Medical Problems Involving Upper GI Tract Flashcards
What does the GI tract consist of
- oesophagus
- stomach
- duodenum
What is dysphagia
Difficulty in swallowing
Does dysphagia need to be investigated in all cases
Always needs urgent investigation to exclude malignancy unless of short duration or associated with a sore throat
What does painful swallowing indicate
Suggests oesophageal cancer, ulcer, spasm, candidiasis
What does difficulty making the swallowing movement suggest
Suspect ‘bulbar’ palsy (especially if swallowing
causes coughing)
What does difficulty to swallow solids and liquids from the outset indicate
Motility disorder or pharyngeal cause
What does intermittent dysphagia suggest
Oesophageal spasms
What does constant and declining dysphagia indicate
malignant stricture
What does the neck bulging or gurgling on swallowing indicate
Pharyngeal pouch
What malignant strictures can cause dysphagia
Pharyngeal stricture
Oesophageal stricture
Gastric cancer
What benign strictures can cause dysphagia
Oesophageal web or ring
What extrinsic pressure can cause dysphagia
Lung cancer
Retrosternal goitre
Aortic aneurysm
Left atrial enlargement
What motility disorders can cause dysphagia
- Achalasia
- Diffuse oesophageal spasm
- Systemic sclerosis
- Myasthenia gravis
- Bulbar / pseudobulbar palsy
What can cause dysphagia that isn’t a mechanical block or motility disorder
- Oesophagitis
* Globus hystericus
What is affected in myasthenia gravis
Autoimmune condition involving antibodies to ACh receptors, affects neuromuscular transmission
What are the signs of myasthenia gravis
Increasing muscular fatigue - Extraocular > Bulbar > face > neck > limbs
Ptosis - early sign
What are the clinical features of bulbar palsy
- Presentation of diseases involving cranial nuclei of IX-XII
- LMN lesion of tongue and muscles of talking and swallowing
- Flacid, fasciculation tongue
- Speech quiet, hoarse or nasal
- Normal or absent jaw jerk
What are some of the causes of bulbar palsy
- Motor Neuron Disease
- Synringobulbia
- Myasthenia gravis
Who does paterson-jelly syndrome happen most commonly in
Females
What are the clinical features of Paterson-Kelly syndrome
- Post cricoid membrane webs making swallowing hard
- Iron-deficiency anaemia
- Glossitis
- Increased incidence of both pharyngeal and oral carcinoma
What is Achalasia a problem with
- The lower oesophageal sphincter as it fails to relax
What degenerates in Achalasia
Degeneration of the Myenteric Plexus
What are the symptoms of Achalasia
Dysphagia
Regurgitation
Substernal cramps
Weight loss
What can be done to show the oesophageal dilatation
Barium swallowing
What is Achalasia a risk factor for
Oesophageal cancer
What is GORD
Gastro-Oesophageal reflux disease
What’s wrong with you in GORD
You reflux the stomach contents causing troublesome symptoms with at least two heartburn episodes each week
Associated with dysfunction of lower oesophageal sphincter
What are the potential sequelae for GORD if its prolonged/excessive
- Oesophagitis
- Benign oesophageal strictures
- Barrett’s oesophagus
What are some predisposing factors for GORD
- Hiatus Hernia
- Lower oesophageal sphincter hypotension
- Loss of oesophageal peristaltic function
- Gastric acid hypersecretion
- Delayed gastric emptying
- Overeating
- Smoking
- Alcohol
- Pregnancy
Theres more
What are the oesophageal GORD symptoms
- Heartburn
- Belching
- Acid brash (acid or bile reflux)
- Water brash (excessive salivation)
- Odynophagia (painful swallowing)
What are the extra-oesophageal GORD symptoms
- Nocturnal asthma
- Chronic cough
- Laryngitis (hoarseness, throat clearing)
- Sinusitis
What are some of the potential complications of GORD
- Oesophagitis
- Ulcers
- Benign stricture
- Barrett’s oesophagus
- Oesophageal adenocarcinoma
- Iron Deficiency anaemia
What lifestyle treatments can be used to treat GORD
- Weight loss
- Smoking cessation
- Raise bedhead
- Small regular meals
- Avoid hot or caffeinated drinks, alcohol, acidic fruits, spicy food and eating < 3 hours before bed
