Gastroenterology upper GIT Flashcards
What is the upper GI tract made of
- oesophagus
- stomach
- duodenum
What is dysphagia
Difficulty in swallowing
- needs urgent investigation to exclude malignancy
- unless it is short term and associated with sore throat
What does pain on swallowing indicate
Oesophageal cancer, ulcer, spasm or candidiasis infection
What does difficulty to make swallowing movements indicate
Bulbar palsy (especially if swallowing causes coughing)
What does difficulty swallowing solids and liquids from the outset indicate
Motility disorder or pharyngeal cause
What does intermittent dysphagia indicate
Oesophageal spasm
What does consistent and worsening dysphagia indicate
Malignant stricture
What does a neck bulge or gurgle on swallowing with dysphagia indicate
Pharyngeal pouch
What do patients with dysphagia present with
- Cachexia = general muscle wasting due to reduced intake and increased catabolism
- Anaemia = tiredness, parlour of mouth
- Oral examination could show smooth tongue
- Supraclavicular lymph nodes (Virchow’s nodes)
- Other signs of systemic disease
What are the mechanical causes of dysphagia
- Malignant stricture; pharyngeal, oesophageal, gastric cancer
- Benign stricture; oesophageal web or ring (iron deficiency anaemia)
- Extrinsic pressure; lung cancer, retrosternal goitre, aortic aneurysm, left atrial enlargement
- Pharyngeal pouch
What are the motility causes of dysphagia
- Achalasia
- Diffuse oesophageal spasm
- Systemic sclerosis
- Myasthenia gravis
- Bulbar/pseudobulbar palsy
What is myasthenia gravis
Autoimmune condition involving antibodies to ACh receptors affecting neuromuscular transmission causing increasing muscular fatigue
In which order does muscular fatigue occur in patient with myasthenia gravis
- Extraocular (ptosis)
- Bulbar (cranial nerve affecting swallowing)
- Face
- Neck
- Limbs
What treatment is given for myasthenia gravis
Pyridostigmine treatment for ACh replacement
What is bulbar palsy and what is it caused by
Presentation of diseases involving cranial nuclei of CNIX-XII and is a result of motor neurone disease, syringobulbia (increased cavity in upper spinal chord) or myasthenia gravis
How does bulbar palsy present
LMN lesion of tongue and muscles of talking and swallowing
- flaccid, fasciculating tongue
- quit, hoarse and nasal speech
- normal or absent jaw jerk
What is Paterson-Kelly syndrome
Iron-deficiency anaemia occurring in females which presents with glossitis due to low iron and post-cricoid web causing dysphagia
What dies Paterson-Kelly syndrome increase the incidence of
Pharyngeal and oral carcinoma
What is achalasia
When the lower oesophageal sphincter fails to relax due to degeneration of myenteric plexus causing food to collect; this is a risk factor for oesophageal cancer
What are the clinical presentations of achalasia
- dysphagia
- regurgitation
- substernal cramps
- weight loss due to less food absorption
What is GORD
Gastro-oesophageal reflux = reflux of stomach contents causing symptoms with at least two heartburn episodes per week - it is associated with dysfunction of lower oesophageal sphincter
What can prolonged GORD cause
- Oesophagitis
- Benign oesophageal strictures
- Barrett’s oesophagus which is pre-cancerous
- Ulcers
- Oesophageal adenocarcinoma
- Iron deficiency anaemia
Describe the oesophageal symptoms of GORD
- heartburn
- belching
- acid brash
- water brash (XS salivation)
- odynophagia (painful swallowing)
Describe the extra-oesophageal symptoms of GORM
- nocturnal asthma
- chronic cough
- laryngitis (hoarseness, throat clearing)
- sinusitis
How can GORD be treated through lifestyle changes
- weightloss
- smoking cessation
- raising bedhead (preventing reflux)
- small regular meals
- avoidance of caffeine, alcohol, acidic fruit, spicy food
- not eating 3 hours before bed
