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GI > Oesophageal Problems > Flashcards

Oesophageal Problems Flashcards

1
Q

What is GORD

A

Reflux of gastric contents into the oesophagus which irritates squamous lining causing oesophagitis

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2
Q

What causes GORD and what worsens

A

Increased relaxation of LOS (never full contracts)
Oesophageal dysmotility
Decreased resistance to bile

Worsens  
Hiatus hernia - size doesn't correlate 
Delayed gastric emptying
Pregnancy
Obesity
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3
Q

What can cause oesophagitis (inflammation of oesophagus)

A 
GORD 
Hernia
Alcohol 
Biphosphonates
Steroid 
NSAID
Theophylline 
Candida
Herpes 
Ulcer
Cancer
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4
Q

What are the symptoms of GORD

A 
Dyspepsia 
Acid brash 
Odnyophagia 
Erosive oesophagitis
Sleep disturbance
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5
Q

What are the RF for GORD

A 
Male 
Caucasian
Obesity
Alcohol 
Smoking
Pregnancy 
Drugs lower LOS pressure
Hypomotility
Hypercalcium
H.pylori but no role in eradication
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6
Q

What drugs affect motility

A

CCB
Nitrate
Anti-cholinergic

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7
Q

What drugs cause oesophagitis

A

Biphosphonate
Steroid
NSAID
Theophylline

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8
Q

What should you do with NSAID

A

Always prescribe with a PPI esp if >65

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9
Q

How do you Dx GORD

A

Clinical Dx
Trial PPI if uncertain
Endoscopy if >55 + alarm symptoms / resistant dyspepsia or refractory to Rx

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10
Q

What do you do if endoscopy normal

A

Manometry
pH studies
Barium swallow

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11
Q

What is necessary before fundolipication

A

Manometry and pH studies

Barium swallow

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12
Q

What does manometry look at

A

Lower sphincter tonicity / relaxation

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13
Q

What does barium swallow look for

A

Motility

Stricture

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14
Q

How do you treat GORD

A 
As per dyspepsia 
Lifestyle measures
Alginates - Gaviscon / Peptac
Antacids - 
PPI - omeprazole = mainstay 
- 10 or 20mg = starting dose 
- 40mg = very high dose 
H2 - ranitidine if refractory (no longer given)
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15
Q

When do you consider fundolipication

A

Refractory to Rx
Severe reflux
Must perform manometry before to ensure due to low pressure of LOS as can tighten

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16
Q

What are the complications of GORD

A 
Oesophagitis
Ulcers 
Anaemia if bleed 
Strictures - benign 
Fibrosis 
Impaired motility 
Barret's
Adenocarcinoma
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17
Q

What are complications of hernia repair / fundolipication

A

Dysphagia
Diarrhoea
Cant belch / vomit
Bloating

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18
Q

What does endoscopy involve

A

Tube down throat
Can have sedation (midazalam)
Can’t drive for 24 hours or stay by yourself

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19
Q

What is Barrets oesophagus

A

Metaplasia
Transformation of squamous to columnar (glandular)
Pre-malignant change to adenocarcinoma

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20
Q

What causes Barret

A

Long standing GORD

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21
Q

What are the RF for Barret

A

Male
Obesity
Smoking
GORD

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22
Q

What is risk of progression to cancer

A

Long segment >3cm
Age
Dysplasia

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23
Q

How do you Dx Barret

A

Usually found on endoscopy for upper GI symptoms

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24
Q

How do you treat Barret and what reduces risk of transformation

A

PPI

2 yearly endoscopy + biopsy as surveillance

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25
Q

When do you treat Barret

A

If HGD or cancer detected

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26
Q

How do you treat

A

Endoscopic mucosal resection
Radiofrequency ablation
Oesophagectomy but high mortality

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27
Q

What are the risks of oesophagectomy

A

Anastomotic leak

High mortality due to mediastinitis

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28
Q

What is dyspepsia

A

A group of symptoms related to the gut
Non-ulcer if no cause found
Major symptom of GORD

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29
Q

What causes dyspepsia

A 
GORD
Ulcers - duodenal / gastric 
Gastritis
Malignancy
Drugs
Other
Pancreatitis
Hepatic / gall bladder
IBS 
Celiac 
Anxiety 
Delayed gastric emptying
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30
Q

What symptoms make up dyspepsia

A 
Non-specific term for indigestion 
Retrosternal discomfort - related to food / hunger (heartburn)
Less severe than ulcer 
Acid regurgitation 
Cough
Water brash
Weight loss 
Early satiety
Bloating 
N+V
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31
Q

