Gastroenterology Flashcards
What epithelium lines the oesophagus ?
- Non keratanised stratified squamous epithelium
what plexus controlks the instrinsic peristaltic movement of the oesophagus ?
Enteric plexus : consists of an outer myenteric plexus and inner submucosal plexus
Explain the pathophysiology behind achalasia
- Loss of inhibitory ganglion cells of the myenteric plexus in the distal oesophagus and LOS.
- Leads to a failure of peristalsis and relaxation of the LOS
How does Achalasia present ?
- Dysphagia of BOTH liquids and solids
- Heartburn, unresponsive to Tx
- Regurgitation of undigested food
- Weight loss
- Chest pain
What is the initial Ix for achalasia ?
- Barium swallow -> will show dilated oesophagus with narrowing at LOS (birds beak)
What is the diagnostic investigation for achalasia ?
- Oesophageal manometry
What is pseuodachalasia ?
- Obstruction of the distal oesophagus by something other than destruction of myenteric plexus
- Caused by : malignancy, scleroderma, strictures.
What are the endoscopic treatment options for achalasia ?
- Pneumatic (balloon) dilation
- Intra-sphincteric injection of botulinum toxin (inhibits Ach release, preventing contraction).
- Perioral endoscopic myotomy
What is the surgical treatment options for achalasia ?
Heller cardiomyotomy
What are the medical treament options for achalasia ?
- CCB (nifedipine)
- Long acting nitrates
- They act to reduce lower oesophageal pressure
What kind of malignancy are patients with achalasia for >10yrs at an increased risk of ?
- Squamous cell carcinoma
What factors can exacerbate / worsen Sx of GORD
- Greasy and spicy foods
- Coffee and tea
- Alcohol
- NSAIDs
- Stress
- Smoking
- Obesity
- Hiatus hernia
What are the symptoms of GORD
- > Dyspepsia
- Heartburn
- Acid regurg
- Retorsternal / epigastric pain
- Bloating
- Nocturnal cough
- Hoarse voice
Red flags for 2 wk wait OGD
- Dysphagia (difficulty swallowing) at any age gets an immediate two week wait referral
- Aged over 55 (this is generally the cut-off for urgent versus routine referrals)
- Weight loss
- Upper abdominal pain
- Reflux
- Treatment-resistant dyspepsia
- Nausea and vomiting
- Upper abdominal mass on palpation
- Low haemoglobin (anaemia)
- Raised platelet count
Stepwise management of GORD
- Lifestyle changes
- Reviewing medications (e.g., stop NSAIDs)
- Antacids (e.g., Gaviscon, Pepto-Bismol and Rennie) – short term only
- Proton pump inhibitors (e.g., omeprazole and lansoprazole)
- Histamine H2-receptor antagonists (e.g., famotidine)
- Surgery
Lifestyle changes for GORD
Reduce tea, coffee and alcohol
Weight loss
Avoid smoking
Smaller, lighter meals
Avoid heavy meals before bedtime
Stay upright after meals rather than lying flat
what should be ruled out when treating GORD
- H. pylori -> gram neg aerobic bacteria
H.pylori eradication
- Triple therapy
- PPI (e.g., omeprazole)
Two antibiotics (e.g., amoxicillin and clarithromycin) for 7 days
Complication of GORD
- Barrett’s oesophagus
Epithelial changes in Barrett’s
squamous to columnar epithelium = metaplasia
Management of Barrett’s
- Endoscopic monitoring for progression to adenocarcinoma
- PPI
- Endoscopic ablation (e.g., radiofrequency ablation)
Rare condition causing severe dyspepsia, diarrhoea and peptic ulcers
- Zollinger-Ellison Syndrome
- Duodenal or pancreatic tumour secretes excessive gastrin
- Gastrin = stimulates acid secretion in the stomach
RF for peptic ulcers
-> Disrupting mucus barrier = H.pylori, NSAIDs
-> Increasing stomach acid = stress, alcohol, caffeine, smoking, spicy foods
How do peptic ulcers present ?
- Epigastric pain -> worse on eating with gastric, better after eating with duodenal
- N&V
- Dyspepsia
Signs of UGIB from a peptic ulcer (4)
- Haematemesis
- Melaena
- Hypotension
- tachycardia
Diagnosis of a peptic ulcer
- Endoscopy with a rapid urease test to check for H.pylori
Treatment of peptic ulcer
- Stopping NSAIDs
- Treating H. pylori infections
- Proton pump inhibitors (e.g., lansoprazole or omeprazole)
Repeat endoscopy 4-8 wks later to ensure healing of ulcer
Complications of a peptic ulcer
-> Bleeding
-> Perforation = acute abdominal pain and peritonitis
-> Scaring and strictures = can lead to gastric outlet obstruction = presents with early fullness / upper abdo discomfort / abdo distention and vomiting, particularly after eating
4 causes of an UGIB
- Peptic ulcers (most common)
- Mallory-Weiss tear
- Oesophageal varices
- Stomach cancers
3 presenting features of an UGIB
- Haematemesis
- Coffee ground vomit
- Meleana
What score is used to assess the risk of a pt having an UGIB based on inital presentation ?
Glasgow-Blatchford Bleeding Score
- Haemoglobin (falls in upper GI bleeding)
- Urea (rises in upper GI bleeding)
- Systolic blood pressure
- Heart rate
- Presence of melaena (black, tarry stools)
- Syncope (loss of consciousness)
- Liver disease
- Heart failure
An isolated rise in what suggest an UGIB
UREA
what score is used after endoscopy to estimate the risk of rebledding and mortality in an UGIB
-> Rockall score
- Age
- Features of shock (e.g., tachycardia or hypotension)
- Co-morbidities
- Cause of bleeding (e.g., Mallory-Weiss tear or malignancy)
- Endoscopic findings of recent bleeding (e.g., clots and visible bleeding vessels)
Initial management of UGIB
-> A – ABCDE approach to immediate resuscitation
-> B – Bloods
-> A – Access (ideally 2 x large bore cannula)
-> T – Transfusions are required
-> E – Endoscopy (within 24 hours)
-> D – Drugs (stop anticoagulants and NSAIDs)
what bloods are sent in an UGIB
- Haemoglobin (FBC)
- Urea (U&Es)
- Coagulation (INR and FBC for platelets)
- Liver disease (LFTs)
- Crossmatch 2 units of blood
what additional medications are given if an UGIB is due to suspected oesophageal varcies ?
Terlipressin
Blood spectrum Abx
Features of crohn’s disease
NESTS
-> N – No blood or mucus (PR bleeding is less common).
-> E – Entire gastrointestinal tract affected (from mouth to anus).
-> S – “Skip lesions” on endoscopy.
-> T – Terminal ileum most affected and Transmural (full thickness) inflammation.
-> S – Smoking is a risk factor (don’t set the nest on fire).