- avoiding the following drugs
- nitrates, anticholinergics, tricyclic antidepressants
- NSAIDs, bisphosphonates
How can GORD be treated through medication
- Antacids; alginates such as gaviscon
- Proton pump inhibitors such as omeprazole, lansoprazole
- Surgery when severe symptoms (Nissen fundoplication)
What is Nissen fundoplication
Treatment for GORD where
- Fundus (top of stomach) is wrapped around back side of oesophagus
- Wrap is secured with sutures to anchor lower oesophagus below diaphragm
What is the dental relevance of GORD
- unpleasant taste due to acids in mouth
- enamel erosion especially on palatal aspect of upper teeth
- may be exacerbated by treatment with NSAIDs
What is sliding hiatus hernia
More common; Where the gastro-oesophageal junction slides into the chest and is associated with reflux - the lower oesophageal sphincter is less competent
What is rolling hiatus hernia
Less common; Where the gastro-oesophageal junction remains in abdomen but a bulge of the stomach herniates into chest alongside the oesophagus and acid reflux is rare - this can cause strangulation and so is a medical emergency
What is Barrett’s oesophagus
When there is chronic reflux oesophagitis, the normal squamous epithelium is replaced by columnar gastric epithelium and this is a premalignant lesion where metaplasia may occur
What are the clinical features of oesophageal carcinoma
- hoarseness, cough
- dysphagia
- loss of weight
- retrosternal chest pain
- lymphadenopathy
Which type of cancer occurs in each third of the oesophagus most commonly
Upper third = squamous cell carcinoma
Middle third = squamous cell carcinoma
Lower third = adenocarcinoma
What is tylosis
Genetic disorder characterised by thickening (hyperkeratosis) of palms and soles and oral leukoplakia (white patches in the mouth) which increases risk of oesophageal cancer
What are patients with tylosis predisposed to
Genetic syndrome predisposes patients to squamous cell carcinoma of oesophagus; this is autosomal dominant and mapped to chromosome 17q25
= nonepidermolytic palmoplantar keratoderma
Outline the typical signs and symptoms of pharyngeal pouches
- > 70yrs
- Dysphagia
- Regurgitation
- Aspiration
- Cough
- Borborygmi (stomach growling)
- Chocking
- Halitosis (bad breath)
- Weight loss
- Hoarseness
What is dyspepsia
A nonspecific group of symptoms related to upper GIT
What nonspecific symptoms are related to dyspepsia
ALARMS
- Anaemia (iron deficiency related)
- Loss of weight
- Anorexia
- Recent onset with progressive symptoms
- Melanea (blood stools) or haematemesis (blood in vomit)
- Swallowing difficulty
What is epigastric pain associated with
- related to eating specific foods, hunger or time of day
- associated with bloating and fullness after meals
- heartburn (retrosternal pain with acid reflux)
What are the risk factors for peptic ulcers
- Helicobacter pylori infection
- Aspirin
- NSAIDs
- Corticosteroids
- Smoking
- Stress
Why does corticosteroid usage increase the risk of peptic ulceration
Because it decreases prostaglandin production and this has a protector effect from stomach acid
Outline the clinical presentation of gastric ulceration
- Elderly
- Less curve
- Asymptomatic
- Epigastric pain related to meals and relieved by antacids
- Weightloss due to less break down of food and thus less absorption
Outline the clinical presentation of duodenal ulceration
- More common
- Asymptomatic
- Epigastric pain before eating or at night
- Relieved by drinking milk
Describe the incidence of gastric cancer
More common in males, peak indigence at 60-84yrs
- highest in Eastern Asia, Eastern Europe and South America
- early diagnosis is important as quickly metastases
- polypoid, ulcerative, diffuse infiltrative
Poor prognosis (<5years)
Outline the risk factors for gastric cancer
