Gastroenterology: Dysphagia, HRS

Question 1

What causes Oesophageal candidiasis?

Answer 1

There may be a history of HIV or other risk factors such as steroid inhaler use

Question 2

What are Pharyngeal Pouches?

Answer 2

• Represents a posteromedial herniation between thyropharyngeus and cricopharyngeus muscles
• Usually not seen but if large then a midline lump in the neck that gurgles on palpation
• More common in older men

Question 3

What are symptoms of Pharyngeal Pouches?

Answer 3

• Dysphagia
• Regurgitation
• Aspiration
• Chronic cough
• Halitosis may occasionally be seen

Question 4

How does Systemic Sclerosis present with dysphagia?

Answer 4

• As well as oesophageal dysmotility the lower oesophageal sphincter (LES) pressure is decreased.
• This contrasts to achalasia where the LES pressure is increased
• Features of CREST syndrome may be present, namely Calcinosis, Raynaud’s phenomenon, Esophageal dysmotility, Sclerodactyly, Telangiectasia

Question 5

How does Myasthenia Gravis present with dysphagia?

Answer 5

• Other symptoms may include extraocular muscle weakness or ptosis
• Dysphagia with liquids as well as solids

Question 6

How does Globus Hystericus present with Dysphagia?

Answer 6

Globus hystericus

• There may be a history of anxiety
• Symptoms are often intermittent and relieved by swallowing
• Usually painless - the presence of pain should warrant further investigation for organic causes

Question 7

What are causes of Extrinsic Dysphagia?

Answer 7

• Mediastinal masses
• Cervical spondylosis

Question 8

What are causes of Oesophageal Wall dysphagia?

Answer 8

• Achalasia
• Diffuse oesophageal spasm
• Hypertensive lower oesophageal sphincter

Question 9

What are causes of Intrinsic Wall Dysphagia?

Answer 9

• Tumours
• Strictures
• Oesophageal web
• Schatzki rings

Question 10

What are causes of Neurological Dysphagia?

Answer 10

• CVA
• Parkinson’s disease
• Multiple Sclerosis
• Brainstem pathology
• Myasthenia Gravis

Question 11

What is Budd-Chiari syndrome?

Answer 11

Hepatic vein thrombosis

• usually seen in the context of underlying haematological disease or another procoagulant condition.

Question 12

How does Hepatorenal Syndrome Occur?

Answer 12

• Vasoactive mediators cause splanchnic vasodilation which in turn reduces the systemic vascular resistance.
• This results in ‘underfilling’ of the kidneys.
• This is sensed by the juxtaglomerular apparatus which then activates RAAS, causing renal vasoconstriction which is not enough to counterbalance the effects of the splanchnic vasodilation.

Question 13

How is Hepatorenal syndrome managed?

Answer 13

• Vasopressin analogues, for example terlipressin.
  
  • work by causing vasoconstriction of the splanchnic circulation
• Volume expansion with 20% albumin
• Transjugular intrahepatic portosystemic shunt

Question 14

What are the types of Hepatorenal Syndrome?

Answer 14

Type 1 HRS

• Rapidly progressive
• Doubling of serum creatinine to > 221 µmol/L or a halving of the creatinine clearance to less than 20 ml/min over a period of less than 2 weeks
• Very poor prognosis

Type 2 HRS

• Slowly progressive
• Prognosis poor, but patients may live for longer

Question 15

What are causes of Budd-Chiari syndrome?

Answer 15

• Polycythaemia rubra vera
• Thrombophilia: activated protein C resistance, antithrombin III deficiency, protein C & S deficiencies
• Pregnancy
• Oral contraceptive pill

Question 16

What are features of Budd-Chiari syndrome?

Answer 16

• Abdominal pain: sudden onset, severe
• Ascites
• Tender hepatomegaly

Question 17

How is Budd-Chiari syndrome investigated?

Answer 17

Ultrasound with Doppler flow studies

• very sensitive and should be the initial radiological investigation