Gastro Flashcards
What are the anatomical factors predisposing to GORD?
Hiatus hernia
What are the physiological factors pre-disposing to GORD?
Raised IAP (pregnancy/obesity) Large meals, eaten late at night Smoking High caffeinated drink intake High fatty food intake Drugs (anticholinergics, nitrates, tricyclics, calcium channel inhibitors)
What is an oesophageal hiatus?
An oval aperture in the right crus of the diaphragm at T10
The oesophagus, vagal nerve trunks, oesophageal branches of the left gastric vessels and lymphatics pass through it
What are hiatus hernia?
hernia allowing Allow part of the stomach into the thoracic cavity
What are the two types of hiatus herniae?
Sliding hiatus hernia
Para-oesophageal / rolling hernia
What happens in a sliding hiatus hernia?
The gastro-oesophageal junction slides through the hiatus to lie above the diaphragm
This occurs in 30% adults >50 and is usually of no significance, however symptoms may occur due to associated reflux
What is a para-oesophageal / rolling hernia?
A small part of the fundus rolls up through the hernia alongside the oesophagus, but the sphincter remains competent below the diaphragm
Very occasionally tis can present with severe pain, requiring surgical intervention for gastric volvulus / strangulation
What is dyspepsia?
Chronic upper abdominal pain / discomfort
What are the three different types of dyspepsia?
Reflux type (heartburn and regurgitation aka GORD) Ulcer type (epigastric pain) Dysmotility type (bloating and nausea)
What are the major features of dyspepsia?
Heartburn / indigestion
worse on bending/lying down, when drinking hot liquids or alcohol
Relieved by antacids
Regurgitation of food/acid
Passive process, more common when ending/lying. Can aspirate
Waterbrash
Odynophagia
How is GORD diagnosed?
Clinically
What are the red flag symptoms for GORD?
ALARM 55 Anaemia Loss of weight Anorexia Recent onset, progressive symptoms Melaena or haematemesis Swallowing difficulties >55 years of age
What further investigations can be done for GORD?
Treat empirically with PPI but: Barium swallow (if suspecting hiatus hernia) 24 hours luminal pH monitoring and manometry to diagnose GORD if endoscopy is normal
What is the management for GORD?
Lifestyle:
Encourage weight loss and smoking cessation
Eat small/regular meals >3h before bed and avoid hot drinks/alcohol
Raise the head of the bed at night
Avoid drugs that exacerbate the condition (above) or those that damage the mucosa (NSAIDs, potassium salts)
What medications can be used for GORD?
Antacids = mgOH2 +/- alginates = gaviscon
H2RAs (ranitidine) and then PPIs are used in a stepwise approach if antacids/alginates do not provide relief
Prokinetic drugs: metoclopramide/domperidone to promote gastric emptying
What is the surgical management of GORD?
Surgery should never be performed for hiatus hernia alone - only if symptoms are severe, refractory to medical management and there is pH monitoring evidence of acid reflux
Nissen fundoplication: gastric fundus wrapped around the oesophagus and stitched in place, so that when teh fundus contracts it creates a sphincter
What are the possible long term complications of GORD?
Oesophagitis/ulcers
Benign strictures
Barratt’s oesophagus / oesophageal adenocarcinoma
How does Barrett’s oesophagus occur?
In patients with long standing reflux, the normal stratified squamous epithelium of the oesophagus undergoes metaplasia to glandular columnar epithelium
How is Barrett’s oesophagus diagnosed?
Upper GI endoscopy, where if present it will be visible and biopsies taken
What is the management of Barrett’s oesophagus?
Regular endoscopic surveillance with biopsies to look for dysplasia / carcinoma in situ, which can be treated with endoscopic resection
What is dysphagia?
Odynophagia?
Dysphagia = difficulty swallowing
Odynophagia = pain upon swallowing
What are the common causes of dysphagia?
Diseases of the mouth / tongue: e.g. tonsillitis
Neuromuscular disorders: MG, MND, bulbar palsy
Oesophageal motility disorders: achalasia, scleroderma, DM
Extrinsic pressure: goitre, lymph nodes, enlarged left atrium
Intrinsic lesions: FB, benign/malignant stricture, pharyngeal pouch, oesophageal web (Plummer vinson syndrome
What are the two types of dysphagia?
