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Oesophageal disorders/dysphagia Flashcards

1
Q

Common causes of dyspepsia

A

Non-ulcer dyspepsia/functional dyspepsia
GORD (gastro-oesophageal reflux disease)
Peptic ulcer disease
gastritis
Barrett’s oesophagus

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2
Q

Referral for 2ww

A

With dysphagia, or
Aged 55 years and over with weight loss and any of the following:
- Upper abdominal pain.
- Reflux.
- Dyspepsia.

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3
Q

Factors that exacerbate dyspepsia

A

◦Obesity
◦Trigger foods eg coffee, chocolate, tomatoes, fatty, spicy foods, eating patterns (missed meals, large meals)
◦Alcohol consumption
◦Stress, anxiety or depressio

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4
Q

Medications that exacerbate dyspepsia

A

aspirin, NSAIDs, corticosteroids, beta blockers, Ca blockers, anticholinergics, tricyclics , BDZ

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5
Q

Conservative dyspepsia Mx

A

Stop offending meds if possible
Lifestyle advice
- Healthy eating
- Weight reduction
- Smoking cessation
- Avoid known precipitants like alcohol, coffee, chocolate, fatty foods
- Raising head of the bed
- Early main meal before going to bed

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6
Q

Medical dyspepsia Mx

A

Trial of over the counter medications – antacids or alginates
Empirical treatment with PPI (full dose for 1-2 months) or testing and treating for H. Pylori (normally breath test or stool antigen)

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7
Q

Gastro-oesophageal reflux disease

A

lower esophageal sphincter relaxes too frequently and there is reflux of gastric contents into the oesophagus which causes irritation

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8
Q

GORD risk factors

A

Obesity
Pregnancy
Systemic sclerosis
Drugs – nitrates, CCB NSAIDS, steroids
Hiatus hernia/delayed gastric emptying
Family history

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9
Q

GORD clinical features

A

Heartburn – aggravated by bending/lying down
Dry Cough , sometimes nocturnal
Nocturnal asthma
Bloating
Hoarse voice
Wheeze
SOB
Dental erosion
Chest pain

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10
Q

GORD Ix

A

Clinical dx
OGD +/- biopsy may show Oesophagitis
24 hr Intraluminal pH monitoring for quantifying gastroesophageal reflux

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11
Q

GORD Mx

A

Same as dyspepsia, medications often required
*Antacids/alginates
*Proton pump inhibitors
Usually first line with Full-dose PPI for 1-2 months
If symptoms persist could double dose of PPI or add H2 antagonist
*Prokinetics – metoclopramide/ domperidone

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12
Q

Nissen fundoplication

A

fundus of stomach sutured around the lower oesophagus to form new sphincter

surgical Tx of GORD

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13
Q

Gastritis

A

irritation and inflammation of the stomach lining

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14
Q

Gastritis symptoms

A

dyspepsia, intermittent epigastric pain, loss of appetite, bloating, retching , N +V, feeling v full after meal

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15
Q

Peptic ulcer epidemiology

A

Duodenal ulcers are 3-4 times more common than gastric + more common in men than women

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16
Q

Risk factors for PUD include

A

H.pylori
NSAIDs, Aspirins, Steroids and SSRIS (duodenal ulcers) Bisphosphonates
Smoking
Gastrinomas
Genetic factors
Severe stress (gastric ulcer)
Zollinger ellison syndrome ( triad of severe PUD, gastric acid hypersecretion and gastrinoma)
Blood group O ( duodenal ulcer)

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17
Q

PUD symptoms

A

Pain
Nausea and vomiting- haematemesis ,coffee ground
Melaena
anorexia
weight loss

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18
Q

Gastric ulcer pain

A

pain soon after meals
not relieved by eating
eating makes it worse
as food passes into the stomach it irritates the ulcer due to acid secretion

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19
Q

Duodenal ulcer pain

A

pain 2-3h after meals (when the pyloric sphincter relaxes to allow the acidic food contents into the duodenum)
relieved by eating.Food in the stomach mops up some of the acid so that it doesn’t go into the duodenum
pain when hungry
pain is often worse at night radiating into the back
patients tend to put weight on

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20
Q

PUD Ix

A

OGD endoscopy
If gastric ulcer – will take biopsies to rule out malignancy.
Test for pylori - GU

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21
Q

PUD Mx

A

Lifestyle advice- eg eating habits, foods to avoid, weight loss

Medical
- H pylori eradication with triple therapy if confirmed
- PPI to reduce acid in stomach – full dose for 1-2 months then low dose> no as-required basis
- Other antacid treatments

Endoscopic treatment for bleeding ulcers

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22
Q

PUD Cx

A

Bleeding from ulcer
Perforation
Scarring and strictures of stomach and mucosa

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23
Q

H. Pylori

A
  • spiral shaped, gram negative, urease producing bacterium
  • Found predominantly in the gastric antrum
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24
Q

