Gastric Disease Flashcards
An older obese man comes in who is a heavy smoker and drinker. He is complaining of a retrosternal burning chest pain which is made worse after eating, lying down, bending over or straining.
He also complains of odynophagia & a cough that won’t go.
What is wrong with him and what do you need to check for?
GORD (LOS relaxation more frequent)
🚩 dysphagia, weight loss, early satiety, malaise, loss appetite - malignancy (oesophageal/ gastric)
- peptic ulcers
- oesophageal motility disorders
- oesophagitis
- coronary artery disease
- biliary colic
- Barrett’s
- strictures
- aspiration pneumonia
After endoscopy a patient has been told they have reflux oesophagitis with mucosal breaks extending between the tops of 2 mucosal folds but involves less than 75% of the circumference. What grade is this on the LA classification of reflux. What are the other grades?
Grace C
A - break(s) <5mm
B - break(s) >5mm
D - break(s) involves 75%+ oesophageal circumference
What investigations are required for GORD?
Most patients clinical diagnosis -> trial PPI
If dysphagia or >55yrs with weight loss + upper abdo pain/ dyspepsia/ reflux = urgent endoscopy
Or new symptoms particularly older, worsening despite PPI
- 24hr PH monitoring (time acid is present oesophagus & correlation w symptoms = DeMeester score) if medical treatment fails and surgery considered + oesophageal manometery to exclude dysmotility
A patient has recently been diagnosed with GORD and has stopped drinking coffee and alcohol but still is suffering what else can you suggest?
Other conservative: fatty food, weight loss, smoking cessation, spicy food
PPI (+ lifestyle= first line) life long
When would surgery be an option for GORD? What are the surgeries? What are the side effects?
- failure/ partial response medical therapy
- patient preference
- complications e.g. resp recurrent pneumonia/ bronchiectasis
Not with:
Severe oesophagitis
Caution motility disorders
- fundoplication
Gastrooesophageal junction & hiatus dissected
Fundus wrapped around GOJ ->
Physiological LOS
(Posterior 360 Nissen’s approach or partial anterior)
:(( dysphagia, bloating, inability vomit - often settle 6 weeks - stretta radio-frequency energy to thicken LOS
- Linxa magnetic beads inserted around LOS
Immediately after surgery for severe oesophagitis a patient reports: difficulty belching, increases saliva & abdo pain. What is the likely cause of the symptoms?
The Nissan fundoplication procedure wrapped fundus around GOJ too tightly
Define a hiatus hernia
How common are they?
What are the risk factors?
Protrusion of an organ from the abdo cavity into the thorax through the oesophageal hiatus (wall of cavity that contains it)
Usually the stomach (rarer: SB, colon, Mesentery)
Extremely common, 1/3 >50yrs - majority asymptomatic
RFS:
Older, pregnancy, obesity, ascites
How could you classify hiatus hernias?
- sliding HH (80%)
GOJ, abdo part of oesophagus & often cardia stomach SLIDE UPWARD through diaphragmatic hiatus -> thorax - rolling/ para-oesophageal hernia (20%)
Upward movement gastric fundus -> lies along GOJ -> bubble of stomach in thorax = true hernia with peritoneal sac
Can also be mixed sliding & rolling
How can you differentiate someone with GORD from someone with a hiatus hernia?
What is a rare but serious presentation of a HH, how would you manage it?
If the patient has bleeding or anaemia what does it suggest?
What other symptoms could you look for and what do they show?
HH: Worse when lying flat, treatment won’t work, more severe
Vomiting & weight loss - gastric outflow blocked - early satiety/ vomiting & nutritional failure -> transfer to nearest oesophago- gastric unit
Ulceration of oesophagus
Hiccups or palpitations - sufficient size HH -> irritation to diaphragm or pericardial sac
Dysphagia - oesophageal strictures or rarely incarceration
Bowel sounds in chest - large HH
What are some important differentials for hiatus hernias?
- cardiac chest pain
- gastric or pancreatic cancer (gastric outlet obstruction, early satiety, weight loss)
- GORD
What’s the gold standard investigation for suspected hiatus hernias? How else may they be diagnosed? If there are symptoms of gastric outflow obstruction or weight loss what investigations are mandatory?
- oesophagogastroduodenoscopy (OGD) shows upward displacement of GOJ/ the z line
- diagnosed incidentally on CT/ MR
- contrast swallow used less commonly
- urgent Ct thorax + abdomen
A patient diagnosed with a hiatus hernia comes in complaining that the PPIs she’s been given aren’t working and wants surgery. What might you suggest before surgery is done?
PPIs first line - check she is taking them in the morning before food or drugs binding site internalised & ineffective
Lifestyle modification: weight loss, low fat/ earlier/ smaller meals, sleeping more pillows, smoking cessation/ reduce alcohol (inhibit LOS function)
What scenarios with a hiatus hernia would you offer surgery? What does surgery involve? How successful is it and what are potential complications?