Orophayngeal
Oesophageal
What is oropharyngeal dysphagia
What is it caused by?
Orophayngeal: difficulty initiating swallowing +/- choking / aspiration
Caused by neurological disease
Ix with neurological examination and video fluoroscopic swallowing assessment
What is oesophageal dysphagia?
Food sticks after swallowing +/- regurgitation Causes: Dysmotility e.g. achalasia Stricture: benign or malignant Oesophagitis (reflux, candidiasis) Pharyngeal pouch
Investigate with barium swallow, endoscopy and biopsy
What is Plummer-Vinson syndrome?
Triad of dysphagia + koilonychia + glossitis (IDA signs)
Pre-malignant condition due to hyperkeratinisation of the oesophagus causing an oesophageal web
Treatment is with iron and dilation of the web via OGD
What are the symptoms of oesophageal malignancy?
Progressive dysphagia, starting with solids and progressing to liquids and eventually difficulty swallowing saliva
Weight loss and anorexia
Retrosternal chest pain
Coughing/aspiration
Occasional lymphadenopathy
what kind of cancers are most oesophageal malignancies?
Mainly adenocarcinomas (lower 1/3) some SCC (upper 2/3)
What are the risk factors for adenocarcinoma?
GORD Barrett's oesophagus smoking achalasia obesity
Who tends to get oesophageal SCC?
Heavy smoking and drinking males
What is the prognosis like for adenocarcinoma / SCC?
Poor
SCC has a slightly better prognosis as it is more responsive to radiotherapy
mets are common at diagnosis: in the liver/lungs/bone
How is staging of oesophageal malignancy done?
Staging/Grading:
OGD including trans-oesophageal USS and biopsy
CT of the thorax/abdomen
PET to assess for metastatic disease
Laparoscopy to exclude peritoneal mets prior to resection
What is the management of oesophageal malignancy
Operable disease is best managed by surgical resection.
In addition to surgical resection many patients will be treated with adjuvant chemotherapy.
Palliation: can involve oesophageal stunting to restore swallowing
What is the presentation of achalasia?
Dysphagia, regurgitation, substernal cramps, nocturnal cough and weight loss, often in the third decade
Describe why achalasia occurs
Lack of co-ordinated muscle contraction and relaxation at the lower end of the oesophagus, leading to retention of the food bolus
bird beak appearance on barium studies
How is diagnosis of achalasia done?
Barium swallow
OGD shows dilated oesophagus with a pond of stagnant food/fluid and finally oesophageal manometry to show increased lower oesophageal sphincter
What is the management of achalasia?
Conservative/lifestyle: chew food well, always eat upright, drink lots with meals etc
BOTOX: temporary relief
Endoscopic balloon dilation
Heller’s cardiomyotomy - muscles of the cardia are divided
Describe the aetiology of peptic ulcer disease
Helicobacter pylori infection (90% duodenal/70% gastric ulcers)
NSAIDs
Zollinger-Ellison syndrome
Other: smoking, coffee consumption and hepatic/renal failure
What are the symptoms of peptic ulcer disease?
Epigastric pain, related to food intake, relieved by antacids
Nausea
anorexia and weight loss
Haematemesis / meleana
What are the investigations for peptic ulcer disease?
Urgent oesophago-gastro-duodenoscopy (OGD) if fit ALARM 55
If resolves on antacid / GORD no investigations
If persist, investigate for H pylori
If previous ulcer, assume H.Pylori infection and eradicate
How are patients investigated for H.Pylori?
C13 urea breath test –> 13Co2
Stool test
Patient should not take antibiotic drugs for 4 weeks and PPIs for 2 weeks before testing as these can cause a false negatives
Which are more common , gastric or duodenal ulcers?
Duodenal (4x commoner)
Where do duodenal ulcers tend to occur?
When does pain occur?
90% within 2cm of the pylorus
Pain at night and before meals, relieved by eating
Where do gastric ulcers occur?
When does pain occur?
Mainly on the lesser curve of the stomach
Pain worse on eating and relieved by antacids
How does HPylori cause peptic ulceration?