H pylori associations

A

atrophic gastritis, peptic ulceration, gastric cancer + ( MALT) b cell lymphoma

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25
H pylori Ix
CLO test featuring biopsy sample Urea breath test Stool antigen testing For both tests Patient needs to be off PPI for 14 days before test or Abx for 4 weeks
26
H pylori Tx
``` Triple therapy - at least 2 antibiotics and PPI for 7 days (Clear All Pylori Microbes ) Clar-ithromycin 500mg bd Amoxicillin 1gram bd PPI (omeprazole) 20mg bd Metronidazole ( if allergic) 400mg bd Ethanol should be advised to avoid with this eradication therapy. ```
27
Barett oesophagus
metaplasia from squamous to columnar epithelium in lower oesophagus premalignant condition for oesophageal adenocarcinoma
28
2 types of oesophageal cancer
adenocarcinoma squamous
29
Squamous cell carcinoma of the oesophagus feautres
History of progressive dysphagia. Often signs of weight loss. Usually little or no history of previous GORD type symptoms upper 2/3 of oesophagus smoking and alcohol RF
30
Adenocarcinoma of the oesophagus features
Progressive dysphagia Prev GORD sx or Barretts oesophagus obesity distal ⅓ of oesophagus Most common
31
Oesophageal cancer symptoms
Dysphagia Odynophagia Weight loss hoarse voice (recurrent laryngeal nerve) hiccups (phrenic nerve)
32
Mx oesophageal cancer
Endoscopic resection (ER) with or without ablation oesophagectomy Palliative relief with stents, laser, and photodynamic therapy (PDT)
33
Boorhaeve’s syndrome
transmural tear of the distal oesophagus induced by a sudden increase in pressure. classic triad of 1. vomiting 2. abdominal/chest pain 3. subcutaneous emphysema
34
Mechanical causes of dysphagia
Oesophageal or gastric malignancy Benign oesophageal strictures Extrinsic compression Pharyngeal pouch Foreign body (mainly in children) Oesophageal web
35
Neurological causes of dysphagia
CVA/brain injury affecting the brainstem Achalasia Diffuse esophageal spasm Myasthenia gravis ( dysphagia is often 1st presentation) MS MND PD (80% of patients develop dysphagia) Diabetes Diffuse oesophageal spasm
36
Achalasia
Failure of oesophageal peristalsis and of relaxation of the lower oesophageal sphincter (LOS) due to degenerative loss of ganglia from Auerbach's plexus
37
Achalasia features
dysphagia of BOTH liquids and solids typically variation in severity of symptoms heartburn regurgitation of food - may lead to cough, aspiration pneumonia etc malignant change in small number of patients
38
Achalasia Ix
oesophageal manometry barium swallow - birds beak , expanded oesophagus, fluid level CXR - widened mediastinum and fluid level
39
Achalasia Mx
1. Pneumatic (balloon) dilation 2. Medical -injection of botulinum, nitrates/CCB 3. Heller cardiomyotomy
40
Oesophagitis clinical presentation
'heartburn'(retrosternal burning pain) nausea +/- vomiting odynophagia(painful swallowing) no weight loss and systemically well
41
Mallory-Weiss syndrome
Severe vomiting → painful mucosal lacerations at the gastroesophageal junction resulting in haematemesis. Common in alcoholics
42
Plummer-Vinson syndrome
Triad of: dysphagia (secondary to oesophageal webs) glossitis iron-deficiency anaemia Treatment includes iron supplementation and dilation of the webs
43
Gastric cancer epidemiology
More common in men highest incidence in Far East
44
Gastric cancer histology
>90% are adenocarcinomas 40% found in antrum
45
Risk Factors for gastric cancer
Genetics H pylori Excessive intake of salted food Smoking Alcohol Pernicious anaemia, achlorhydria Blood group A Ademotaous polyps
46
Sister Mary Joseph nodule
Subcutaneous peri-umbilical metastasis associated with intestinal type of gastric cancer
47
Linitis plastica
Muscles of the stomach wall become thicker and more rigid. The stomach holds less food as it cannot stretch and transition of food is slower due to decreased relaxation of the stomach It is sometimes known as leather bottle stomach Associated with diffuse type of stomach cancer
48
Krukenberg tumour
known as a 'signet ring' tumour, due to the pathological appearance of these cells. The most common primary site is the stomach and the colon These cells readily secrete mucin and readily metastasize to the ovaries. Patients often present with abdominal bloating, ascites or pain during intercourse.
49
Blumer’s shelf
A shelf-like tumor of the anterior rectal wall felt on rectal examination indicating implantation metastases in Douglas' pouch as in gastric carcinoma
50
Virchow’s node (Troisier sign )
palpable left lymph node in supraclavicular fossa
51
Gastric cancer Mx
Surgery only option for cure in locally advanced Gastric cancer Endoscopic mucosal resection (EMR) used for early cancers confined to the mucosa Palliative chemotherapy ymptom relief surgery e.g. pyloric stent for gastric outlet obstruction
52
Oesophageal candidiasis
dysphagia may be a history of HIV or other risk factors such as steroid inhaler use
53
Pharyngeal pouch clinical presentation
dysphagia, regurgitation of undigested food, aspiration, chronic cough, halitosis
54
Pharyngeal Pouch Ix
Avoid endoscopy due to risk of perforating the lesion Barium swallow – shows residual pool of contrast within the pouch
55
Pharyngeal pouch Mx
Depends on size of pouch If small and asymptomatic, no treatment necessary Surgical approaches – resection of the diverticulum, or incision of cricopharyngeus muscle Most cases are now treated with endoscopic stapling
56
Systemic sclerosis can cause dysphagia
Other features of CREST syndrome may be present, namely Calcinosis, Raynaud's phenomenon, oEsophageal dysmotility, Sclerodactyly, Telangiectasia As well as oesophageal dysmotility the lower oesophageal sphincter (LES) pressure is decreased. This contrasts to achalasia where the LES pressure is increased
57
Diffuse oesophageal spasm
May show 'nutcracker oesophagus' on barium swallow Symptoms include dysphagia, retrosternal discomfort and dyspepsia
58
Oesophageal rupture
Complete disruption of the oesophageal wall in absence of per-existing pathology. Left postero-lateral oesophageal is commonest site severe chest pain without cardiac dx, vomiting Erect CXR shows infiltrate or effusion in 90% of cases
59
2 types of oesophageal cancer
adenocarcinoma squamous
60
Mx oesophageal cancer
Endoscopic resection (ER) with or without ablation oesophagectomy Palliative relief with stents, laser, and photodynamic therapy (PDT)

Medicine (72 decks)

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