- remain synyompatic despite max medical therapy
- increased risk strangulation/ volvulus (rolling/ mixed/ other abdo viscera)
- nutritional failure
(Suspected obstruction/ strangulation/ stomach volvulus - NG tube decompression prior surgery)
Two aspects:
- cruroplasty hernia reduced from thorax into abdo & hiatus reapproximated to appropriate size (may require mesh)
- fundoplication fundus wrapped LOS & stitched
Success rate >90% good Lt outcome
Complications: recurrence, abdo bloating, dysphagia (majority settles), fundal necrosis (emergency major gastric resection)
What is Bourchardt’s triad? What does it suggest?
Severe epigastric pain
Retching without vomiting
Inability to pass an NG tube
Suggests: gastric volvulus -> obstruction of gastric passage & tissue necrosis
✅ surgical intervention
What is a peptic ulcer? Where can they form? What presents earlier? How do they present?
A break in the lining of the GI tract extending through to the muscular layer (muscularis mucosae)of bowel wall - endoscopic diagnosis
Can form anywhere in tract but most often
- lesser curvature proximal stomach
- first part duodenum
Duodenal classically present 20yrs earlier
Presentation:
70% asymptomatic
Epigastric/ retrosternal pain (gastric- worse eating, duodenal 2/3hrs later/ alleviated)
Nausea
Bloating Post-prandial discomfit
Early satiety
Complications: bleeding, perforation, gastric outlet obstruction
How are peptic ulcers caused? What are the risk factors?
Imbalance between protective defence mechanisms (surface mucous secretion + HCO3 - ions) & damaging mechanisms
Most often thorough Helicobacter Pylori (duodenal 90%/ gastric 70% -> cytokines & interleukin driven inflammatory response -> H2 -> acid)
OR NSAID use (❌PGs-> reduced glycoproteins/ mucous/ phospholipids)
RFS:
H.Pylori, prolonged NSAIDS, corticosteroids, gastric bypass surgery, physiological stress (severe burns curlings ulcers), head trauma (Cushing’s ulcer),zolinger- Ellison syndrome
According to NICE when should a referral for an urgent upper oesophago-gastro-duodenoscopy for suspected peptic ulcers be done? What are the differentials?
New onset dysphagia
> 55yrs + weight loss + upper abdo pain/ reflux/ dyspepsia
New onset dyspepsia not responding PPIs
-> biopsies + rapid urease test -> PPI -> repeat endoscopy
DD:
GORD, gallstones, gastric malignancy, pancreatitis
What is Zollinger-Ellison syndrome?
Triad: severe peptic ulcer disease, gastric acid hypersecretion, gastrinoma
Fasting gastrin >1000 pg/ml
1/3 present as multiple endocrine neoplasia type 1 syndrome (pancreas/ pituitary/ parathyroid tumours)
Most patients, especially younger with suspected peptic ulcer disease should undergo non-invasive H.pylori testing, how can this be done?
Prior to tests stop current meds 2weeks
- C-13 urea breath test
- serum ABs
- stool antigen test
Positive -> eradication therapy
Describe treatment for peptic ulcer disease
Conservative:
Smoking cessation, weight loss, reduction alcohol, reduce NSAIDs
Medical:
PPI 4-8weeks -> reassessed -> positive triple therapy (PPI + amoxicillin+ clarythromycin/ metronidazole 7 days)
If fails: urgent OGD
Surgery:
Rare except emergency or ZES
Severe/ relapsing - partial gastrectomy/ selective vagotomy
How common are gastric cancers? What type of cancers are they? Risk factors?
Fith most common cancer globally
Second highest cancer related death
> 90% adenocarcinomas
CT, lymphoid, neuroendocrine
Risk factors: Male, H.pylori (6X), older, smoking, alcohol, salt, FH, pernicious anaemia, low fibre, chronic gastritis
How does gastric cancer normally present? When would you send someone for an urgent OGD?
Often vague & non-specific
Often presenting advanced
Dyspepsia Dysphagia Early satiety Vomiting Melena
Epigastric mass
Non-specific cancer:
Anorexia, weight loss, anaemia
Urgent OGD:
New dysphagia
OR >55yrs + weight loss + upper abdo pain/ reflux/ dyspepsia
How would you investigate gastric cancer?
Any clinical features (haematemesis, melena) - urgent routine bloods (FBC, LFTs)
Primary investigation - urgent upper GI endoscopy + biopsies
Histology, CLO test, HER2/neu protein expression
CT scan can show thickening not visualisation/ biopsy
Staging:
CT chest-abdo-pelvis + staging laparoscopy (TNM)
How do you manage gastric cancer?
Discussed at a specialist upper GI cancer MDT
Nutritional status assessment - reviewed dietician
Many pre/ post treatment NG tube OR RIG tube
Curative:
Peri-operative chemoT (3 cycles neoadjuvant + 3 adjuvant)
Proximal - total gastrectomy
Distal (antrum/ pylorus) - subtotal gastrectomy
-> Roux-en-Y reconstruction (oesophagus anastomosed SB)
Early T1a - endoscopic mucosal resection (EMR)
Palliative (most): Chemotherapy Stunting Surgery (distal gastrectomy or bypass surgery) 10yr survival 15%