Produces gastritis + activation of inflammatory infiltrate
Increased acid secretion in the presence of H.Pylori and abnormal mucus production - leading to epithelial damage
How does smoking cause peptic ulceration?
Impairs gastric mucosal healing
Nicotine increases acid secretion
How do NSAIDs cause peptic ulceration?
NSAIDs inhibit COX which have anti-inflammatory properties as COX-2 isoform normally causes inflammatory prostaglandin synthesis
What is the management for peptic ulceration?
If no ALARM55
Stop smoking and avoid food that worsen symptoms
Medications: PPI/H2RA to reduce acid secretion
Stop NSAIDs if possible
Check H pylori and eradicate if present
How is H.Pylori treated?
TRIPLE THERAPY:
PPI + antibiotics for 7 days:
Omeprazole + clarithromycin + amoxicillin
Metronidazole can be used in penicillin allergic patients
What surgery is done for peptic ulceration?
Vagotomy - severing of vagus nerve to reduce acid production
Vagotomy + pyloroplasty
Gastrectomy: may be required
What are the causes of upper GI bleeding?
Peptic ulceration (40%) Gastroduodenal erosions (15%) Oesophagitis (15%) Mallory-Weiss syndrome (tears at GO junction due to violent vomiting 15%) Varices (10%) Upper GI malignancy (1%)
What are the symptoms of upper GI bleeds?
Haematemesis
Meleaena
Haematochezia
Abdominal pain
Chronic GI blood loss –> signs of iron-deficient anaemia
What is the management of GI haemorrhage?
Manage as per haemorrhagic shock
Transfuse to keep Hb >8
Endoscopy within 4 hours
IV omeprazole to reduce risk of rebleed: 80mg stat then 8mg/hr
Definitive surgery or angiographic embolisation if:
bleeding recurs after endoscopy
persistent despite endoscopic treatment
bleeding is torrential
Angiographic embolisation if unfit for laparotomy
How should haemorrhagic shock be scored?
Glasgow Blatchford:
SBP, pulse, Hb, blood urea
Scores >6 = mortality 50% so urgent intervention
What are the risk factors of gastric cancer?
H.Pylori infection leading to metaplasia
High salt/nitrate diet
Smoking
Genetic: blood group A / HNPCC / Japanese heritage
Pernicious anaemia
Adenomatous polyps
Low S/E status
What are the symptoms of gastric cancer?
Epigastric pain as with gastric peptic ulcer
Nausea and vomiting (vomiting is frequent if the tumour is near the fundus)
Dysphagia (if tumour is near fundus)
Anorexia/weight loss
What are the signs of gastric cancer?
Palpable epigastric mass (50%)
Large left supraclavicular node (Virchow’s)
Hepatomegaly, jaundice and ascites
Acanthosis nigricans
What investigations can be done for gastric cancer?
OGD and multiple ulcer edge biopsy
Endoscopic USS and CT for staging
Staging laparoscopy for locally advanced tumours if no other metastases are detected
Who does gastric cancer tend to affect?
50-70 y/o
Especially in Japanese populations
What kind of cancers are most gastric cancers?
Adenocarcinomas, occurring in the antrum
What are the appearances of gastric cancer?
Polypoids / ulcerating lesions with rolled edges
Leather bottle stomach
How do mets of gastric cancers occur?
Direct invasion of abdominal viscera, lymphatic and then to the liver by portal dissemination
Transcoelomic spread may cause peritoneal seedings, including bilateral ovarian Krunkenberg tumours
What are the more rare types of gastric cancers?
Stromal tumours (leiomyomas / leiomyosarcomas) Arise from interstitial cells of Cajal usually slow growing/benign
What are the management options for gastric cancers?
Partial gastrectomy for tumours in the distal 2/3rd of stomach, or total gastrectomy, with extensive lymphatic clearance
Combination chemotherapy can increase survival in advanced disease
Endoscopic mucosal resection can be used for tumours confined to the mucosa
Stenting of pylorus can be palliative to relieve gastric outlet obstruction in patients with pyloric tumours
Wide local excision for stomal tumours
What are the complications of gastrectomy?