- H pylori infection
- Cigarettes
- Alcohol
- Dietary salt and food preservation
- Dietary fruit and vegetable
- Pernicious anaemia = autoimmune and no B12 absorption
Outline the clinical presentation of gastric cancer
- nausea
- dysphagia
- melaena
- anaemia
- virchow’s node
- sister Mary Joseph’s nodule
What is Virchow’s node
The supraclavicular lymph nodes on the left side are called Virchow’s nodes
What is Sister Mary Joseph nodule
- palpable nodule protruding into umbilicus
- resulting from metastasis of a malignant cancer in pelvis or abdomen
- gastric, colonic or pancreatic cancer
What is haematemesis
Vomitting of blood; may be red or like coffee grounds (broken down blood)
What is melaena
Black motions with a tarry appearance and smell
What do haematemesis and melaena indicate
Upper GI bleeding
What are the common causes of upper GI bleeding
- gastritis or gastric erosions
- duodenitis
- oesophagitis
- peptic ulcers
- NSAIDs, aspirin, corticosteroids, warfarin, thrombolytics
- Mallory-Weiss tear
- oesophageal varices
- malignancy
What are the rare causes of upper GI bleeding
- bleeding disorders
- hereditary hemorrhagic telangiectasia
- peutz-jeghers syndrome
- portal hypertensive gastropathy (in patients with cirrhosis)
What are varicies
Dilated collateral veins at sites of portosystemic anastomosis caused by portal hypertension - most common in lower oesophagus but also stomach
- it is associated with liver cirrhosis
What is Mallory-Weiss tear caused by
Forceful/long-term vomitting or coughing resulting in bleeding via oesophageal tear involving mucosa and submucosa (not muscular layer) which is more common in men over 60 and can leat to haematemesis and melaena
What is associated with Mallory-Weiss tear
- alcoholism
- eating disorders
- hyperemesis gravidarum (in long pregnancies)
- epileptic convulsions
- NSAID abuse
How is Mallory-Weiss tear treated
Usually self-healing but can be supported with PPI or H2 antagonists; bleeding stops after 24-48 hours
- endoscopic cauterisation, injection of adrenaline or surgical management may be required
Outline the initial management procedure for upper GI bleeds
- Protect airway and give high flow O2
- Resuscitate ABC
- 2 large born cannulae
- FBC, U&E, LFT, crossmatch, clotting
- IV fluids and omeprazole
- Urinary catheter
- Transfuse
- Urgent endoscopy
What are the classic indications of myasthenia gravis
Ptosis = classic early sign
Myasthenic snarl on smiling
Voice deteriorates whilst counting to 50
How can achalasia be diagnosed
Give patient barium swallow and this will show a tapered dilated lower oesophagus
How are hiatus hernias treated
Weight loss
Treat reflux symptoms - alginates and PPIs
Surgical repair with complications and always with rolling hiatus hernias
How are hiatus hernias investigated
Barium swallows
Upper GI endoscopy
What is the dental relevance of tylosis
Increases chance of developing second cancer in H+N
May occur secondary to Patterson-Kelly syndrome
Patients may have tylosis and oral leukoplakia (tylosis with oesophageal cancer = TOC or Howel-Evans syndrome)
Where does swelling occur in patients with pharyngeal pouches
Lateral pharynx in the Killian’s dehiscence area
Outline general features of pharyngeal pouches
M>F Emaciation (weight loss) Swelling may be felt in neck Swelling ma gurgle on palpitation = Boyce's sign Diagnosed on barium swallow
What are alarming features suggestive of gastric cancer
New onset dyspepsia in patients >55 FH of upper GIT cancers Unintended weight loss Upper/lower GI bleeding Progressive dysphagia and odynophagia Persistent vomitting Palpable mass or lymphadenopathy Jaundice (metastasise to liver)
How is gastric cancer investigated
Endoscopy and biopsy of primary tumour
6 biopsy samples
Staging involving endoscopic ultrasonography, CT abdomen, PET
