Oesophageal and Gastric Disorders Flashcards
3 things that can cause GORD
incompetent LOS, poor oesophageal clearance, barrier function/ visceral sensitivity.
In GORD there is a _____ correlation between symptoms and endoscopic findings, this is because people have varying sensitivities to _____
poor
acid
9 symptoms of GORDS
- Heartburn
- Acid reflux
- Waterbrash
- Dysphagia
- Odynophagia
- Weight loss
- Chest pain
- Hoarseness
- Coughing
3 investigations for reflux?
- Endoscopy
- Barium swallow (much less likely to do this)
- Oesophageal manometry and pH studies (put probe down and when you get acid in your oesophagus it will register this, probe stay there for 24hrs)
In GORD what are alarm symptoms in which endoscopy will be immediately done?
- Dysphagia
- Weight loss
- Anaemia
- Vomiting
- Family History
- Barretts
Two complications of GORD?
- Adenocarcinoma
* Barretts
What drug for GORD provides both symptom relief and heals oesophagitis?
PPIs- omeprazole
What do all people with Barrett’s oesophagus go on?
Life long PPIs twice a day
If high grade dysplasia is found in Barretts oesophagus what is done?
Nodular lesions can be removed if not nodular can be given high dose protein pumps
What is Achalasia?
Lower oesophageal sphincter doesn’t open properly so get dysphagia and food sticks around in the oesophagus
Clinical features of achalasia?
Long history of Intermittent dysphagia
Regurgitation of food from dilated oesophagus
Complication of achalasia?
Aspiration pneumonia
What is gastroparesis?
Delayed gastric emptying but no physical obstruction, can be caused by diabetes, drugs or be idiopathic
Symptoms of gastroparesis?
Feeling full a lot of time, Nausea, Vomiting, Weight loss, Upper abdominal pain
Management of gastroparesis?
Removal of precipitating factors, eat more liquids, eat little and often
Define dyspepsia
Basically indigestion
symptoms of bothersome postprandial fullness, early satiation, epigastric pain, epigastric burning
Causes of dyspepsia
Peptic ulcer disease
Drugs NSAIDs
Gastric cancer
Management of dyspepsia/ patient complaining of indigestion?
Consider other organs
If predominant heart burn manage as GORD
If it is true dyspepsia then check for alarm symptoms: dysphagia, weight loss, GI bleeding, persistent vomiting, unexplained weight loss, upper abdominal mass
If there are no alarm symptoms can manage as functional dyspepsia and give lifestyle advice if alarm symptoms make relevant referral.
What is functional dyspepsia?
Presence of one of the symptoms of bothersome postprandial fullness, early satiation, epigastric pain, epigastric burning AND no evidence of structural disease on endoscopy
Define a peptic ulcer
A break in the superficial epithelial cells penetrating down to the muscularis mucosa of either the stomach or the duodenum, there is a fibrous base and an increase in inflammatory cells
Duodenal ulcers are most commonly found in the ___________ and gastric ulcers are most commonly seen on ___________. Duodenal ulcers are more _________
duodenal cap
the lesser curve near the incisura
common
2 causes of peptic ulcer disease?
H. pylori infection or NSAID induced
Clinical features of peptic ulcers?
Recurrent burning epigastric pain. Anorexia and weight loss may occur.
Gastric ulcers tend to have worse pain when eating and duodenal ulcer pain tends to be relieved by eating.
Describe H pylori infection and how it relates to gastric disease
This is acquired in infancy
The majority of people have no pathology
Some develop ulcers
Even smaller amount get cancer
Diagnosis of H. Pylori?
- gastric biopsy and do urease test, histology or culture
- urease breath test
- FAT (faecal antigen test)
- serology (IgA antibodies) - not accurate with increasing patient age
Treatment of peptic ulcers?
Patients that are H. Pylori positive should have eradication therapy- this involves antibiotics and PPIs
PPI + amoxycillin 1g bd + clarithromycin/ metranidazole 500mg bd
PPI + metronidazole 400mg bd + clarithromycin 250mg bd (if pen allergic)
If H. pylori negative go on antisecretory therapy- PPIs
With gastric ulcers there is follow up at 6-8 weeks to ensure healing and no malignancy
Achlorhydria increases risk of __________and this is absence of hydrochloric acid in secretions
gastric cancer
Cardinal features of an acute upper GI bleed are?
haematesmesis (vomiting of blood) and melaena (the passage of black tarry stools the colour due to blood altered by passage through the gut)
What is the most common cause of serious and life threatening upper GI bleeding?