What drugs can cause dyspepsia

A 
NSAID
Steroid
BIphosphonate
Theophylline
Nitrates
CCB
Anti-cholinergic
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32
Q

What do you do for dyspepsia <55 and no alarm symptoms

A

Stop drugs / review
Lifestyle measure
Antacids
Test for H.pylori - urea breath or stool antigen

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33
Q

When can you not test for H.pyolori

A

If Ax within 4 weeks or on PPI

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34
Q

When do you do further tests in dyspepsia

A

If treatment resistant i.e. still symptoms after 4 weeks
Alarm symptoms
- Do abdo exam for Virchow’s node / mass / weight loss
Requires endoscopy with rapid urease CLO and FBC to look for anaemia suggesting bleed

35
Q

What bloods should you get for dyspepsia

A 
FBC, U+E, LFT 
Ferritin if anaemia  
Lactate if suspect perforation 
Amylase 
Calcium
Glucose 
Coeliac
Troponin if abdominal pain
36
Q

What are lifestyle measures

A 
Diet 
Alcohol
Stop smoking
Exercise more
Eat 2 hours before sleep
Lose weight
Stop drugs that could cause
37
Q

How do you eradicate H.pylori if +ve

A

Triple therapy
Ax - clarithromycin (500mg) + Amox (1g) for 7 days or Metronidazole if no response
PPI
H2 antagonist - not always needed

38
Q

When do you check for cure

A

3 months
Usually urea breath
Will also have +ve serology
Can do stool antigen test

39
Q

What do you do if H.pylori -ve

A

H2 or PPI for 4 weeks

If no improvement = endoscopy

40
Q

When do you treat H.plyori

A

Even if asymptomatic as carcinogen

41
Q

What are SE of PPI

A

Microscopic colitis
C.diff
Osteoporosis
Hyponatraemia and Mg - muscle aches

42
Q

What is dysphagia

A

Trouble swallowing

43
Q

What is odynophagia

A

Painful swallowing

44
Q

What does odynophagia suggest

A

Oesophagitis
Ulceration - malignancy / GORD / candida
Spasm

45
Q

What causes dysphagia

A

Extra-mural

  • Neck mass - goite
  • Lung cancer
  • Any mediastinal mass
  • Vascular malformation
  • SVC obstruction
Intra-mural 
Achalasia
Spasm
Sysemic sclerosis
Stricture 
Bulbar palsy
Pharyngeal pouch
Neuromuscular - MS / myasthenia gravis / Parkinson
Intra-luminal 
Barret's
Oesophageal cancer 
Oesophagiitis - eosinophilic or GORD 
Benign or malignan stricture 
FB
Candidiasis - HIV / steroid 
Plumer-Winson
46
Q

Wha is important in the history and exam

A 
Solids or liquids
Same from start or getting worse 
Progressive or constant 
Intermittent or constant
Where in the chest
- Difficulty initiating swallow
- Or after swallow does it get stuck 
- Any regurg
Any pain 
Associated Sx 
- Odynophagia / otalgia / regurg / weight loss / signs of GI bleed - blood / change in bowel habit / chest infections as may aspirate 
RF - smoking / alcohol
Mass - para-aortic Ln / gastric acner
Dysphonia - laryngeal palsy 
Cough - if trachea invaded
Swelling - SVC obstruction
Neuro features
47
Q

How do you investigate dysphagia

A 
ENDOSCOPY + BIOPSY = gold standard
Do contrast swallow before if any risk of condition that scope could perforate e.g. diverticulum 
FBC + U+E
CXR if suspect lung cancer 
Manometry / pH
VIdeo fluroscopy for motility disorder
CT if suspecting neurological
48
Q

How do you treat

A

Treat cause
SALT review
Benign = balloon dilatation
CNS = specialist

49
Q

What is suggestive of oesophagitis

A

Heartburn after eating
Odynophagia
Systemically wel

50
Q

What suggest pharyngeal pouch (out-pouching of mucosa and submucosa in the pharynx)
- Thyropharyngeus and cricopharyngeus inferior constrict muscle and what can it cause

A 
Elderly male tend to be affected
Can be asymptomatic if small 
Progressive dysphagia
Regurg
Aspiration
Cough
Halitosis 
Recurrent chest infection due to aspiration 
Neck swelling
Gurgling on palpation

Can lead to

  • Oesopheageal perforation = mediasinitis / surgical emphysema
  • Pneumothorax
  • Hoarse voice
  • Fistula
  • Stricture
51
Q

How do you Dx and Rx pouch

A

ENT exam usually normal
Contrast swallow = definite
Consider MRI if -ve to look for malignancy

