General - Stomach + Oesophagus Flashcards
Define a hiatus hernia
Protrusion of an organ from the abdominal cavity into the thorax via the oesophageal hiatus
What are the two subtypes of hiatus herniae?
Sliding hiatus hernia (80%)
Rolling or para-oesophageal hernia (20%)
List some of the risk factors for developing a hiatus hernia
Age - loss of diaphragmatic tone, increased intra-abdominal pressure, increased size of hiatus
Pregnancy
Obesity
Ascites
Describe the typical presentations of a hiatus hernia
- Completely asymptomatic
- GORD symptoms
- Vomiting + weight loss
- Bleeding +/- anaemia
- Hiccups or palpitations
- Swallowing difficulties
Why may you get bleeding with or without anaemia in a hiatus hernia?
Secondary to oesophageal ulceration
What are the examination findings of a patient with a hiatus hernia?
Typically normal
If large then bowel sounds may be heard in the chest
What are the main DDx to exclude in a case of a hiatus hernia?
- Cardiac chest pain
- Gastric or pancreatic cancer
- GORD
What is the gold standard investigation for a hiatus hernia?
OGD - will show displacement of the GOJ
What conservative management is indicated for a hiatus hernia?
PPIs Weight loss Alteration of diet - low fat, earlier meals, smaller portions Sleeping more uprights Smoking cessation Reduced alcohol intake
When is surgical management indicated for a hiatus hernia?
- Patient remains symptomatic regardless of max medical therapy
- Increased risk of strangulation/volvulus
- Nutritional failure due to gastric outlet obstruction
What are the main aspects of hiatus hernia surgery
Cruroplasty (reduction of hernia and hiatus size)
Fundoplication (strengthens the LOS)
What are specific complications related to hiatus hernia surgery?
- Hernia recurrence
- Abdominal bloating (unable to belch)
- Dysphagia
- Fundal necrosis
What are the main complications of hiatus herniae?
Incarceration
Strangulation
What is the name given for the clinical presentation of gastric volvulus and what is it?
Borchardt’s triad:
- Severe epigastric pain
- Retching without vomiting
- Inability to pass an NG tube
Define a peptic ulcer
A break in the lining of the GI tract, extending through the muscular mucosae
Where are peptic ulcers most commonly located?
Lesser curvature of the proximal stomach or first part of the duodenum
What are the common causes for peptic ulcer disease?
- H pylori infection
- NSAID overuse
- Excess alcohol
- Steroid overuse
- Zollinger-Ellison syndrome
What is helicobacter pylori?
Gram negative spiral bacillus
Survives by producing an alkaline micro-environment which induces an inflammatory response in the mucosa
How does H pylori cause ulceration?
- Cytokine and interleukin driven inflammatory response
- Increasing gastric acid secretion (induces histamine release)
- Degredation of surface glycoproteins and down regulating bicarb production (damages mucous secretion)
What mnemonic can be used for basis of referral for urgent endoscopy for malignancy?
ALARMS A - Anaemia L - Lost weight A - Anorexia R - Recent rapid onset M - Melaena S - Swallowing difficulties
When do the NICE guidelines suggest referral for urgent OGD?
- New onset dysphagia
- Age >55yrs with weight loss and
1. upper abdominal pain
2. Reflux
3. Dyspepsia - New onset dyspepsia not responding to PPIs
What is the classic clinical presentation of a gastric ulcer?
- Epigastric pain, typically exacerbated by eating
- Nausea and anorexia
- Weight loss
What is the typical presentation of a duodenal ulcer?
Epigastric pain - worse around 2-5hrs post meal, but often alleviated by eating
What differentials should be ruled out before diagnosing a peptic ulcer?
- Gastric malignancy
- Pancreatitis
- ACS
- GORD
- Gallstone disease
What is Zollinger-Ellison Syndrome?
Triad of
- Severe peptic ulcer disease
- Gastric acid hypersecretion
- Gastrinoma
What non-invasive H pylori testing is there?
