
What is fundoplication?
Wrapping fundus of stomach around lower oesophageal sphincter.
27
What is the main complication of achalasia?
Aspiration pneumonia.
28
What is the epithelium of the oesophagus?
Squamous cell
29
What is the epithelium of the stomach?
Columnar
30
What are the differential diagnoses for heartburn?
GORD, achalasia, eosinophilic oesophagitis, pericarditis, ischaemic heart disease, peptic ulcer disease, oesophageal/gastric cancer.
31
What are the complications of GORD?
Oesophagitis: inflammation of oesophagus. Oesophageal stricture: scarring and narrowing of oesophagus. Barrett’s oesophagus: columnar metaplasia of oesophagus from squamous mucosa.
32
How does H.pylori damage stomach?
It avoids the acidic environment by forcing its way into the gastric mucosa, creating breaks in the mucosa exposing epithelial cells to acid. Also produces ammonia which damages epithelial cells.
33
Treatment of oesophageal strictures?
Balloon dilation via endoscopy or stent.
34
Where can oesophageal cancers metastasise to?
Liver, bone and lung.
35
Describe TNM staging
Used to describe the extent of cancer spread. Tumour size, lymph node involvement, distant metastasis. TX, T0, Tis, T1, T2, T3, T4. NX, N0, N1, N2, N3. MX, M0, M1.
36
Define GORD
Acid from stomach reflexes through lower oesophageal sphincter, irritating the oesophagus.
37
What is the prevalence of GORD?
10-20%
38
What are the complications from GORD?
Erosions, strictures, Barrett’s oesophagus.
39
Name the 2 main risk factors for GORD
High BMI, smoking.
40
Describe the clinical features of GORD
Dyspepsia, heartburn, bloating, regurgitation, epigastric pain, nocturnal cough, hoarse voice, N+V, dysphagia and odynophagia.
41
What are the red flag symptoms for endoscopy referral for reflux?
Dysphagia, new onset dyspepsia (>55), weight loss, upper abdominal pain, treatment resistant dyspepsia, N+V, low Hb, increased platelets, upper abdominal mass.
42
Name 3 investigations for H.pylori
Urea breath test, stool antigen test, rapid urease (CLO) test.
43
What is the management for GORD?
Lifestyle e.g. stop smoking, weight loss, reduce caffeine and alcohol. Antacids: gaviscon, rennie. PPIs: omeprazole, lansoprazole. H2 receptor antagonists: ranitidine. Laparoscopic fundoplication.
44
Describe Barrett’s oesophagus
Metaplasia of distal oesophagus from squamous to columnar epithelium.
45
What causes Barrett’s oesophagus?
Chronic oesophageal damage from prolonged acid reflux, leads to metaplasia.
46
Barrett’s oesophagus is a risk factor for what?
Oesophageal adenocarcinoma.
47
Why can Barrett’s oesophagus sometimes be asymptomatic?
Columnar epithelium doesn’t get irritated by acid.
48
How is Barrett’s oesophagus diagnosed?
OGD endoscopy and biopsy.
49
What is the treatment for Barrett’s oesophagus?
PPIs, ablation treatment during endoscopy.
50
What are the 2 main types of oesophageal cancer?
Squamous cell carcinoma and adenocarcinoma.
51
Which part of the oesophagus does squamous cell carcinoma affect?
Upper and middle
52
Which part of the oesophagus does adenocarcinoma affect?
Lower
53
What are main risk factors for oesophageal squamous cell carcinoma?
Smoking and alcohol.
54
What are the main risk factors for oesophageal adenocarcinoma?
Barrett’s and obesity.
55
What are the clinical features of oesophageal cancer?
Dysphagia, weight loss, decreased appetite, haematemesis, melaena, odynophagia, hoarse voice.
56
What is an important clinical sign of GI cancer?
Virchow’s node.
57
What investigations would you do for suspected oesophageal cancer?
Bloods: FBC, iron studies, U&Es, LTFs, bone profile, clotting screen. OGD endoscopy and biopsy. CT chest/abdomen/pelvis. Abdominal US (liver mets). PET scan. Endoscopic ultrasound.
58
What is the management for oesophageal cancer?
Oesophagectomy. Chemotherapy. Radiotherapy.
59
What is the most common type of oesophageal cancer in UK/US?
Adenocarcinoma
60
When treating dyspepsia, if either a PPI or H.pylori test/treat has failed, what are the next steps?
Other approach tried next.
61
What type of cancer is gastric?
Adenocarcinoma
62
What are the 2 types of gastric cancer?
Intestinal-type and diffuse-type.
63
What is the most common type of gastric adenocarcinoma?
Intestinal-type
64
What is the aetiology of the intestinal-type of gastric cancer?
