Gastroenterology - Presenting problems Flashcards
What is dysphagia?
Dysphagia means difficulty swallowing, and is distinct from globus (a “lump” in the throat without organic cause) and odynophagia (pain during swallowing).
Dysphagia can be caused by neuromuscular disorders, oral disease and oesophageal disorders.
What neuromuscular conditions cause dysphagia?
These can broadly be divided into (i) central, (ii) bulbar and (iii) muscular/myenteric plexus disorders.
1) Central
- CVA - extensive small vessel disease
- Parkinson’s esp. PSP
- Psychiatric - globus pharyngeus
2) Bulbar palsy (lower motor neurone)
- Brainstem: synringobulbia, infarction (lateral medullary syn), MS
- MND, polio
- Peripheral autonomic neuropathy (e.g. diphtheria, GBS, Chagas’ disease)
3) Muscular/ myenteric plexus
- NMJ: myasthenia, botulism
- Myopathy
- Ganglion/ peristalsis dysfunction - e.g. CREST, lower oesophageal achalasia
What oral conditions cause dysphagia?
Pharyngitis and oral ulcers cause painful swallowing (odynophagia) with secondary dysphagia.
How can oesophageal causes of dysphagia be classified?
These can be broken down into luminal, intrinsic and extrinsic causes:
1) Luminal - FB or large food bolus
2) Intrinsic
- upper - pharyngeal pouch, post-cricoid web
- middle - oesophagitis, oesophageal stricture, oesophageal carcinoma
- lower - hiatus hernia, Schatzki ring
3) Extrinsic - “BULGIN”
Bone: cervical spondylosis
U: dysphagia LUsoria, vascular compression (e.g. aberrant R subclavian artery, aortic aneurysm, mitral stenosis (enlarged left atrium)
Lymphadenopathy
Goitre
Infection: retropharyngeal abscess
Neoplasia: pancreatic cancer
How does dysphagia present?
The presentation of dysphagia can give clues as to the underlying cause, and is different for neurological, oral and oesophageal disorders.
Neuromuscular cases tend to present with equal intolerance to solids and liquids. Nasal regurgitation, aspiration (when attempting to swallow) and other neurological signs (e.g. diplopia, ataxia).
Oral causes of dysphagia present with odynophagia.
Oesophageal causes present with difficulty swallowing solids > liquids. Aspiration that occurs is unrelated to swallowing, and patients may also complain of chest pain, dyspepsia and hiccups.
What examination findings may help confirm a neuromuscular cause of dysphagia?
Other neurological deficits - e.g. ataxia, dysarthria and Horner’s syndrome
What examination findings are associated with oesophageal causes of dysphagia?
1) Hoarse voice
- Laryngitis (GORD)
- Left recurrent laryngeal nerve palsy (carcinoma, lymph nodes)
2) Respiratory symptoms
- Right middle lobe consolidation (aspiration pneumonia)
- Unilateral wheeze (main bronchus compression)
How should dysphagia be investigated?
All patients require an upper GI endoscopy unless there are compelling reasons for this not to be performed. Motility disorders (neuromuscular) may be best appreciated by undertaking fluoroscopic swallowing studies.
A full blood count should be performed.
Ambulatory oesophageal pH and manometry studies will be required to evaluate conditions such as achalasia and patients with GORD being considered for fundoplication surgery.
What is a post cricoid web?
Occurs as part of Plummer-Vinson or Paterson-brown-Kelly syndrome. Also characterised by Fe deficiency aneamia, koilonychia, glossitis and risk of squamous cell carcinoma.
How can oesophageal cancer, oesophagitis and oesophageal candidiasis be differentiated?
Oesophageal cancer = dysphagia associated with weight loss, anorexia or vomiting during eating
Past history may include Barrett’s oesophagus, GORD, excessive smoking or alcohol use
Oesophagitis = may be history of heartburn
Odynophagia but no weight loss and systemically well
Oesophageal candidiasis = there may be a history of HIV or other risk factors such as steroid inhaler use
What is dyspepsia?
Dyspepsia is indigestion and causes may arise from within or outside the GIT.
Name some causes of dyspepsia
GI disorders: Peptic ulcer disease Acute gastritis Gallstones Colonic carcinoma Pancreatic disease
Systemic disease:
Hypercalcaemia
Renal failure
Drugs:
NSAIDS
Digoxin
Iron supplements
What are the “alarm” features of dyspepsia?
Weight loss Anaemia Vomiting Haematemesis Dysphagia Palpable abdominal mass
How should patients with dyspepsia be investigated?
Patients with any of the alarm features or who are >55 with new onset dyspepsia are classed as urgent and should be referred for endoscopy.