- Urea breath test
- Serum antibodies to H pylori
- Stool antigen test
What is needed to reduce risk of a false negative H pylori test?
Stop any current medical therapy 2 weeks prior to test
What is done with biopsies taken from an OGD of a peptic ulcer?
Histology and rapid urease CLO test
What is the triple therapy for H pylori positive peptic ulcers?
- PPI
- Amoxicillin
- Clarithromycin or metronidazole
What is the initial medical treatment for peptic ulcers?
PPI for 8 weeks
What surgery can be done in peptic ulcer disease?
Partial gastrectomy
Selective vagotomy
By what mechanism are NSAIDs responsible for causing gastric ulceration?
Inhibition of prostaglandin secretion
What condition is most commonly associated with Zollinger-Ellison syndrome?
Multiple Endocrine Neoplasia
1/3 of cases are discovered as part of type 1 MEN
What is used in the diagnosis of Zollinger Ellison Syndrome?
Fasting gastrin levels
gastrin level >1000pg/ml
Why are gastric cancers the 2nd highest cause of cancer related deaths?
Patients often present with advanced disease
What are the different types of gastric cancers?
- Adenocarcinomas (>90%)
- CT malignancy
- Lymphoid
- Neuroendocrine
Where is gastric cancer more common?
Far Eastern countries eg. Japan and Korea
What are the major risk factors for development of gastric cancer?
- Male
- H pylori infection (^6x)
- Increasing age
- Smoking
- Alcohol consumption
(+high salt diet, FHx, pernicious anaemia)
How does H pylori create an alkaline microenvironment?
Produces urease which breaks down urea into CO2 and ammonia. The ammonia neutralises the stomach acid
What are the common presenting symptoms of gastric cancer?
- Dyspepsia (new onset or non responsive to PPI)
- Dysphagia
- Early satiety
- Vomiting
- Melena
What is used for the definitive diagnosis of gastric malignancy?
OGD + biopsy for:
- Histology
- CLO test
- HER2/neu protein expression
Why is a CT scan not used for gastric malignancies?
It does not allow for direct visualisation or biopsy
What is used for staging of gastric cancers?
CT Chest-Abdo-Pelvis + staging laparoscopy (look for mets)
What is required to maintain adequate nutrition in a patient with gastric cancer?
Nutritional status assessment
+ Review with a dietician
What does peri-operative chemotherapy in gastric cancer consist of?
3 cycles of neoadjuvant therapy and 3 cycles of adjuvant
What surgery is indicated for proximal gastric cancers?
Total gastrectomy
What surgery is indicated for distal gastric cancers? What part does this refer to?
Antrum or pylorus
Subtotal gastrectomy
What method is most commonly used for reconstructing the GI tract? Why?
Roux-en-Y reconstruction
Best functional result - less bile reflux
What may be offered to patients with early T1a gastric tumours (confined to muscularis mucosa)?
Endoscopic Mucosal Resection
What complications are there for gastrectomy?
- Death (3-5%)
- Anastomotic leak
- Reoperation
- Dumping syndrome
- Vit B12 deficiency
What is included in the palliative management for gastric cancer?
- Chemotherapy
- Best supportive care
- Stenting (for outlet obstruction)
- Palliative surgery
What are the main complications of gastric cancers?
- Gastric outlet obstruction
- Iron deficiency anaemia
- Perforation
- Malnutrition
Why is a PET scan not used for imaging of gastric cancers?
They do not take up the radioactive tracer well
What is a Mallory-Weiss tear?
Superficial mucosal tear of the oesophageal wall - usually at the gastro-oesophageal junction
What is Boerhaave’s syndrome?
Spontaneous full thickness rupture of the oesophageal wall
What is Mackler’s triad?
For oesophageal rupture
- Vomiting
- Chest pain
- Subcutaneous emphysema
What are the most common causes for oesophageal rupture?
- Iatrogenic
- Severe forceful vomiting
What is the definitive investigation for oesophageal rupture? What is seen on this?