Chronic diarrhoea/vomiting Dumping syndrome (third space fluid shifts due to foods with high osmotic potential being dumped in jej)
Bacterial overgrowth with malabsorption
Anaemia (Iron / B12 deficiency)
Osteomalacia
What is the prognosis for gastric cancer?
<10% 5 year survival
<20% for those undergoing radical surgery
What is diarrhoea?
3 loose/watery stools per day
Acute: <14 days
Chronic >14 days
What are the causes of diarrhoea?
Gastroenteritis
Diverticulitis
Antibiotic therapy
Constipation causing overflow
What defines traveller’s diarrhoea?
At least 3+ watery stools per day plus 1 of: Abdominal cramps Fever N+V Bloody stool
What is the usual cause of traveller’s diarrhoea?
E.coli
What are the causes of food poisoning?
Staph A or Clostridium perfringens
What are the features of C diff infection?
Diarrhoea
Abdo pain
Increased WBC count
What are the risk factors for C diff?
Clindamycin
2nd/3rd gen cephalosporins
PPI’s
What is the treatment for C diff?
1st line: oral metronidazole 10-14 days
2nd line: oral vancomycin
Life threatening: Oral Vanc and IV metronidazole
What is the presentation of malabsorption
Diarrhoea
decreased weight
lethargy
Anaemia, bleeding disorders, oedema, osteomalacia, neuropathy
What are the causes of malabsorption?
Common:
Coeliac
Chronic pancreatitis
Chron’s
rare: BILE: obstruction
pancreatic insufficiency (CF or cancer)
Bacterial overgrowth
infection
What investigations can be done for malabsorption?
Bloods: FBC, U+E, LFT, CRP Iron, B12/folate Ca, Mg, Phosphate Lipids TFT
Coeliac Serology
Stool studies: MC&S, OCP, C.diff toxin, elastase (pancreatitis), calprotectin
Endoscopy:
OGD+duodenal biopsy - coeliac
Colonoscopy + biopsy - Chron’s
ERCP - pancreatitis/biliary obstruction
Why does coeliac disease occur?
Inflammation of jejunal mucosa in response to gluten
Biopsy will show flattened mucosa due to decreased villi
Crypt hyperplasia
increased intraepithelial lymphocytes
What is the presentation of coeliac disease?
Asymptomatic
IDA, decreased weight, fatigue
Diarrhoea, abdo pain, bloating, vomiting
Dermatitis herpetiformis
What investigations are done for coeliac?
FBC, clotting, bone profile
Antibodies: EMA and TTG
Duodenal biopsy = gold standard
What is the management for coeliac disease?
Lifelong gluten free diet
What are the symptoms of IBS?
6 months of:
Abdominal pain
Bloating
Change in bowel habit
+ve diagnosis made if:
abdo pain - relieved by defecation, associated with change in bowel habit
other symptoms: altered stool passage - straining, urgerny, mucus
What red flags should be excluded in IBS?
weight loss
rectal bleeding
FH of bowel cancer
>60 years
What investigations can be done for IBS?
Examination - anaemia or mass
Coeliac screen - CRP/ESR/TTG/EMA aabs
What is the management of IBS?
Lifestyle
Exercise
Diet - FODMAP
Regular mealtimes, water, decreased caffeine and alcohol
Diarrhoea: loperamide
Constipation: laxatives
1st line - antispasmodic for pain
Mebeverine
+/- diarrhoea/constipation meds
2nd line - low dose/TCA
What is the management of bleeding oesophageal varices?
A-E correct clotting: FFP, vitamin K vasoactive agents: terlipressin prophylactic antibiotics: Quinolones are typically used
endoscopy: endoscopic variceal band ligation is superior to endoscopic sclerotherapy. NICE recommend band ligation
Sengstaken-Blakemore tube if uncontrolled haemorrhage
Transjugular Intrahepatic Portosystemic Shunt (TIPSS) if above measures fail
connects the hepatic vein to the portal vein
What is the prophylactic management of variceal haemorrhage?
propranolol
endoscopic variceal band ligation (EVL) is superior to endoscopic sclerotherapy. Proton pump inhibitor cover is given to prevent EVL-induced ulceration.