Non urgent patients include:
- Patients with haematemesis
- Patients aged >= 55 years who’ve got:
treatment-resistant dyspepsia or
- upper abdominal pain with low haemoglobin levels or
- raised platelet count with any of the following: nausea, vomiting, weight loss, reflux, dyspepsia, upper abdominal pain
- nausea or vomiting with any of the following: weight loss, reflux, dyspepsia, upper abdominal pain
Which patients should be tested for H.pylori infection?
Young patients or patients that do not meet the referral criteria (labelled as “undiagnosed dyspepsia”). If symptoms persist after treatment they should be referred for endoscopy.
Management of these patients can be summarised at a step-wise approach
- Review medications for possible causes of dyspepsia
- Lifestyle advice
- Trial of full-dose proton pump inhibitor for one month OR a ‘test and treat’ approach for H. pylori
What are the causes of nausea and vomiting?
This is a wide list, but a broad overview can be remembered by: too many "GIN & TONICS" Gastrointestinal Infection Neoplasia Toxins Obstetric Ophthalmic Neurology Infarction Calcium/ endocrine dysfunction Systemic
What gastrointestinal disorders can cause vomiting?
Gastro-oesophageal: reflux, ulcer, pyloric stenosis
Pancreatic, liver, gallbladder disease
Obstruction
Peritonitis
What infections can cause nausea and vomiting?
GIT: gastroenteritis; hepatitis; visceral abscess
Systemic: RTI (esp. tonsillitis, otitis media); UTI; sepsis
What are the important features of a nausea and vomiting history?
The history should reveal associated abdominal pain, fever, diarrhoea, relationship to food, drugs, headache, vertigo and weight loss. Pregnancy, alcoholism and bulimia should be considered.
How is nausea and vomiting treated?
There is a whole deck on anti-emetics, but a basic way to remember is "A123": Muscarinic (ACh) receptor antagonists Histamine type 1 receptor antagonist Dopamine type 2 receptor antagonist Serotonin type 3 receptor antagonist
How do patients with upper GI bleeds present?
Patients may present with the following:
- Haematemesis and/ or malaena
- Epigastric discomfort
- Sudden collapse
Haematemesis may be red with clots when bleeding is profuse, or black (‘coffee grounds’) when less severe. Syncope may occur with rapid bleeding. Anaemia suggests chronic bleeding. Melaena is the passage of black, tarry stools containing altered blood. This is usually due to upper GI bleeding, although the ascending colon is occasionally responsible. Severe acute upper GI bleeding occasionally causes maroon or bright red stool.
The extent to which these will occur will depend upon the source. Mortality is higher in patients presenting with haematemesis than malaena alone.
What can cause oesophageal bleeding? What clinical features are associated with these?
1) Oesophagitis - small volume of fresh blood, often streaking vomit. Malaena rare. Often ceases spontaneously. Usually history of antecedent GORD type symptoms.
2) Cancer - usually small volume of blood, except as pre terminal event with erosion of major vessels. Often associated symptoms of dysphagia and constitutional symptoms such as weight loss. May be recurrent until malignancy managed.
3) Mallory -Weiss tear - typically brisk small to moderate volume of bright red blood following bout of repeated vomiting. Malaena rare. Usually ceases spontaneously
4) Varices - usually large volume of fresh blood. Swallowed blood may cause malaena. Often associated with haemodynamic compromise. May stop spontaneously but re-bleeds are common until appropriately managed.
What gastric diseases can cause upper GI bleeding? What features are associated with each?
1) Gastric cancer - may be frank haematemesis or altered blood mixed with vomit. Usually prodromal features of dyspepsia and may have constitutional symptoms. Amount of bleeding variable but erosion of major vessel may produce considerable haemorrhage.
2) Dieulafoy Lesion - often no prodromal features prior to haematemesis and malaena, but this arteriovenous malformation may produce quite considerable haemorrhage and may be difficult to detect endoscopically
3) Diffuse erosive gastritis - usually haematemesis and epigastric discomfort. Usually there is an underlying cause such as recent NSAID usage. Large volume haemorrhage may occur with considerable haemodynamic compromise
4) Gastric ulcer (MCC) - small low volume bleeds more common so would tend to present as iron deficiency anaemia. Erosion into a significant vessel may produce considerable haemorrhage and haematemesis
What is the most common cause of duodenal bleeding?
Most common cause of major haemorrhage is a posteriorly sited duodenal ulcer. However, ulcers at any site in the duodenum may present with haematemesis, malaena and epigastric discomfort. The pain of duodenal ulcer is slightly different to that of gastric ulcers and often occurs several hours after eating. Peri ampullary tumours may bleed but these are rare. In patients with previous abdominal aortic aneurysm surgery aorto-enteric fistulation remains a rare but important cause of major haemorrhage associated with high mortality.
Summarise the causes of haematemesis?