CT chest/abdo/pelvis with IV + oral contrast
–> air/fluid in the mediastinum or pleural cavity - leakage of oral contrast from oesophagus into mediastinum/chest is pathognomonic
What are the principles of definitive management for an oesophageal rupture?
- Control of the leak
- Eradication of mediastinal/pleural contamination
- Decompression of the oesophagus
- Nutritional support
What is the surgical management for an oesophageal rupture?
- On table OGD –> find the site of perforation for site of incision
- Immediate surgery (usually thoracotomy) –> control leak + wash out chest
(- Feeding jejunostomy –> for nutrition)
What is required prior to commencing oral intake in an oesophageal rupture? Why?
CT scan 10-14 days before –> leakage is common
What non-operative management is there for oesophageal rupture?
- Resuscitation + transfer to ICU/HDU
- Abx and anti-fungal cover
- NBM for 1-2 weeks
- Endoscopic insertion of an NG tube
- Large bore chest drain insertion
- TPN or feeding jejunostomy
What is the prognosis for oesophageal rupture?
High morbidity and mortality (50-80%)
What is the usual history for a Mallory-Weiss tear?
Period of profuse vomiting –> short period of haematemesis
How are Mallory-Weiss tears generally managed?
Conservatively - usually small and self limiting
What are two major causes of oesophageal dysmotility?
- Achalasia
- Diffuse oesophageal spasm
What is achalasia characterised by?
Failure of relaxation of the lower oesophageal sphincter + progressive failure of contraction of the oesophageal smooth muscle
What histological feature is characteristic for achalasia?
Progressive destruction of ganglion cells in the myenteric plexus
How will patients with achalasia often present?
- Progressive dysphagia
- Vomiting
- Chest discomfort
- Regurgitation of food
- Coughing
- Chest pain
- Weight loss
What initial investigation is used for dysphagia? Why?
Urgent endoscopy
–> Exclude oesophageal cancer
What is the gold standard investigation for oesophageal motility disorders?
Oesophageal manometry - pressure sensitive probe inserted into oesophagus to measure pressure of sphincter + surrounding muscle
What are the key features of achalasia on manometry?
- Absence of oesophageal peristalsis
- Failure of relaxation of the LOS
- High resting LOS tone
What is characteristically seen on a barium swallow for achalasia?
‘Birds beak’ distally + proximal dilation
What conservative management is there for achalasia?
- Sleeping with multiple pillows
- Eating slowly + chewing thoroughly
- Plenty of fluids with food
- CCB’s/nitrates (temporary relief)
- Botox injections into LOS
What are the main surgical treatments for achalasia?
- Endoscopic balloon dilatation
- Laparascopic Heller myotomy
What is diffuse oesophageal spasm?
Disease caused by multifocal high amplitude contractions of the oesophagus
What causes diffuse oesophageal spasm?
Dysfunction of oesophageal inhibitory nerves
What is seen on a barium swallow for diffuse oesophageal spasm?
Corkscrew appearance
What is seen on manometry for diffuse oesophageal spasm?
Repetitive, simultaneous and ineffective contractions of the oesophagus
+/- LOS dysfunction
What is the management for diffuse oesophageal spasm?
- Nitrates or CCB –> relax oesophageal smooth muscle
- Pneumatic dilatation (if hypotension of LOS)
- Myotomy (if very severe)
What autoimmune and CT disorders are associated with oesophageal dysmotility?
- Systemic sclerosis
- Polymyositis
- Dermatomyositis
What are the two main types of oesophageal cancer?
- Squamous cell carcinoma
- Adenocarcinoma
What is squamous cell carcinoma of the oesophagus strongly associated with?
- Smoking
- Excessive alcohol consumption
- Chronic achalasia
- Low vitamin A
- Iron deficiency (rare)
What are the risk factors of adenocarcinoma of the oesophagus?
- Long standing GORD
- Obesity
- High dietary fat
Which part of the oesophagus does squamous cell carcinoma tend to affect?
