GI1 Flashcards
Upper GI
What is the definition of peptic ulcer disease?
Break in the epithelial lining of the gastrum or duodenum
What are the symptoms of PUD?
Recurrent epigastric pain related to eating Early satiety Nausea and vomiting Potential anorexia and weight loss Anaemic symptoms
What are the signs of PUD?
Epigastric tenderness
Pointing sign (able to locate specific pain)
Anaemic signs
Are duodenal or gastric ulcers more common?
Duodenal ulcers
What are the key characteristics of duodenal ulcers?
Pain 2-3 hrs after eating
Antacids relieve pain
Weight gain due to overeating
What are the key characteristics of gastric ulcers?
Pain shortly after eating
Antacids don’t relieve pain
Weight loss due to undereating
What are the risk factors for PUD?
H pylori NSAIDS Bisphosphonates Smoking Head trauma (Cushing ulcer) Zollinger Ellison syndrome
What is the mechanism of NSAID induced PUD?
NSAIDs inhibit COX1
Decreased prostaglandin production decreases mucosal protection
Decreased thromboxane reduces gastric mucosal blood flow
What type of bacteria is Helicobacter pylori?
Gram negative rod flagellate
What investigations can be done for a H pylori-induced ulcer?
13C urea breath test (stop PPI before test)
Stool antigen test
What is the treatment for H pylori-induced ulcers?
Diet, smoking, NSAIDs/bisphosphonates
PPI
Clarithromycin
Amoxicillin OR metronidazole
What are the complications of a H pylori-induced ulcer?
Perforation
Gastric carcinoma
Lymphoma
What is Zollinger-Ellison syndrome?
Pacreatic neuroendocrine tumour Secretes gastrin (gastrinoma) Increased gastric acids therefore PUD Associated with MEN1 Malabsorption
When should you consider Zollinger-Ellison syndrome?
Multiple peptic ulcers refractory to treatment
FHx of MEN
What investigations should you do on a Pt with Zollinger-Ellison syndrome?
Fasting serum gastrin
Serum calcium (parathyroid tests)
Gastric acid secretory tests
What is the management for Zollinger-Ellison syndrome?
PPI
Surgical resection
What is the prognosis for Zollinger-Ellison syndrome?
Good, as long as the tumour has not metastasised
How does Cushing’s ulcer occur?
Head trauma
Raised ICP
Increased vagal stimulation
Increased gastric acid secretion
How does Curling’s ulcer occur?
Severe burn injuries
Reduced plasma volume
Ischaemia and necrosis of gastric mucosa
What is the treatment for H pylori negative ulcers?
Diet, smoking, NSAIDs, bisphosphonates
PPI or H2 antagonist (ranitidine)
How would you manage a haemorrhagic ulcer?
Visualise bleed (endoscopy)
Adrenaline
IV PPI
+/- transfusion
How would you manage a perforated ulcer?
NBM
IV ABx
Surgery
What is the most common gastric cancer?
Adenocarcinoma
What are the symptoms of gastric cancer?
Epigastric pain
Nausea + vomiting
Anorexia
Weight loss
What are the risk factors of gastric cancer?
Smoking
H pylori
Chronic gastritis
What are the signs of gastric cancer?
Palpable Virchow’s node/Troisier’s sign
Palpable epigastric mass
Sister Mary Joseph nodule (mass in the umbilicus)
[NB: these are non-specific for abdominal cancer, not just gastric]
What is the cause of GORD?
Reflux of gastric contents in to the oesophagus
What may a Pt with GORD present with?
Heartburn Regurgitation Dysphagia Coughing/wheezing Hoarseness/sore throat Non-cardiac chest pain Enamel erosion
What are the risk factors for GORD?
Increased intra-abdominal pressure: -Obesity -Pregnancy Lower oesophageal sphincter hypotension: -Drugs (anti-muscarinics, CCBs, nitrates, smoking) -Achalasia treatment -Hiatus hernia Gastric hypersecretion: -Diet -Smoking -Zollinger Ellison syndrome
What are the types of hiatus hernias?
Congenital vs acquired
Acquired can be: traumatic vs non-traumatic
NT can be: sliding vs para-oesophageal
What are the risk factors for hiatus hernias?
Similar to GORD Muscle weakening w/ age Pregnancy Obesity Abdominal ascites
What investigations would you do on a Pt with a hiatus hernia?
Barium swallow
Chext x-ray
Endoscopy
What is the management for a Pt with a hiatus hernia?
Risk factor modification
PPIs
Nissen fundoplication
What is the investigation for a Pt with GORD?
NA
GORD is a clinical diagnosis
What is the management for a Pt with GORD?
Conservative: -Avoid precipitants/lose weight -Sleep with more pillows -Stop smoking Medical: -PPI/H2 antagonist Surgical: -Nissen fundoplication (if HH is the cause) -Endoluminal gastroplication
What if the GORD symptoms persist/get worse after a trial of PPIs?
