Gastroenterology: Upper GI

Question 1

What 4 conditions present with a progressive dysphagia?

Answer 1

Oesophageal cancer (adenocarcinoma and SCC)
Achlasia
Pharyngeal pouch
Bulbar palsy

Question 2

What is the main risk factor present in adenocarcinoma but not SCC

Answer 2

GORD/Barrett’s

Question 3

What is the significance of a left supraclavicular node with regards to GI conditions

Answer 3

Virchow’s node: Suggests an intra-abdominal malignancy

Question 4

How does adeno and Squamous carcinoma differ in their location in oesophageal cancer?

Answer 4

Adeno: Lower 1/3

Squamous: Upper 2/3

Question 5

What is the first line investigation for suspected oesophageal malignancy?

Answer 5

1st line: Upper endoscopy

Question 6

What is the treatment for oesophageal cancer?

Answer 6

Resection + adjuvant chemo if operable
Palliative chemoradiotherapy if not

Question 7

What are the 2 conditions that present with non-progressive dysphagia

Answer 7

Benign stricture
Benign oesophageal spasm

Question 8

How does a benign stricture present differently to oesophageal carcinoma?

Answer 8

Non-progressive

Longer standing GORD symptoms

No systemic symptoms

Question 9

How does achalasia differ from oesophageal cancer given the fact they all have progressive dysphagia?

Answer 9

Achalasia can present with regurgitation of food rather than vomiting

Question 10

How is achalasia treated?

Answer 10

Endoscopic balloon dilatation/Heller’s cardiotomy

Question 11

How can the dysphagia in benign oesophageal spasm be distinguished from malignancy?

Answer 11

Tends to be episodic and non-progressive

Solids and liquids (motor issue instead of mechanical)

Question 12

What investigation can confirm benign oesophageal spasm?

Answer 12

Contrast swallow/manometry will reveal abnormal contractions

Question 13

How can a pharyngeal pouch be distinguished from other casues of dysphagia?

Answer 13

Regurgitation of food

Aspiration

Neck swelling that gurgles on palpation

Question 14

How do you treat a pharyngeal pouch?

Answer 14

Surgical resection

Question 15

What are the ALARMS symptoms in dyspepsia?

Answer 15

Anaemia

Loss of weight

Anorexia

Recent history of progressive symptoms

Masses

Swallowing difficulties

(or Vomiting, Bleeding/Anaemia, Anorexia/loss of weight, Dysphagia)

Question 16

What are the indications for UGI endoscopy in dyspepsia?

Answer 16

All with dysphagia

All with suspected malignancy

>55 years with ALARMS symptoms

Question 17

What is the treatment pathway for a patient with GORD?

Answer 17

1 month trial high dose PPI

If response: commence low dose longer term

No response + Endoscopy +ve: double dose 1 month

No response + ES -ve: Trial H₂RA or prokinetic

Question 18

What is the management of suspected peptic ulcer disease?

Answer 18

UGI endoscopy if dysphagia/>55 with ALARM symptoms

Lifestyle changes with OTC antacids for 1 month

Test for H.Pylori

+ve test: Commence PPI + Amoxicillin + metronidazole/clarithromycin

-ve test or eradicated: PPIs/H2RA for 1 month

If no improvement: low dose PPI 1 month and consider endoscopy

Question 19

If oesophageal endoscopy finds goblet cells and brush border in the columnar epithelium, what does this indicate?

Answer 19

Barrett’s Oesophagus

Question 20

How is barrett’s oesophagus managed?

Answer 20

Metaplastic: Surveillance every 3-5 years

Dysplastic: Resect/ablate

Question 21

How can you determine if a peptic ulcer is gastric or duodenal?

Answer 21

Duodenal: RELIEVED on eating

Gastric: WORSENED on eating

Question 22

Which two groups of people is gastric cancer more common in?

Answer 22

Over 75s

Males

Question 23

What are the features of gastric cancer?

Answer 23

Epigastric pain, vague

Weight loss and anorexia

Dysphagia

Nodes: Left supraclavicular (Virchow’s) and periumbilical (Sister Mary Joseph)

Question 24

What are the risk factors for developing gastric cancer?

Answer 24

think SHADO

Smoking

H. Pylori

Atrophic gastritis

Diet high in salt and nitrates (smoked food)

O blood group

Question 25

What 2 investigations confirm a diagnosis of gastric cancer?

Answer 25

Endoscopy with biopsy: signet ring cells (more rings = worse prognosis)

CT for staging

Question 26

How is gastric cancer managed?

Answer 26

Surgical resection or gastrectomy

Chemotherapy

Question 27

What are the 3 typical features of an upper GI bleed?

Answer 27

Vomiting fresh/’coffee ground’ blood

Melaena

Abdominal tenderness

Question 28

Outline the management of an upper GI bleed

Answer 28

Resuscitate via ABCDE

If variceal: Terlipressin + Prophylactic IV broad spec antibiotics

Endoscopy to investigate and treat

• Immediate if severe bleed
• Otherwise within 24 hours

Give PPIs post-endoscopy if needed

Question 29

How can you tell the difference between oesophageal varices and Mallory weiss tear?

Answer 29

Malaena: More common in OVs

Prior vomiting: More common in MW tears

Question 30

What 3 historical features are typical in an oesophageal varices patient?

Answer 30

Previous ulcers

Liver cirrhosis

Heavy alcohol use

Question 31

What artery may be at risk of rupture in a duodenal ulcer

Answer 31

Gastroduodenal artery

Question 32

A patient presents with haematemesis. They appear to have pigmented lesions on the face, lips, palms and soles. they mention a history of consitpation due to ‘blocked bowels’. What diagnosis do you have to bear in mind?

Answer 32

Peutz-Jegher’s syndrome

AD mutation of LKB1/STK1

Bleeding prone polyps in GI tract

Pigmented lesions on face, palms and soles

Conservative management

Question 33

What AV malformation causes UGI bleeding without prior symptoms?

Answer 33

Dieulafoy lesion