Gastrointestinal - Level 2 Flashcards
Definition of malnutrition?
o Nutrient deficient state of protein, energy or micronutrients
Definition and symptoms of Kwashikor?
o Inadequate protein intake o Moon facies, swollen abdomen (pot belly) o Hepatomegaly o Pitting oedema o Dry, dark skin which splits
Definition and symptoms of marasmus?
o Inadequate energy and protein intake o Loss of weight and reduction in muscle mass o Thin, atrophic skin o Alopecia, brittle hair o Lanugo hair
Symptoms and management of iodine deficiency?
Symptoms - Goitre, hypothyroidism, growth restriction
Management - Iodine supplements, seafood
Symptoms and management of vitamin A deficiency?
Symptoms - Night blindness, oval Bitot’s spots, cloudy corneas, immune dysfunction, increased illnesses
Management – dark green leafy vegetables, animal products, vitamin Asupplements
Symptoms and management of vitamin C deficiency?
Symptoms – listlessness, anorexia, bleeding gums, gingivitis, loose teeth, halitosis, muscle pain
Management – increase vitamin C, supplements (Ascorbic Acid PO)
Symptoms and management of Vitamin B1 (thiamine) deficiency?
Symptoms – beri beri – heart failure with oedema, neuropathy
Management – Thiamine urgently
Symptoms of vitamin B2 (riboflavin) deficiency?
Symptoms – angular stomatitis, cheilitis
Symptoms of Vitamin B6 (pyridoxine) deficiency?
Symptoms – polyneuropathy
Symptoms of Vitamin E deficiency?
Symptoms – haemolysis, neurological deficit
Symptoms of Vitamin K deficiency?
Symptoms – bleeding disorders
Symptoms and management nicotinic acid deficiency?
Symptoms – Pellegra – diarrhoea, dementia, dermatitis (Casal’s necklace)
Rx – Nicotinamide PO
Risk factors for malnutrition?
o Young age o Neglect o Poverty o Living alone o Severe learning difficulties or mental health problems o Gastric surgery o Malabsorption ~(CF, Crohn’s disease, Coeliac disease, chronic pancreatitis) o Stroke o Cancer
Symptoms of malnutrition?
- BMI <18.5
- Increasing fatigue
- Non-healing wounds
- Slowed growth
- Reduced muscle mass
Definition of dyspepsia?
- Dyspepsia – upper abdominal pain, heartburn, acid reflux, nausea and/or vomiting, typically >4 weeks
o Most common cause of dyspepsia – GORD, PUD, functional dyspepsia, upper GI malignancy
Pathology of GORD?
Reflux of gastric contents (acid, bile and pepsin) into oesophagus causing heartburn
Due to transient relaxation (reduced tone) of LOS, increased intra-abdominal pressure, delayed gastric emptying and impaired oesophageal clearance of acid
Epidemiology of dyspepsia?
- Dyspepsia occurs in 40% each year
o At endoscopy 40% have GORD - Higher prevalence in Northern Europe
- Increases with age and more common in women
Risk factors of GORD?
o Stress/Anxiety o Smoking o Alcohol o Foods – coffee, chocolate, fatty foods o Obesity o Drugs – alpha-blockers, anticholinergics, benzodiazepines, BB, bisphosphonates, CCB, corticosteroids, NSAIDs, nitrates, theophylline, TCA o Pregnancy o Hiatus hernia o FHx
Causes of dyspepsia?
o Oesophagitis
o Endoscopy-negative
Risk factors for Barrett’s oesophagus?
o Male, long duration/severe of GORD, previous oesophagitis/hiatus hernia/ulcers
Symptoms of GORD?
Heartburn
Burning epigastric/retrosternal pain
Worse on bending, lying down, with hot drinks, alcohol
Relieved by antacids
Regurgitation
Belching
Odynophagia (pain on swallowing)
Increased salivation (waterbrash)
Nocturnal cough/asthma
Atypical symptoms of GORD?
hoarseness, cough, asthma, dental erosions
Investigations to perform in dyspepsia?
o FBC (low Hb, raised platelets)
Referral to endoscopy within 2-weeks under what criteria?
With dysphagia or
Aged 55 and over with weight loss and any of the following:
• Upper abdominal pain
• Reflux
• Dyspepsia
Referral to endoscopy non-urgently under what criteria?
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, or
Nausea or vomiting with any of the following: • Weight loss • Reflux • Dyspepsia • Upper abdominal pain
Management of dyspepsia with unknown cause - lifestyle advice?
Lose weight, avoid triggers (coffee, chocolate, tomatoes, fatty/spicy foods)
Eat smaller meals, eat in evening 3-4 hours before going to bed
Stop smoking
Reduce alcohol
Sleep with head of bed raised
Antacids - OTC
Review medications
Management of dyspepsia with unknown cause -if persistent symptoms?
o If persistent symptoms – FBC (check for anaemia or high platelets)
Management of dyspepsia with unknown cause - initial drug treatment?