Middle + upper 2/3rds
What does adenocarcinoma of the oesophagus develop from? Where does it affect?
Barrett’s oesophagus
Lower 1/3rd
What are the red flag symptoms indicated by NICE for urgent endoscopy for suspected oesophageal malignancy?
- Patients with dysphagia
- Patients >55yrs with weight loss + upper abdo pain, dyspepsia or reflux
What symptoms may a patient with oesophageal cancer present with?
- Dysphagia (progressive)
- Significant weight loss
- Odonyphagia
- Hoarseness
What is the investigation of choice for suspected oesophageal malignancy?
OGD –> biopsy + send for histology
What staging investigations are done before treatment is commenced in oesophageal malignancy?
- CT chest/abdo/pelvis
- PET-CT scan
- Endoscopic USS
- Staging laparoscopy
What is the curative treatment for squamous cell carcinomas of the oesophagus?
- Upper –> definitive chemoradiotherapy
- Middle/lower –> definitive chemoradiotherapy or neoadjuvant CRT + then surgery
What is the curative management for an adenocarcinoma of the oesophagus?
Neoadjuvant chemotherapy or chemoradiotherapy followed by oesophageal resection
What are the main complications for oesophageal surgery?
- Anastamotic leak
- Re-operation
- Pneumonia
- Death
What is involved in an oesophagectomy?
Removal of the tumour, top of the stomach and surrounding lymph nodes –> stomach made into a conduit to replace the oesophagus
What palliative options may be given for a patient with oesophageal cancer?
- Oesophageal stent
- Radiotherapy + chemotherapy (reduce tumour size + bleeding - improves symptoms)
- Photodynamic therapy
- Nutritional support
- RIG tube
What is the five year survival for oesophageal cancer? Why?
5-10%
Late presentation
What is the pathophysiology being GORD?
Frequent reflux of gastric contents into the oesophagus –> pain + mucosal damage
What are the risk factors for GORD?
- Age
- Obesity
- Male
- Alcohol
- Smoking
- Caffeine
- Fatty or spicy foods
What are the clinical features of GORD?
- Burning retrosternal chest pain
- Pain worse after meals, lying down or bending over
- Belching excessively
- Odynophagia
- Chronic cough
What classification system is used to grade GORD? Briefly outline this
Los Angeles Classification Grade A - breaks ≤ 5mm Grade B - breaks >5mm Grade C - breaks extending between the tops of ≥2 mucosal folds but <75% circumference Grade D - circumferential breaks (≥75%)
What are the main DDx to consider for GORD?
- Malignancy
- Peptic ulceration
- Oesophageal motility disorders
- Oesophagitis
- Coronary artery disease
- Biliary colic
When is upper GI endoscopy used for GORD?
- New onset in older patients
- Worsening despite PPI treatment
What is the gold standard in diagnosis for GORD? When is it used?
24hr pH monitoring
Used if medical treatment fails and surgery is considered
What are the indications for surgery in GORD?
- Failure to respond/partial response to medical therapy
- Patient preference to avoid life-long medication
- Patients with complications of GORD (particularly respiratory complications)
What surgical option is there for GORD? What does this involve?
Fundoplication - fundus wrapped around the GOJ
What are the main complications of GORD?
- Aspiration pneumonia
- Barrett’s oesophagus
- Oesophagitis
- Oesophageal strictures
- Oesophageal cancer
Define Barrett’s oesophagus
Metaplasia of the oesophageal epithelial lining - normal stratified squamous epithelium is replaced by simple columnar epithelium
What is seen on OGD for Barrett’s oesophagus?
- Red + velvety oesophagus
- Preserved pale squamous islands
What is the management for Barrett’s oesophagus?
- High dose PPI
- Stop NSAIDs
- Lifestyle advice
- Regular endoscopy (check for progression to adenocarcinoma)
What surgical management is there for high grade dysplasia of Barrett’s oesophagus?
- Endoscopic mucosal resection (EMR)
- Endoscopic submucosal dissection (ESD)