H.pylori infection causes chronic gastritis, which over time leads to metaplasia, then hyperplasia creating polyps. Dysplasia of polyps leads to adenoma formation (precursor lesion). Adenocarcinoma forms from adenoma.
65
Which type of cells are found in diffuse-type of gastric cancer on histology?
Signet cells
66
Are there precursor lesions with diffuse-type gastric cancer?
No, fibrosis reaction.
67
Which type of gastric cancer has a familial element?
Diffuse-type - CDH1 mutation.
68
What are the risk factors for the development of gastric cancer?
H.pylori, smoking, diet, alcohol and genetics.
69
Describe the symptoms of gastric cancer
Dysphagia, dyspepsia, N+V, haematemesis/melaena, weight loss, decreased appetite, satiety, fatigue.
70
What is the clinical sign of periumbilical metastasis?
Sister Mary Joseph nodule
71
Describe the investigations you would carry out for suspected gastric cancer
Bloods: FBC, iron studies, U&Es, LFTs, bone profile, clotting screen. OGD endoscopy. Endoscopic US. CT chest/abdomen/pelvis. Abdominal US. PET scan.
72
What is the surgical resection of the stomach called?
Gastrectomy
73
What questions would you ask a patient presenting with dysphagia?
Progressive? Constant or intermittent? Solids, liquids or both? GORD symptoms - acid reflux, regurgitation, bloating, epigastric pain? Weight loss? Haematemesis? Melaena? Hoarse voice? Cough?
74
What is the treatment for gastric MALT lymphoma?
H.pylori eradication
75
Patients with achalasia have an increased risk of which oesophageal cancer?
Squamous cell carcinoma.
76
A 73 year old lady presents with dysphagia, regurgitation and halitosis. An upper GI endoscopy is attempted but abandoned due to difficulty in achieving intubation.
Pharyngeal pouch
77
What is the aim of fundoplication?
To strengthen LOS preventing reflux and keeps the GOJ in place below the diaphragm.
78
What is the treatment for H.pylori in a patient with a penicillin allergy?
PPI + clarithromycin + metronidazole
79
What are the adverse side effects of PPIs?
Hyponatraemia and hypomagnasaemia. Osteoporosis/increased risk of fractures. Microscopic colitis Increased risk of C.difficile infections.
80
A 40-year-old man presents with dysphagia. He reports being reasonably well in himself other than an occasional cough. The dysphagia occurs with both liquids and solids. Clinical examination is normal.
Achalasia
81
A 55-year-old woman presents with swallowing difficulties for the past 5 weeks. She has also noticed some double vision.
Myasthenia gravis
82
A 42-year-old haemophiliac who is known to be HIV positive presents with pain on swallowing for the past week. He has been generally unwell for the past 3 months with diarrhoea and weight loss.
Oesophageal candidiasis
83
Describe the guidelines for urgent 2 week wait referral for suspected upper GI cancer
Dysphagia, or Upper GI mass consistent with stomach cancer, or Patient aged >= 55 with weight plus: upper abdominal pain, reflux or dyspepsia.
84
Describe the guidelines for non-urgent referral for suspected upper GI cancer
Haematemesis, or Patients aged >= 55 with: treatment resistant dyspepsia, upper abdominal pain with low Hb, raised platelet count (with N+V, weight loss, reflux or upper abdominal pain), or N+V (with weight loss, ref,I’d, dyspepsia or upper abdominal pain).
85
Define eosinophilic oesophagitis
A chronic immune-mediated disease, characterised by eosinophil-predominant inflammation of the oesophagus. Presents in 30s and 40s, commonly affecting men.
86
Describe the clinical features of eosinophilic oesophagitis
Dysphagia, heartburn, dyspepsia, chest pain.
87
What are the classical features of eosinophilic oesophagitis on endoscopy?
Linear furrows (longitudinal cracks in the oesophageal mucosa), white spots due to eosinophilic abscesses, schatzki rings (narrowing at the lower oesophagus) or multiple circular rings (termed ‘trachealisation’).
88
What is the management for eosinophilic oesophagitis?
PPIs and topical steroids.
89
A 22-year-old man is admitted with severe retrosternal chest pain and recurrent episodes of dysphagia. These occur sporadically and often resolve spontaneously. On examination there are no physical abnormalities and the patient seems well.
Achalasia
90
An obese 53-year-old man presents with symptoms of recurrent retrosternal discomfort and dyspepsia. This is typically worse at night after eating a large meal. On examination there is no physical abnormality to find.
GORD
91
How long should PPIs be stopped for before endoscopy?
2 weeks before
92
Dysphagia, glossitis and iron-deficiency anaemia
Plummer-Vinson syndrome

GI and Surgery (14 decks)

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