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Gastro > Oesophageal Problems > Flashcards

Oesophageal Problems Flashcards

1
Q

What is GORD

A

Reflux of gastric contents into the oesophagus

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2
Q

What causes GORD [5]

A 
Hiatus hernia - size doesn't correlate 
Increased relaxation of LOS
Oesophageal dysmotility 
Decreased gastric emptying
Decreased resistance to bile
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3
Q

What can cause oesophagitis (inflammation of oesophagus) [6]

A 
GORD, ulcer
Hernia
Alcohol 
Biphosphonates, steroid 
Candida, Herpes 
Cancer
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4
Q

What are the symptoms of GORD [5]

A 
Dyspepsia 
Acid brash 
Odnyophagia 
Erosive oesophagitis
Sleep disturbance
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5
Q

What are the RF for GORD [7]

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

What drugs affect motility [3]

A

CCB
Nitrate
Anti-cholinergic

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7
Q

What drugs cause oesophagitis [4]

A

Biphosphonate
Steroid
NSAID
Theophylline

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8
Q

Indications of endoscopy [3]

A

Endoscopy if >55 / alarm symptoms / resistant dyspepsia or refractory to Rx

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9
Q

What do you do if endoscopy normal [3]

A

Manometry
pH studies
Barium swallow

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10
Q

What is necessary before fundoplication [2]

A

Manometry and pH studies

Barium swallow

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11
Q

Oesophageal manometry and pH monitoring
LOS tone
Indications [3]

A
  • Oesophageal manometry involves the passage of a thin, pressure sensitive catheter to the lower oesophagus to assess the function of the upper and lower oesophageal sphincter (LOS) and assess oesophageal motility. The normal LOS tone is between 10–30 mmHg.
    Indications
  • Investigation of dysphagia and non-cardiac chest pain.
  • Diagnosis and ongoing assessment of patients with GORD.
  • Preoperative evaluation of patients with GORD in whom fundoplication or alternative surgery is being considered, to select patients likely to benefit.
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12
Q

What does barium swallow look for [2]

A

Motility

Stricture

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13
Q

How do you treat GORD [5]

A 
Lifestyle measures
Alginates - Gaviscon
Antacids - 
PPI - omeprazole
H2 - ranitidine if refractory
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14
Q

When do you consider fundolipication [2]

A

Refractory to Rx

Severe reflux

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15
Q

What are the complications of GORD [6]

A

Oesophagitis
Anaemia if bleed
Strictures
Fibrosis
Impaired motility
Barret’s, Adenocarcinoma

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16
Q

What are complications of hernia repair / fundolipication [4]

A

Dysphagia
Diarrhoea
Cant belch / vomit
Bloating

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17
Q

What does endoscopy involve: What will the patient need to know? [3]

A

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

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18
Q

What is Barrets oesophagus [3]

A

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

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19
Q

What causes Barret

A

Long standing GORD

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20
Q

What are the RF for Barret [4]

A

Male
Obesity
Smoking
GORD

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21
Q

What is risk of progression to cancer [3]

A

Long segment >3cm vs short segment <3cm
Age
Dysplasia

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22
Q

How do you Dx Barret

A

Usually found on endoscopy for upper GI symptoms

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23
Q

What reduces risk of transformation. Long term follow up of Barrets? [2]

A

PPI

2 yearly endoscopy + biopsy as surveillance

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24
Q

When do you treat Barret [2]

A

If high grade dysplasia or cancer detected

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25
Q

How do you treat [3]

A

Endoscopic mucosal resection
Radiofrequency ablation
Oesophagectomy but high mortality

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26
Q

What are the risks of oesophagectomy [2]

A

Anastomotic leak

High mortality due to mediastinitis

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27
Q

What is dyspepsia [3]

A

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

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28
Q

What causes dyspepsia: name top 5 causes and 5 others

A

GORD
Ulcers - duodenal / gastric
Gastritis
Malignancy
Drugs

Other
Pancreatitis
Hepatic / gall bladder
IBS, Celiac
Anxiety
Delayed gastric emptying

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29
Q

What symptoms make up dyspepsia [6]

A

Retrosternal discomfort - related to food / hunger
Less severe than ulcer
Cough
Water brash
Early satiety, Bloating
N+V

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30
Q

What are red flag symptoms of dyspepsia? [6]