Peptic ulcer
Emergency endoscopic treatment of peptic ulcers?
- Injection
- Heater probe coagulation
- Combinations
- Clips
- Haemospray
What are varices? Explain acute variceal bleeding
Varices are dilated blood vessels in the esophagus or stomach caused by portal hypertension.
If they rupture they will bleed
Complication of liver failure
When do you suspect someone with varices with an upper GI bleed?
Known history of cirrhosis with varices
History: chronic alcohol excess, chronic viral hepatitis infection, metabolic or autoimmune liver disease, intra-abdominal sepsis/surgery
Oesophageal tumours risk factors?
High levels of tobacco for both
Alcohol more for squamous
Adeno is associated with Barretts and therefore reflux
What part of oesophagus do squamous cell carcinomas and adenocarcinomas affect?
Squamous affects mainly the upper oesophagus
Adenocarcinoma affects mainly the lower oesophagus
Presentation of oesophageal cancer?
Progressive dysphagia Pain from impaction of food, more persistent pain may imply invasion of surrounding structures Weight loss Anrorexia Lymphadenopathy
Investigations that can be done for oesophageal cancer?
Endoscopy to obtain biopsy
Barium swallow allows you to rule out other diagnoses such as achalasia
Treatment for oesophageal cancer?
Surgery is the best option but should only be used when imaging shows the tumour has not infiltrated outside the oesophageal wall. Some patients are given preoperative chen-radiation therapy. Often palliative therapy is the only option. It is important that patients are given nutritional support.
Risk factors for gastric carcinomas?
H. pylori infection
Dietary factors
Tobacco smoking
Genetic abnormality
Presentation of gastric carcinomas?
Often presents late as can be quite asymptomatic
Epigastric pain similar to peptic ulcers
Predominant symptom is usually weight loss
May also get nausea and get dysphagia if the tumour is in the funds
May only get symptoms of spread e.g. malignant ascites
What investigation can be done to diagnose gastric carcinoma?
Gastroscopy
Treatment for gastric carcinoma?
Non-ulcerated mucosal lesions can be removed endoscopically
Surgery is the most effective form of treatment and may be combined with chemotherapy
May need palliative care and relief of symptoms
What do you inject into bleeds and why?
Dilute adrenaline- will cause vasoconstriction
What is involved in dual therapy treatment of GI bleeds?
Injection of dilute adrenaline and heater probe treatment
Bleeding peptic ulcer management plan?
Adrenaline – heater probe therapy
If bleed stops give IV omeprazole and potentially H. Pylori eradication
If they re-bleed give omeprazole with further endoscopic intervention. If this fails then they need surgery.
Risk factors for variceal bleed?
- portal pressure > 12mmHg
- varices > 25% oesophageal lumen
- presence of red signs
- degree of liver failure (Child’s A<b></b>
Treatment for variceal bleeding?
- Terlipressin (vasopressin analogue)- in everyone
- Endoscopic variceal ligation (banding)
- (Sclerotherapy)
- Sengstaken-Blakemore balloon
- TIPS
Secondary treatment involves banding and propranolol
Are peptic ulcers more common in old or young people?
Old people as sanitation was poorer when they were younger so they are more likely to be infected with H. Pylori
What allows helicobacter to infect the duodenum?
Gastric metaplasia that occurs in the duodenum to increased acid
5 causes of dysphagia?
Candidiaisis (white patches on mouth that don't wipe away) Neuromuscular disorders (bulbar palsy) Oesophageal motility disorders (spasm or achalasia) Extrinsic pressure (mediastinal glands or enlarged LA) Intrinsic lesion (stricture benign or malignant, webs, foreign bodies, pharyngeal pouches)
Palliative treatment for oesophageal cancer?
Endoscopic dilation
Treatment of achalasia?
Balloon dilation or myotomy (cut away part of stomach)
Barium swallow of oesophageal spasm will show?
cork screw oesophagus
First line investigations for most oesophageal disorders?
gastroscopy
Manometry is done when
you can’t get diagnosis from endoscopy, this looks at motility
Oesophageal dysplasia is managed by?
radio frequency ablation
Peptic strictures are surgically managed by?
endoscopic dilation
Surgical management of gord is?
Nissen fundoplication
If someone has dysphagia more for liquids than solids what should you think?
More likely to be a motility issue as opposed to a physical obstruction