- Avoid drugs affecting oesophageal motility (nitrates, anticholinergics, tricyclic antidepressants) or damage mucosa (NSAIDs, bisphosphonates)
What medication can be used to treat GORD
- Antacids e.g. alginates like Gaviscon
- Proton pump inhibitors e.g. omeprazole, lansoperazole, better than H2 antagonists like ranitidine
What surgery can be done to treat GORD
- Only if symptoms are severe and refractory to medical measures and there is severe reflux
- Eg Nissen fundoplication
What are the dental features of GORD
- Unpleasant taste
- Enamel erosion
- Maybe exacerbated by treatment with NSAIDs
What causes hiatus hernia
Proximal stomach herniates into thorax
What types of hiatus hernia are there
Sliding
Rolling
AY BAWS CAN I HABE DE NOTE PLZ
50% of hiatus hernia patients have symptomatic gastro-oesophageal reflux
What form of hiatus hernia is the most common
Sliding - 80%
Rolling - 20%
What are the clinical features of sliding hiatus hernia
• Gastro-oesophageal
junction slides into chest
• Often associated with acid reflux
• Lower oesophageal sphincter less competent
What are the clinical features of rolling hiatus hernia
- Gastro-oesophageal junction remains in abdomen
- Bulge of stomach herniates into chest alongside oesophagus
- ‘para-oesophageal hernia’
- Acid reflux uncommon
- May strangulate
What investigations can be done for hiatus herniae
- Barium swallow
- Upper GI endoscopy
What treatments are there fore hiatus hernia
- Lose weight
- Treat reflux symptoms
- Surgery
When is surgical repair used in patients with hiatus hernia
- Intractable symptoms despite maximum medical therapy
- Complications
- Rolling hiatus hernia even if asymptomatic
What is Barrett’s Oesophagus caused by
Chronic reflux oesophagitis
What happens to the epithelium of a patient with barrett’s oesophagus
Normal oesophageal squamous epithelial is replaced by columnar gastric epithelium that may be continuous or patchy
What does Barrett’s oesophagus cause a much higher risk of
Adenocarcinoma of the oesophagus
AY BAWS CAN I HABE DE NOTE PLZ
Unlike gastro-oesophageal reflux disease (GORD) there is no link in barrett’s oesophagus to Helicobacter pylori
Who is mainly affected by oesophageal carcinoma
Typically in men over the age of 50
What are some of the oesophageal carcinoma risk factors
- XS alcohol
- Smoking
- Achalasia
- Obesity
- Low vitamin A and C
- GORD
- Nitrosamine exposure
- Barrett’s
- Tylosis
What are the classic clinical features of oesophageal carcinoma
- Hoarseness, cough
- Dysphagia
- Loss of weight
- Retrosternal chest pain
- Lymphadenopathy occ
What sections of the oesophagus can be affected by which types of carcinoma
Upper third - Squamous cell carcinoma
Middle third - Squamous cell carcinoma
Lower third - Adenocarcinoma
Which sections of the oesophagus are most commonly affected by carcinomas
Upper third - 20%
Middle third - 50%
Lower third - 30%
What is Tylosis characterised by (clinical features pretty much)
- Genetic disorder
- Thickening (hyperkeratosis) of palms and soles
- White patches in the mouth (oral leukoplakia)
- Very high risk of oesophageal cancer
What kind of inheritance does tylosis show
Autosomal dominant
What are the dental aspects to consider in patients with Tylosis
- Increased chance of developing second cancer in the head and neck
- May occur secondary to patterson-kelly syndrome
- Rarely patients may have tylosis and oral leukoplakia
What are some things that can indicated pharyngeal pouches
- Examinations finding are few
- Includes emaciation
- Rarely a swelling might be felt in the neck that may gurgle on palpation (Boyce’s)
- Diagnosis on barium swallow
What is Killian’s Dehiscence and how does it relate to pharyngeal pouches
This is an area of weakness between the thyropharyngeus and then cricopharyngeus, this is where the swelling will appear in the pharyngeal pouch
What are the typical signs and symptoms of pharyngeal pouches
- Age over 70
- Dysphagia
- Regurgitation
- Aspiration