Endoscopy
What may be seen upon endoscopy of a Pt with GORD?
Oesophagitis
Barrett’s
What are the complications of GORD?
GORD -> metaplasia ->
Barrett’s -> dysplasia ->
Oesophageal cancer
What is Barrett’s oesophagus?
Metaplasia of the oesophagus due to chronic oesophagitis
What is the histological change in Barrett’s oesophagus?
Squamous epithelia into columnar epithelia
What is the risk of oesophageal cancer for a Pt with Barrett’s?
11 times
What is the management for high grade dysplasia Barrett’s?
Radiofrequency ablation
PPIs
What is the management for nodule dysplasia Barrett’s?
Endoscopic mucosal resection
PPIs
What are the symptoms of oesophageal cancer?
Progressive dysphagia from solids to liquids
Burning chest pain
Red flag symptoms (weight loss, anaemia)
What are the two types of oesophageal cancer?
Adenocarcinoma
Sqaumous cell
Where are oesophageal adenocarcinomas located and what are the associated risk factors?
Lower third
Barrett’s
Where are oesophageal squamous cell carcinomas located and what are the associated risk factors?
Middle third
Smoking, alcohol
What are the investigations for a Pt with oesophageal cancers?
OGD endoscopy and biopsy
CT to stage cancer
How can dysphagia be categorised?
High or low dysphagia
Functional or structural
What are the causes of functional high dysphagia?
Stroke Parkinsons Myaesthenia gravis MS MND
What are the causes of structural high dysphagia?
Cancer
Pharyngeal pouch
What are the causes of functional low dysphagia?
Achalasia
Oesophageal spasm
Limited cutaneous scleroderma (CREST syndrome)
What are the causes of structural low dysphagia?
Cancer
Stricture
Plummer-Vinson syndrome
Foreign body
What are the symptoms of achalasia?
Dysphagia- solids and liquids
Regurgitation
Dyspepsia
Weight loss
What is the cause of achalasia?
Absence of oesophageal peristalsis
Failure of LOS relaxation
Due to lack of ganglion cells in myenteric plexus
In what situation should you assume dysphagia is due to oesophageal cancer?
New onset dysphagia
Age >55
Carcinoma until proven otherwise
What are the potential investigations for dysphagia?
Barium swallow
Endoscopy
Videofluoroscopy
Manometry
When would you consider the use of a barium swallow?
Pharyngeal pouch- avoid perf on endoscopy
Achalasia
Hiatus hernia
When would you consider the use of endoscopy?
First line, most specific and sensitive
When would you consider the use of videfluoroscopy?
Used by SALT as a treatment
Can help modify a Pt’s swallowing technique
When would you consider the use of manometry?
Useful for achalasia/oesophageal spasm
Often used only when other investigations are unremarkable
What is a Mallory-Weiss tear?
Tear in the mucosal layer of the oesophagus
What is the cause of a Mallory-Weiss tear?
Raising intra-gastric pressure
- Vomiting
- Alcohol intake
- Bulimia
How do you diagnose a Mallory-Weiss tear?
Endoscopy
What is Boerhaave syndrome?
Full tear of the oesophageal wall, from a Mallory-Weiss tear
What investigations would you do on a Pt with Boerhaave syndrome?
CXR
CT Chest
What are you looking for in a CXR/CT of a Pt with Boerhaave syndrome?
Pneumomediastinum
Can also see pleural effusion, pneumothorax, wide mediastinum, subcutaneous emphysema
What is the management for a Pt with Boerhaave syndrome?
Analgesic, antiemetic, fluid resusitation
Surgical management
What is Mackler’s triad for Boerhaave syndrome?
Chest pain
Vomiting
Subcutaneous emphysema
What are oesophageal varices?
Dilated submucosal veins in lower third of oesophagus
What is the cause of oesophageal varices?
Portal hypertension
Due to cirrhosis
What is the presentation of oesophageal varices?
Extreme haematemesis
May be unconscious/in shock
Malaena
What investigations would you do on a Pt with oesophageal varices?
FBC- macrocytic anaemia, dec platelets
LFT- inc GGT, inc bilirubin, dec albumin
U+E- inc urea
(signs of alcoholism/cirrhosis)
What is the management of a Pt with oesophageal varices
ABCDE
Fluid resus
Terlipressin- reduce portal hypertension
Endoscopy- band ligation is first line
What is the presentation of a ruptured peptic ulcer?
Background of PUD
(Long term NSAID use/H pylori infx)
Coffee ground emesis
Malaena
What investigations would you do for a Pt with a ruptured peptic ulcer?
BP- low
FBC/LFTs- normal (rule out varices)
Endoscopy
What is the management for a Pt with a ruptured peptic ulcer?
Endoscopy w/ IM adrenaline at site of ulcer
PPI
Triple therapy if H pylori infx
A 45 year old woman presents with a 2 month history of upper abdominal pain, occurring 2-3 hours after meals. The GP orders some blood tests, which shows microcytic anaemia and normal LFTs. Which of these is the likely diagnosis?