This can best be remembered as “VINTAGE”:
Varices
Inflammation (e.g. oesophagitis or peptic ulcer)
Neoplasia (e.g. oesophageal or gastric)
Trauma
- 1) Mallory-Weiss tear
- 2) Surgery, ERCP, aorto-duodenal fistula
- 3) Hypovolaemic shock: ischaemic, stress ulcer in stomach
Angiodysplasia + other vascular abnormalities
- angiodysplasia (dilated vessel complexes in clusters)
- hereditary haemorrhagic telangiectasia (dilated vessels ALL over bowel wall)
- others (e.g. Dieulafoy lesion, PAN)
Generalised bleeding disorder
Epistaxis
Exogenous
Outline the management of upper GI bleed? When should patients undergo endoscopy?
1) IV access
2) Clinical assessment - risk of complications related to circulatory status, liver disease, and comorbidity (i.e. cardiorespiratory, cerebrovascular or renal disease that increases the hazards of endoscopy and surgery)
3) Bloods - cross match blood, check FBC, LFTs, U+E and Clotting (as a minimum)
4) Resuscitation - oxygen is given to patients in shock. IV crystalloid infusion restores BP, and blood transfusion is indicated if there is shock and active bleeding. Antibiotics are given in chronic liver
5) Endoscopy - ideally all patients admitted with upper gastrointestinal haemorrhage should undergo Upper GI endoscopy within 24 hours of admission. In those who are unstable this should occur immediately after resuscitation or in tandem with it
6) Monitoring - hourly pulse, BP and urine output should be monitored
What are the indications for surgery in patients with upper GI bleeding?
Patients > 60 years
Continued bleeding despite endoscopic intervention
Recurrent bleeding
Known cardiovascular disease with poor response to hypotension
How should oesophageal varices be managed?
Patients with suspected varices should receive terlipressin prior to endoscopy.
Varices should be banded or subjected to sclerotherapy. If this is not possible owing to active bleeding then a Sengaksten- Blakemore tube (or Minnesota tube) should be inserted. This should be done with care; gastric balloon should be inflated first and oesophageal balloon second. Remember the balloon with need deflating after 12 hours (ideally sooner) to prevent necrosis. Portal pressure should be lowered by combination of medical therapy +/- TIPSS.
Identifiable bleeding points should receive combination therapy of injection of adrenaline and either a thermal or mechanical treatment. All who have received intervention should receive a continuous infusion of a proton pump inhibitor (IV omeprazole for 72 hours) to reduce the re-bleeding rate.
What is the Blatchford score?
The need for admission and timing of endoscopic intervention may be predicted by using the Blatchford score. This considers a patients Hb, serum urea, pulse rate and blood pressure. Those patients with a score of 0 are low risk, all others are considered high risk and require admission and endoscopy.
Should patients with GI bleeding receive PPI prior to endoscopy?
The requirement for pre endoscopic proton pump inhibition is contentious. In the UK the National Institute of Clinical Excellence guidelines suggest the pre endoscopic PPI therapy is unnecessary. Whilst it is accepted that such treatment has no impact on mortality or morbidity a Cochrane review of this practice in 2007 did suggest that it reduced the stigmata or recent haemorrhage at endoscopy. As a result many will still administer PPI to patients prior to endoscopic intervention.
What is the Rockall score?
Following endoscopy it is important to calculate the Rockall score for patients to determine their risk of rebleeding and mortality. A score of 3 or less is associated with a rebleeding rate of 4% and a very low risk of mortality and identifies a group of patients suitable for early discharge.
Lower gastrointestinal bleeding occurs due to haemorrhage from the small bowel, colon or anal canal. How does colonic bleeding present?
This typically presents as bright red or dark red blood per rectum. Colonic bleeding rarely presents as malaena type stool, this is because blood in the colon has a powerful laxative effect and is rarely retained long enough for transformation to occur and because the digestive enzymes present in the small bowel are not present in the colon. Up to 15% of patients presenting with haemochezia will have an upper gastrointestinal source of haemorrhage.
As a general rule right sided bleeds tend to present with darker coloured blood than left sided bleeds. Haemorrhoidal bleeding typically presents as bright red rectal bleeding that occurs post defecation either onto toilet paper or into the toilet pan. It is very unusual for haemorrhoids alone to cause any degree of haemodynamic compromise.
What are the causes of lower GI bleeding?
Remember these by using “DRIPPING TAPS”
Diverticulae (e.g. colonic, Meckel’s, jejunal)
Rectal
Infection
Polpys - both benign and neoplastic
Inflammation (e.g. ulcerative colitis - blood diarrhoea)
Neoplasia (e.g. carcinoma, lymphoma)
Gastric upper bowel bleeding (bloody if rapid transit)
Trauma (e.g. surgery, radiation colitis)
Arterial/ Angiodysplasia/ AVM)
Pseudomembranous colitis
Systemic (e.g. coagulopathy, amyloid)