PPI for 1 month
• Lansoprazole 30mg, Omeprazole 20-40mg, esomeprazole 20mg
Management of dyspepsia with unknown cause - initial testing and eradication?
H.pylori test – if positive then eradication therapy
• Carbon-13 urea breath test or stool antigen test (no PPI in last 2w, no Abx in last 4w)
• Eradication 7-days triple therapy - Omeprazole 20mg BD/Lansoprazole 30mg BD, amoxicillin 1g BD + clarithromycin 500mg BD (or metronidazole 400mg BDS)
If persists then switch
Management of dyspepsia with unknown cause - recurrent/refractory symptoms?
H2-receptor antagonists
Re-test H.pylori only if – poor compliance, NSAIDs indicated, FHx of gastric malignancy, severe symptoms or patient request
Management of dyspepsia with unknown cause - when to refer to endoscopy?
Refractory or recurrent symptoms
Treatment with 2nd line H.pylori unsuccessful
Management of endoscopically proven GORD - lifestyle measures?
Lose weight, avoid triggers (coffee, chocolate, tomatoes, fatty/spicy foods)
Eat smaller meals, eat in evening 3-4 hours before going to bed
Stop smoking
Reduce alcohol
Sleep with head of bed raised
Management of endoscopically proven GORD -if proven GORD?
PPI for 4-8 weeks
• Lansoprazole 30mg, omeprazole 20-40mg, esomeprazole 20mg, pantoprazole 40mg, rabeprazole 20mg
If symptoms recur:
• Offer PPI at lowest dose possible to control symptoms
• H2RA therapy if inadequate response to PPIs
Management of endoscopically proven GORD - if proven severe oesophagitis?
PPI for 8 weeks
• If treatment fails – switch to another PPI
• Maintenance treatment – Full-dose PPI long-term
If symptoms recur:
• Further 1 month PPI course
• Double dose of PPI
• H2RA therapy if inadequate response to PPIs
Management of endoscopically proven GORD - when to consider endoscopy?
o Consider endoscopy to diagnose Barrett’s oesophagus if long duration of symptoms, increased frequency of symptoms, previous oesophagitis, previous hiatus hernia
Referral to GI or upper GI surgeon - when?
- Refractory, persistent or unexplained
- Controlled on PPI but does not want to continue or PPI not tolerated
- RF of Barrett’s oesophagus – upper GI endoscopy
Referral to GI or upper GI surgeon - specialist investigations?
- Oesophageal manometry
- Ambulatory 24-hour oesophageal pH monitoring (exclude achalasia, hypomotility)
- Barium swallow (exclude structural disorders – hiatus hernia, achalasia)
Referral to GI or upper GI surgeon - specialist management?
• Laparoscopic Nissen fundoplication
o Confirmed diagnosis of acid reflux and adequate symptom control but does not want to continue on long-term PPI or cannot tolerate PPI
• Endoscopic radiofrequency ablation
• Laparoscopic insertion of magnetic bead band
• Endoscopic infection of bulking agent
Complications of GORD?
o Oesophageal ulcers/haemorrhages/strictures o Anaemia o Aspiration pneumonia o Barrett’s oesophagus o Dental erosions, gingivitis, halitosis
What is Barrett’s oesophagus?
Columnar metaplasia of distal oesophagus, malignant potential and risk of adenocarcinoma
Endoscopy surveillance needed
Prognosis of GORD?
o Recurrence is 80%
o 10-15% of people with GORD symptoms will develop Barrett’s oesophagus, of these 1-10% will develop oesophageal adenocarcinoma over 10-20 years
Risk factors for GORD in children?
o Fluid diet, horizontal stature and short intra-abdominal length of oesophagus
o Cerebral palsy
o Preterm infants
o Following surgery for oesophageal atresia or diaphragmatic hernia
Symptoms of GORD in children?
- Recurrent regurgitation/vomiting - Possetting
- May contain some blood
- Increased salivations
- Chronic cough
- Normal weight and otherwise well
when to investigated GORD in children?
o Upper GI contrast with Hx of bile stained vomiting or Hx of GORD
o Specialist assessment for endoscopy with biopsies if:
Haematemesis, melaena, dysphagia, no improvement after 1 year old, faltering growth, distress, feeding aversion, iron-deficiency anaemia
o Oesophageal pH study – recurrent aspiration pneumonia, unexplained apnoea/seizure-like events/upper airway inflammation, frequent otitis media
Management of GORD in infants?
- Position at 30o head-up prone position after feeds
- Dietary: Thickened milk feeds (Carobel), small frequent meals, avoid food before sleep, avoid fatty foods, caffeine, citrus juices, alcohol, smoking
• Drugs:
1-2 weeks Gaviscon added to feeds (antacid and alginate forms viscous layer)
4 week trial H2 receptor antagonists (ranitidine) or PPI (omeprazole)
- If unexplained feeding difficulty, distressed, faltering growth
• Surgery if failed medical therapy
Upper GI endoscopy
Fundoplication – fundus of stomach wrapped around intra-abdominal oesophagus
Management of GORD in children?
