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Medicine > Oesophageal disorders/dysphagia > Flashcards

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
Q

H pylori Ix

A

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
Q

H pylori Tx

A 
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
Q

Barett oesophagus

A

metaplasia from squamous to columnar epithelium in lower oesophagus

premalignant condition for oesophageal adenocarcinoma

28
Q

2 types of oesophageal cancer

A

adenocarcinoma
squamous

29
Q

Squamous cell carcinoma of the oesophagus feautres

A

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
Q

Adenocarcinoma of the oesophagus features

A

Progressive dysphagia
Prev GORD sx or Barretts oesophagus
obesity
distal ⅓ of oesophagus
Most common

31
Q

Oesophageal cancer symptoms

A

Dysphagia
Odynophagia
Weight loss
hoarse voice (recurrent laryngeal nerve)
hiccups (phrenic nerve)

32
Q

Mx oesophageal cancer

A

Endoscopic resection (ER) with or without ablation
oesophagectomy
Palliative relief with stents, laser, and photodynamic therapy (PDT)

33
Q

Boorhaeve’s syndrome

A

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
Q

Mechanical causes of dysphagia

A

Oesophageal or gastric malignancy
Benign oesophageal strictures
Extrinsic compression
Pharyngeal pouch
Foreign body (mainly in children)
Oesophageal web

35
Q

Neurological causes of dysphagia

A

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
Q

Achalasia

A

Failure of oesophageal peristalsis and of relaxation of the lower oesophageal sphincter (LOS) due to degenerative loss of ganglia from Auerbach’s plexus

37
Q

Achalasia features

A

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
Q

Achalasia Ix

A

oesophageal manometry
barium swallow - birds beak , expanded oesophagus, fluid level
CXR - widened mediastinum and fluid level

39
Q

Achalasia Mx

A
  1. Pneumatic (balloon) dilation
  2. Medical -injection of botulinum, nitrates/CCB
  3. Heller cardiomyotomy
40
Q

Oesophagitis clinical presentation

A

‘heartburn’(retrosternal burning pain)
nausea +/- vomiting
odynophagia(painful swallowing)
no weight loss and systemically well

41
Q

Mallory-Weiss syndrome

A

Severe vomiting → painful mucosal lacerations at the gastroesophageal junction resulting in haematemesis. Common in alcoholics

42
Q

Plummer-Vinson syndrome

A

Triad of:
dysphagia (secondary to oesophageal webs)
glossitis
iron-deficiency anaemia

Treatment includes iron supplementation and dilation of the webs

43
Q

Gastric cancer epidemiology

A

More common in men
highest incidence in Far East

44
Q

Gastric cancer histology

A

> 90% are adenocarcinomas
40% found in antrum

45
Q

Risk Factors for gastric cancer

A

Genetics
H pylori
Excessive intake of salted food
Smoking
Alcohol
Pernicious anaemia, achlorhydria
Blood group A
Ademotaous polyps

46
Q

Sister Mary Joseph nodule

A

Subcutaneous peri-umbilical metastasis associated with intestinal type of gastric cancer

47
Q

Linitis plastica

A

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
Q

Krukenberg tumour

A

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
Q

Blumer’s shelf

A

A shelf-like tumor of the anterior rectal wall felt on rectal examination indicating implantation metastases in Douglas’ pouch as in gastric carcinoma

50
Q

Virchow’s node (Troisier sign )

A

palpable left lymph node in supraclavicular fossa

51
Q

Gastric cancer Mx

A

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
Q

Oesophageal candidiasis

A

dysphagia
may be a history of HIV or other risk factors such as steroid inhaler use

53
Q

Pharyngeal pouch clinical presentation

A

dysphagia, regurgitation of undigested food, aspiration, chronic cough, halitosis

54
Q

Pharyngeal Pouch Ix

A

Avoid endoscopy due to risk of perforating the lesion
Barium swallow – shows residual pool of contrast within the pouch

55
Q

Pharyngeal pouch Mx

A

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
Q

Systemic sclerosis can cause dysphagia

A

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
Q

Diffuse oesophageal spasm

A

May show ‘nutcracker oesophagus’ on barium swallow
Symptoms include dysphagia, retrosternal discomfort and dyspepsia

58
Q

Oesophageal rupture

A

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
Q

2 types of oesophageal cancer

A

adenocarcinoma
squamous

60
Q

Mx oesophageal cancer

A

Endoscopic resection (ER) with or without ablation
oesophagectomy
Palliative relief with stents, laser, and photodynamic therapy (PDT)

Medicine (72 decks)

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