- Cough
- borborygmi
- Halitosis
- Hoarseness
What is dyspepsia
Non-specific group of symptoms related to upper GI tract
What are some non-specific symptoms of dyspepsia
- Epigastric pain maybe related to eating some foods, hunger and time of day
- Heartburn
- maybe associated with bloating and fullness after meals
What are the ALARMS/warning signs of non specific symptoms that need to be investigated
- Anaemia
- Loss of weight
- Anorexia
- Recent onset with progressive symptoms
- Melaena or haematemesis
- Swallowing difficulty
What is an ulcer
A break in the continuity of an epithelial surface
What are some of the risk factors of peptic ulceration
Helicobacter pylori infection
Drugs - aspirin, NSAIDs, corticosteroids
Smoking
Stress
Why do drugs like aspirin and dat help to cause peptic ulcers
They reduce prostaglandin production that protects the mucosal surface of the stomach
What are the 2 types of peptic ulceration
Gastric
Duodenal
What are the typical clinical features of gastric ulceration
- Mainly elderly
- Affects lesser curve of stomach
- Asymptomatic
- Epigastric pain related to meals and relieved by antacids
- Weight loss
What are the typical clinical features of duodenal ulceration
- 4x more common than gastric ulceration
- May be asymptomatic
- Epigastric pain typically before eating or at night
- Relieved by eating or drinking milk
What risk factors are there for gastric cancer
- Helicobacter pylori infection
- Cigarette smoking
- Alcohol
- Dietary salt and food preservation
- Dietary fruit and vegetable
- Pernicious anaemia
What are some of the clinical presentations of gastric cancer
- Often non-specific and vague
- Typically male smokers aged 60-84 with upper abdominal pain and weight loss
- Nausea
- Dysphagia
- Melaena
- Anaemia
- Virchow’s node
- Sister Mary Joseph’s nodule
What are some alarm features that are suggestive of gastric cancer that need to be investigated immediately
- New onset dyspepsia in patients > 55 years
- Family history of upper GIT cancer
- Unintended weight loss
- Upper or lower GI bleeding
- Progressive dysphagia
- Odynophagia
- Unexplained iron deficiency anaemia
- Persistent vomiting
- Palpable mass or lymphadenopathy
- Jaundice
What investigations can be done for gastric cancers
- Endoscopy and biopsy or primary tumour
- At least six biopsy samples from mass and adjacent tissue
- Staging may involve endoscopic ultrasonography (EUS)
- CT abdomen for liver metastases
- PET scan
What is haematemesis
Vomiting of blood - may be fresh red or coffee grounds
What is Melaena
Black motions with a tarry appearance and smell
What are some common causes of haemorrhage/GI bleeding
- Gastritis or gastric erosions
- Duodenitis
- Oesophagitis
- Peptic ulcers
- Drugs - NSAIDs, aspirin, corticosteroids, warfarin, thrombolytics
- Mallory-Weiss tear
- Malignancy
What are varices
- Dilated collateral veins at sites of portosystemic anastomosis
What are varices in the GIT caused by
Portal hypertension
Where are varices most commonly found
Lower oesophagus but also the stomach
What is Mallory-Weiss tear/syndrome caused by
Forceful or long-term vomiting or coughing resulting in bleeding via an oesophageal tear
What layers of the GIT does a Mallory-Weiss tear affect
The mucosa and submucosa but not the underlying muscular layer
What are Mallory-Weiss tears/syndrome associated with
- Alcoholism
- Eating disorders
- Hyperemesis
- Gravidarum
- Epileptic convulsions
- NSAID abuse
How are Mallory-Weiss tears treated
- They usually heal themselves without active treatment support with/out PPI or H2 antagonist
- Bleeding usually stops after 24-48 hours
- Endoscopic cauterisation or injection of adrenaline or surgical management or embolisation occasionally required
What are the initial management processes of an upper GI bleed
- Protect the airway and give a high flow of O2
- Resuscitate ABC
- 2 large bore cannulae
- FBC, U&E, LFT, crossmatch, clotting
- IV fluids and omeprazole
- Urinary catheter
- Transfuse
- Urgent endoscopy