A. GORD B. Duodenal ulcer C. Gastric ulcer D. Biliary colic E. Cholecystitis
B. Duodenal ulcer
Normal LFts rules out biliary colic. Microcytic anaemia indicates blood loss, and having a few hours’ interval between the pain indicates a duodenal ulcer.
A 61 year old man presents to his GP with a 3 month history of upper abdominal pain following meals. On questioning, he describes this pain as burning and is able to point to the pain on his abdomen. He reports having noticed his clothes have been looser recently, and has a long standing history of headaches. Which of these is the most important investigation to arrange?
A. H. pylori breath test B. Full blood count C. OGD endoscopy D. Trial of proton pump inhibitor (PPI) E. Abdo XR
C. OGD endoscopy
The diagnosis is likely to be an ulcer due to the burning pain and pointing sign. However there is a risk of this being cancer due to the weight loss and age >55. Therefore this case should be referred for an endoscopy asap. The headache can be indicative of 2 things:
A. a SOL metastasis
B. a headache which is treated with a long term use of NSAIDs, leading to a potential ulcer
A 40 year old lady presents to her GP with heartburn and problems swallowing. She reports that the heartburn worsens at night, and is often accompanied by a ‘funny taste’ in her mouth and cough. She reports no change in weight or systemic symptoms. Which of these should be the next step?
A. OGD endoscopy B. Barium swallow C. Manometry D. Serum gastrin levels E. Trial of proton pump inhibitor (PPI)
E. Trial of proton pump inhibitor (PPI)
This is a classic presentation of GORD, for which a PPI trial is both diagnostic and therapeutic.
A 59 year old man presents with severe retrosternal burning pain. Upper GI endoscopy shows ‘metaplastic changes within the epithelium’. Which of these is the most likely diagnosis?
A. Gastric ulcer B. Gastric carcinoma C. Oesophageal carcinoma D. GORD E. Barrett’s oesophagus
E. Barrett’s oesophagus
The latter 3 are more likely than the first 2, however the histological description is characteristic of Barrett’s oesophagus.
A 28 year old lady presents with a 2-year history of mild dysphagia to both solids and liquids. She has no weight loss, but symptoms of heartburn and nocturnal cough. PPIs and bronchodilators haven’t helped. She is systemically well, and her examination is unremarkable. A “bird’s beak” appearance is noted on barium swallow. What is the most likely diagnosis?
A. Achalasia B. Benign stricture C. Plummer-Vinson syndrome D. Oesophageal spasm E. Stroke
A. Achalasia
Bird-beak is characteristic of achalasia
A 76-year old retiree visits her GP with difficulty swallowing solids. She says this has been getting progressively worse over 1 month. There is no coughing, choking or heartburn. She reports food getting “stuck” 2-3 seconds after swallowing. She attributes her weight loss to not eating properly, and also thinks this has caused loose, brown-black stools. She feels tired. Bloods show a microcytic anaemia. Select the likely diagnosis:
A. Stroke B. Oesophageal cancer C. Pharyngeal pouch D. Plummer-Vinson syndrome E. Benign stricture
B. Oesophageal cancer
A pharyngeal pouch or benign stricture would not cause weight loss. A solid dyphagia and progressive dysphagia means a stroke is unlikely. Although PV syndrome may explain the IDA, it doesn’t explain the malaena or the worsening progression.
A 53-year old man staggers into A&E having vomited 6 times in 2 hours. He is intoxicated and jaundiced. His friend said his vomit was initially “normal”, but after the first couple of episodes had fresh blood in it. His blood pressure is 120/90 and HR 70 bpm. What is the most likely diagnosis?
A. Ruptured oesophageal varices B. Mallory-Weiss tear C. Ruptured peptic ulcer D. Boerhaave syndrome E. Oesophagitis
B. Mallory-Weiss tear
This is unlikely to be a variceal rupture, as they present with sudden vomiting of fresh blood, whereas this case had a period of normal blood followed by bleeding afterwards. The is not in shock, hence further ruling out a varix or Boerhaave syndrome. A ruptured ulcer would present with abdominal pain and coffee ground blood.
A 47 year old man is brought into A&E having vomited blood. His wife reports he developed food poisoning 2 days ago. Suddenly this morning he experienced extreme chest pain and began to vomit blood. His HR is 110 and BP 85/60. On auscultation of his chest you hear a crackling sound and his CXR shows pneumomediastinum. What is the most likely diagnosis?
A. Ruptured oesophageal varices B. Mallory-Weiss tear C. Ruptured peptic ulcer D. Boerhaave syndrome E. Myocardial infarction
D. Boerhaave syndrome
This patient presents with Mackler’s triad: chest pain, emesis, and subcutaneous emphysema. The CXR also shows air in the mediastinum, and the food poisoning indicates a history of abdominal straining.