A

ALARM

  • Anaemia
  • Loss of weight
  • Anorexia
  • Recent onset prog of sx
  • Malaena
  • Swallowing difficulties
31
Q

What do you do for dyspepsia <55 and no alarm symptoms [4]

A

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

32
Q

H. pylori test - caveats [2]

2 ways to test for H. pylori

A

Need to be off PPI for >2w and abx for >4w

  • Carbon-13 urea breath test
  • Stool antigen test
33
Q

When do you do further tests in dyspepsia [3]

A

If treatment resistant
Alarm symptoms

Requires endoscopy with rapid urease CLO

34
Q

What bloods should you get for dyspepsia [6]

A

FBC, Ferritin (anaemia)
U+E (urea elevated in hemorrhage)
LFT
Calcium
Glucose
Coeliac

35
Q

What are lifestyle measures [4]

A

Diet, Exercise more, lose weight
Alcohol moderation, Stop smoking
Eat 2 hours before sleep
Stop drugs that could cause

36
Q

How do you eradicate H.pylori if +ve [5]

A 
Triple therapy 
1. Clarithromycin (500mg)
2. Amox (1g) for 1 week
- Metronidazole if no response
3. PPI
H2 antagonist - not always needed
37
Q

When do you check for cure

Will blood test be positive?

A

3 months - Urea breath test

Will also have +ve serology

38
Q

What do you do if H.pylori -ve? [2]

A

H2 or PPI for 4 weeks

If no improvement = endoscopy

39
Q

When do you treat H.plyori

A

Even if asymptomatic as carcinogenic

40
Q

What are SE of PPI [4]

A

Microscopic colitis
C.diff increased risk
Osteoporosis - malabsorption of ca and mg
Hyponatraemia and Mg - muscle aches

41
Q

What does odynophagia suggest [4]

A

Oesophagitis
Ulceration - malignancy / GORD / candida
Spasm

42
Q

What causes dysphagia [6]

A

Intrinsic, Extrinsic, Motility, Neuromuscular disorders

43
Q

Forms of dysphagia

A

Dysphagia can be classified as:
* Oropharyngeal dysphagia: difficulty initiating swallow, which may be accompanied by coughing, choking, regurgitation or aspiration.
* Oesophageal dysphagia: a sensation of food getting stuck in the oesophagus several seconds after initiating a swallow.

44
Q

How do you investigate dysphagia [5]

A

ENDOSCOPY + BIOPSY = gold standard
FBC
U+E
Manometry / pH
Contrast swallow

All patients with new onset dysphagia should be referred for urgent gastroscopy to be performed within 2 weeks.

45
Q

What is suggestive of oesophagitis [3]

A

Heartburn after eating
Odynophagia
Systemically well

46
Q

What suggest pharyngeal pouch [7]

A 
Elderly
Dysphagia
Regurg
Aspiration 
Cough
Smelly breath
Neck swelling
47
Q

How do you Dx and Rx pouch

A

Contrast swallow

Surgery

48
Q

What suggests myasthenia gravis [3]

A

Ptosis
Extraocular weakness
Swallowing difficulty

49
Q

How do you treat

A

Acetylcholinesterase inhibitor

50
Q

What suggest bulbar palsy [6]

A 
Difficult to initiate swallow 
Dysphagia
Weakness
Drooling
Waste tongue
Dysphonia
51
Q

What suggest systemic sclerosis? [5]

A 
Calcinosis
Raynaud
Eosphageal issue / decreased pressure LOS
S - sclerodactly
Telengtasia
52
Q

What is globus hysterics [2]

A

Dysphagia caused by anxiety

Relieved by swallow

53
Q

What is globus pharynges [3]

A

Feeling of lump in throat
Relieved by food
Worse swallowing saliva

54
Q

What suggest oral candidiasis [2]

What can confirm a suspicion?

A

HIV / inhaler / haemophiliac / Ax

Endoscopy to confirm

55
Q

What does constant and progressive dysphagia suggest

A

Malignancy

56
Q

What is achalasia [2]

A
  1. Motlity disorder where LOS doesn’t relax so increased pressure. Hypertrophy of muscles at LOS
  2. Loss of peristalsis

The pathogenesis is thought to be due to decreased ganglionic cells in the myenteric plexus and degeneration in the vagal fibres of the oesophagus with loss of inhibitory denervation of the LOS.