Conservative if small
Botox to muscle
Surgery - stapling or diverticulotomy

52
Q

What suggests myasthenia gravis

A

Tend to be acute onset
Ptosis
Extraocular weakness
Swallowing difficulty

53
Q

How do you treat

A

Acetylcholinesterase inhibitor

54
Q

What suggest bulbar palsy

A 
Difficult to initiate swallow 
Dysphagia
Weakness
Drooling
Waste tongue
Dysphonia
55
Q

What suggest systemic sclerosis and how do you Rx

A 
Calcinosis
Raynaud
Eoshageal issue / decreased pressure LOS
S - sclerodactly
Telengtasia

PPI
Surgery as last resort

56
Q

What is globus hysterics

A

Dysphagia caused by anxiety

Relieved by swallow

57
Q

What is globus pharynges ‘FOSIT’ and how do you Dx

A

Feeling of lump in throat / FB due to cricopharyngeal spasm
Relieved by food
Worse swallowing saliva
Linked to reflux / spasm

Form of somatisation - linked to stress / anxiety
Dx of exclusion
Flexible nasa-endoscopy to rule out other causes
If smoking / alcohol Hx then consider barium swallow / upper GI endoscopy

58
Q

What suggest oral candidiasis

A

HIV / inhaler / steroid/ haemophiliac / Ax

Endoscopy to confirm

59
Q

What does constant and progressive dysphagia suggest e.g. from solid-liquid

A

Malignancy / benign stricture

- Often Hx smoking / alcohol or GORD

60
Q

What is alchalsia

A

Motlity disorder where LOS doesn’t relax so increased pressure
Loss of peristalsis

61
Q

How does alchasia present

A 
Dysphagia - solid and liquid from start
Weight loss 
Regurg
Aspiration 
Vomit
CHoking 
Chest pain
Systemically well
62
Q

How do you Dx achalasia and what do they show

A

Endoscopy 1st line to exclude cancer
Manometry - sustained higher pressure
Barium swallow - dilated tight sphincter + bird peak
CXR - wide mediastinum +

63
Q

How do you Rx achalasia

A

Balloon dilatation of LOS
Cardiomyotomy
PPI after as balloon can cause heart burn
CCB / nitrate if no surgical or botulism toxin
Ax if aspiration + CXR

64
Q

What are complications of achalasia

A

SCC of the lung

Aspiration pneumonia

65
Q

What does oesophageal spasm present like

A

Intermittent chest pain and dysphagia
Like angina
Odynophagia

66
Q

How do you Dx spasm

A

Contrast swallow - cork screen

Manometry - exaggerated contraction

67
Q

How do you Rx spasm

A

Nitrates and CCB to relax

68
Q

What causes hypo motility

A

Failed relaxation of LOS sphincter
DM
Neuropathy
Connective tissue disease

69
Q

How do hypo motility present

A

Dysphagia
Regurg
Dyspepsia

70
Q

What is a sliding hiatus hernia

A

Gastro-oesophageal junction slides into chest

Acid reflux / GORD as no sphincter

71
Q

What is a para oesophageal hernia

A

Junction stays below diaphragm
Part of stomach into chest
GORD less common

72
Q

Who is at risk of hernia

A

Age
Obese
Female

73
Q

How do you dx hernia

A

Endoscopy for GORD
Contrast swallow for reflux - gastric seen above diaphragm
CXR shows gastric funds above diaphragm

74
Q

How do you treat hernia

A

Lose weight
Treat GORD
FUndolipication for severe complications / strangulated

75
Q

What is a strangulated hernia

A

Necrosis = urgent surgery

76
Q

What are other complications

A

Incarcerated - stuck and unable to reduce

Abscess in sac

77
Q

What are other indications for endoscopy apart from dysphagia / ALARM

A 
Haematemesis
Treatment resistant dyspepsia
H.pylori -ve
Abdo pain and low Hb
Raised platelet + N+V, weight loss, dyspepsia, abdominal pain
78
Q

What causes oesophageal rupture

A 
Iatrogenic after endoscopy 
Trauma 
Carcinoma
Boerhaave - rupture due to violent vomit
Corrosive
79
Q

What are clinical features

A 
Odynophagia
Tachypnoea
Fever
Shcok 
Surgical emphysema
80
Q

How do you Rx

A

Fluid resus
PPI
Ax / anti-fungal
Surgery

81
Q

What are risks

A

Mediastinitis and sepsis

82
Q

What do you do have to be of before endoscopy

A

PPI for 2 weeks as may mask

83
Q

What are alarm Sx

A 
Anaemia
Loss of weight
Anorexia
Recent onset
Melena / haematemesis
Swallowing difficulty (dysphagia)

GI (29 decks)

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