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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
When do you treat Barret
If HGD or cancer detected
26
How do you treat
Endoscopic mucosal resection Radiofrequency ablation Oesophagectomy but high mortality
27
What are the risks of oesophagectomy
Anastomotic leak | High mortality due to mediastinitis
28
What is dyspepsia
A group of symptoms related to the gut Non-ulcer if no cause found Major symptom of GORD
29
What causes dyspepsia
``` GORD Ulcers - duodenal / gastric Gastritis Malignancy Drugs ``` ``` Other Pancreatitis Hepatic / gall bladder IBS Celiac Anxiety Delayed gastric emptying ```
30
What symptoms make up dyspepsia
``` 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 ```
31
What drugs can cause dyspepsia
``` NSAID Steroid BIphosphonate Theophylline Nitrates CCB Anti-cholinergic ```
32
What do you do for dyspepsia <55 and no alarm symptoms
Stop drugs / review Lifestyle measure Antacids Test for H.pylori - urea breath or stool antigen
33
When can you not test for H.pyolori
If Ax within 4 weeks or on PPI
34
When do you do further tests in dyspepsia
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
What bloods should you get for dyspepsia
``` FBC, U+E, LFT Ferritin if anaemia Lactate if suspect perforation Amylase Calcium Glucose Coeliac Troponin if abdominal pain ```
36
What are lifestyle measures
``` Diet Alcohol Stop smoking Exercise more Eat 2 hours before sleep Lose weight Stop drugs that could cause ```
37
How do you eradicate H.pylori if +ve
Triple therapy Ax - clarithromycin (500mg) + Amox (1g) for 7 days or Metronidazole if no response PPI H2 antagonist - not always needed
38
When do you check for cure
3 months Usually urea breath Will also have +ve serology Can do stool antigen test
39
What do you do if H.pylori -ve
H2 or PPI for 4 weeks | If no improvement = endoscopy
40
When do you treat H.plyori
Even if asymptomatic as carcinogen
41
What are SE of PPI
Microscopic colitis C.diff Osteoporosis Hyponatraemia and Mg - muscle aches
42
What is dysphagia
Trouble swallowing
43
What is odynophagia
Painful swallowing
44
What does odynophagia suggest
Oesophagitis Ulceration - malignancy / GORD / candida Spasm
45
What causes dysphagia
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
Wha is important in the history and exam
``` 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
How do you investigate dysphagia
``` 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
How do you treat
Treat cause SALT review Benign = balloon dilatation CNS = specialist
49
What is suggestive of oesophagitis
Heartburn after eating Odynophagia Systemically wel
50
What suggest pharyngeal pouch (out-pouching of mucosa and submucosa in the pharynx) - Thyropharyngeus and cricopharyngeus inferior constrict muscle and what can it cause
``` 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
How do you Dx and Rx pouch
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
What suggests myasthenia gravis
Tend to be acute onset Ptosis Extraocular weakness Swallowing difficulty
53
How do you treat
Acetylcholinesterase inhibitor
54
What suggest bulbar palsy
``` Difficult to initiate swallow Dysphagia Weakness Drooling Waste tongue Dysphonia ```
55
What suggest systemic sclerosis and how do you Rx
``` Calcinosis Raynaud Eoshageal issue / decreased pressure LOS S - sclerodactly Telengtasia ``` PPI Surgery as last resort
56
What is globus hysterics
Dysphagia caused by anxiety | Relieved by swallow
57
What is globus pharynges 'FOSIT' and how do you Dx
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
What suggest oral candidiasis
HIV / inhaler / steroid/ haemophiliac / Ax | Endoscopy to confirm
59
What does constant and progressive dysphagia suggest e.g. from solid-liquid
Malignancy / benign stricture | - Often Hx smoking / alcohol or GORD
60
What is alchalsia
Motlity disorder where LOS doesn't relax so increased pressure Loss of peristalsis
61
How does alchasia present
``` Dysphagia - solid and liquid from start Weight loss Regurg Aspiration Vomit CHoking Chest pain Systemically well ```
62
How do you Dx achalasia and what do they show
Endoscopy 1st line to exclude cancer Manometry - sustained higher pressure Barium swallow - dilated tight sphincter + bird peak CXR - wide mediastinum +
63
How do you Rx achalasia
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
What are complications of achalasia
SCC of the lung | Aspiration pneumonia
65
What does oesophageal spasm present like
Intermittent chest pain and dysphagia Like angina Odynophagia
66
How do you Dx spasm
Contrast swallow - cork screen | Manometry - exaggerated contraction
67
How do you Rx spasm
Nitrates and CCB to relax
68
What causes hypo motility
Failed relaxation of LOS sphincter DM Neuropathy Connective tissue disease
69
How do hypo motility present
Dysphagia Regurg Dyspepsia
70
What is a sliding hiatus hernia
Gastro-oesophageal junction slides into chest | Acid reflux / GORD as no sphincter
71
What is a para oesophageal hernia
Junction stays below diaphragm Part of stomach into chest GORD less common
72
Who is at risk of hernia
Age Obese Female
73
How do you dx hernia
Endoscopy for GORD Contrast swallow for reflux - gastric seen above diaphragm CXR shows gastric funds above diaphragm
74
How do you treat hernia
Lose weight Treat GORD FUndolipication for severe complications / strangulated
75
What is a strangulated hernia
Necrosis = urgent surgery
76
What are other complications
Incarcerated - stuck and unable to reduce | Abscess in sac
77
What are other indications for endoscopy apart from dysphagia / ALARM
``` Haematemesis Treatment resistant dyspepsia H.pylori -ve Abdo pain and low Hb Raised platelet + N+V, weight loss, dyspepsia, abdominal pain ```
78
What causes oesophageal rupture
``` Iatrogenic after endoscopy Trauma Carcinoma Boerhaave - rupture due to violent vomit Corrosive ```
79
What are clinical features
``` Odynophagia Tachypnoea Fever Shcok Surgical emphysema ```
80
How do you Rx
Fluid resus PPI Ax / anti-fungal Surgery
81
What are risks
Mediastinitis and sepsis
82
What do you do have to be of before endoscopy
PPI for 2 weeks as may mask
83
What are alarm Sx
``` Anaemia Loss of weight Anorexia Recent onset Melena / haematemesis Swallowing difficulty (dysphagia) ```

GI (29 decks)

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