57
Q

How does achalasia present [6]

A

Dysphagia - solid and liquid from start over long periods of time
Weight loss
Regurg, Vomit
Aspiration, Choking
Chest pain
Systemically well

58
Q

How do you Dx achalasia and what do they show [4]

A

Endoscopy 1st line to exclude cancer, would be normal
Barium swallow - dilated tight sphincter, birds beak deformity
CXR - wide mediastinum
Oesophageal manometry demonstrates aperistalsis in the distal two-thirds of the oesophagus and impaired relaxation of the LOS (pressure readings of >8 mmHg).

59
Q

How do you Rx achalasia [5]

A
  1. Endoscopic pneumatic dilatation involves forceful disruption of the muscular fibres of the LOS using a balloon. It carries a significant risk of perforation (2–4%).
  2. Laparoscopic myotomy (Heller’s myotomy) involves longitudinal surgical incision of the muscles of the LOS.
  3. Peroral endoscopic myotomy (POEM) is an endoscopic method for performing myotomy of the LOS.
  4. Botulinum toxin injection into the LOS can provide temporary symptomatic benefit (lasting
    ~6 months), thus requiring repeat procedures. It is generally reserved for patients who are poor
    surgical candidates.
  5. Pharmacological therapy, such as nitrates or short-acting calcium channel blockers are the least
    effective in treating achalasia. Their use is limited by side effects (such as headache and dizziness) with nitrates and tachyphylaxis (loss of response) with calcium channel blockers.
60
Q

What are complications of achalasia [3]

A

SCC
Aspiration pneumonia
Lung disease

61
Q

What does oesophageal spasm present like [4]

A

Intermittent chest pain and dysphagia
Like angina
Odynophagia

This is a severe, but rare form of oesophageal dysmotility that typically presents with chest pain and dys- phagia in middle-aged patients.

62
Q

How do you Dx spasm [2]

A

Contrast swallow - cork screw
Oesophageal manometry classically demonstrates >20% simultaneous contractions of the LOS of
>30 mmHg amplitude.

Manometry - exaggerated contraction

63
Q

Rx spasm [2]

A

Nitrates and CCB to relax
TCA

64
Q

What causes hypo motility [4]

A

Failed relaxation of LOS sphincter
DM
Neuropathy
Connective tissue disease

65
Q

How do hypo motility present [3]

A

Dysphagia
Regurg
Dyspepsia

66
Q

What is a sliding hiatus hernia [2]

A

Gastro-oesophageal junction slides into chest

Acid reflux / GORD as no sphincter

67
Q

What is a para-oesophageal hernia [2]

A

Junction stays below diaphragm

Part of stomach into chest

68
Q

Who is at risk of hernia [3]

A

Age
Obese
Female

69
Q

How do you dx hernia [3]

A
  1. Endoscopy for GORD
  2. Contrast swallow for reflux - gastric seen above diaphragm
  3. CXR (gastric fundus above diaphragm)
70
Q

How do you treat hernia [3]

A

Lose weight
Treat GORD
Fundolipication for severe complications / strangulated

71
Q

What is a strangulated hernia

What are other complications [2]

A

Necrosis = urgent surgery

Complications of hernia:
Incarcerated - stuck and unable to reduce
Abscess in sac

72
Q

What do you need to do before considering fundoplication [2]

A

Manometry and pH studies

73
Q

What are other indications for endoscopy apart from dysphagia [5]

A

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

74
Q

Eosinophilic Oesophagitis
Aetiology
Endoscopic features & diagnosis
Management [2]

A
  • Patients often have a history of atopy (e.g. eczema, allergic rhinitis or asthma). Food impaction is common
    Aetiology
  • Chronic immune/antigen-mediated oesophageal disease characterised by symptoms related to oesophageal dysfunction and histologically eosinophilic predominant inflammation.
    Endoscopic features
  • include linear furrowing, circular rings (trachealisation) and stricturing.
  • Mid-oesophageal biopsies in patients with suspected EoE.

Management
* Initially acid suppression with proton pump inhibitors (in treatment naïve patients) followed by topical glucocorticoid therapy (e.g. swallowed fluticasone).
* Allergy testing is often advocated in EoE to determine foods that may present a risk for acute allergic reactions and identify EoE triggers.
Patients may present with oesophageal strictures which require therapeutic dilatation.

Gastro (17 decks)

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