• Lifestyle management
• Drugs
Consider if regurgitation + feeding difficulty/distressed/faltering growth
4-week PPI/H2 – persistent heartburn
- If not resolving – endoscopy
• Enteral Feeding
If faltering growth and no other explanation
• Surgery
Endoscopy and biopsies prior to surgery
Fundoplication if intractable, medical therapy unsuccessful
Complications of GORD in children?
- Failure to thrive
- Oesophagitis – haematemesis and iron deficiency anaemia
- Recurrent pulmonary aspiration – pneumonia, wheeze
- Dystonic neck posturing (Sandifer syndrome – extension and lateral turning of head)
Pathology of oesophageal carcinoma?
o SCC – usually middle 1/3, incidence decreasing, men 2:1
o Adenocarcinoma – arises from Barrett’s oesophagus, lower 1/3 of oesophagus
Types of oesophageal carcinoma?
o Adenocarcinoma – most common Smoking Obesity GORD Barrett’s oesophagus Radiotherapy for breast cancer
o SCC – high in China/Japan Smoking High salt diet Achalasia Coeliac disease Very hot food Plummer Vinson syndrome
Symptoms of oesophageal carcinoma?
o Progressive dysphagia (initially solids then liquids) o Weight loss o Retrosternal chest pain o Hoarseness o Cough (if upper 1/3)
When to offer urgent 2-week upper GI endoscopy of oesophageal carcinoma?
- Offer urgent upper GI endoscopy (to be performed within 2 weeks) to assess for oesophageal cancer in people:
o with dysphagia or
o aged 55 and over with weight loss and any of the following:
upper abdominal pain
reflux
dyspepsia
When to offer non-urgent upper GI endoscopy of oesophageal carcinoma?
o Treatment-resistant dyspepsia or
o Upper abdominal pain with low haemoglobin levels or
o Raised platelet count with any of the following: Nausea Vomiting Weight loss Reflux Dyspepsia Upper abdominal pain, or
o Nausea or vomiting with any of the following: Weight loss Reflux Dyspepsia Upper abdominal pain
Staging tests of oesophageal carcinoma?
o PET-CT whole body
o TNM staging
o Her2 testing in metastatic oesophageal adenocarcinoma
Management of oesophageal carcinoma - radical treatment?
Radical oesophagectomy
o T1N0 (Endoscopic mucosal resection or oesophagectomy)
• +/- lymph node dissection
Neoadjuvant chemradiotherapy
Management of oesophageal carcinoma - follow up?
o Give advice on symptoms of recurrence and advise to contact MDT if symptoms present
Management of oesophageal carcinoma - palliative management - if non-metastatic but not fit for surgery?
Chemoradiotherapy
OR chemo + stenting, palliative radio
Management of oesophageal carcinoma - palliative management - if locally advanced or metastatic?
Palliative Chemotherapy (trastuzumab + cisplatin + 5-FU)
If outflow obstruction:
• Palliative surgery
• Stenting
o Self-expanding if needed to help with dysphagia
• Radiotherapy
Definition of hiatus hernia?
- Protrusion of intra-abdominal contents through enlarged oesophageal hiatus of diaphragm
- Most commonly contains portion of stomach
- Displacement of GOJ above diaphragm reduces LOS pressure and predispose to GORD
Types of hiatus hernia?
o Sliding (Type 1) (80%) – protrusion of GOJ followed by body of stomach above diaphragm
o Type 2 (20%) – Pure para-oesophageal hernia/rolling hernia – herniation of fundus or body with GOJ below
o Type 3 – mixed
o Type 4 – Giant – any type of hernia with herniation of organs
Epidemiology of hiatus hernia?
- Many people asymptomatic
- 95% Type 1
Risk factors of hiatus hernia?
o Obesity
o Previous gastro-oesophageal procedure
o Elevated intra-abdominal pressure – pregnancy, ascites
o Age
Symptoms of hiatus hernia?
o Heartburn Typically, after meals, on bending/lying down Retrosternal burning sensation o Regurgitation Sour/metallic taste in mouth, particularly when lying flat o Dysphagia o Nausea & vomiting o Hiccups
Investigations of hiatus hernia?
- CXR o Soft tissue opacity o Retrocardial air-fluid level diagnostic of para-oesophageal hiatus hernia - Barium studies - Endoscopy - Oesophageal manometry
Management of hiatus hernia - general measures?
o Avoid factors which increase intra-abdominal pressure
o Elevate bed to relieve nocturnal symptoms
o Weight loss
o Small meals and avoid eating just before bed
o Avoid food trigger for GORD – alcohol, acidic foods
Management of hiatus hernia - drug therapy?
o If symptomatic GORD
PPIs - omeprazole