Oesophagus + Stomach Flashcards
What is the pathophysiology of GORD?
Reflux of gastric contents through the lower oesophageal sphincter into the oesophagus
Repeat episodes leads to inflammation of the mucosa of the lower oesophagus
What are some risk factors for GORD?
Male
Obesity
Pregnant
Smoking
Alcohol
Hiatus hernia
What is a common presentation of GORD?
Retrosternal burning pain after meals
No weight loss
No Dysphagia
No alcohol
No smoking
What are some differentials for a presentation that is GORD?
Peptic ulcer disease
Gastric cancer
Oesophageal cancer
MI
What important anatomical features prevent reflux of gastric contents?
Lower oesophageal sphincter
Right crus of diaphragm
Acute angle of entry of oesophagus into stomach
Gastric emptying time
Pressure difference
What is the steps in approaching managing GORD?
Clinical diagnosis so doesn’t require imaging
Advise conservative/lifestyle changes and then medication
Only image if this doesn’t work or they have red flag symptoms
What are the lifestyle changes advised for GORD?
Weight loss
Exercise
Smoking cessation
Reduce fatty/spicy foods
Reduce alcohol intake
What medications are given for GORD?
PPIs like lansoprazole or omeprazole
What are some red flag symptoms that would warrant imaging for?
Progressive Dysphagia
Weight loss
Early satiety
Persistent symptoms despite PPI treatment
What imaging/investigations are done for patients with red flag symtpoms or non resolving GORD with PPIs?
Urgent OGD (2wk wait)
ECG (rules out cardiac cause of pain)
24hr pH monitoring
H-pylori test (CLO test)
What are some complications of GORD?
Barrett’s oesophagus
Oesophageal cancer
Oesophageal strictures
Aspiration pneumonia
What is Barrett’s oesophagus?
Metaplastic changes of the lower 1/3 of the oesophagus from stratified squamous cells to columnar epithelial cells (glandular cells of the stomach)
What are some pre surgical investigations that are done for GORD?
Barium oesophagus
Oesophageal manometer yay
24hr pH monitoring
What are the 2 surgical procedures for GORD?
Fundoplication
Cruroplasty
What is a fundoplication?
Where the fundus of the stomach is wrapped around the gastro-oesphogeal junction acting like another lower oesophageal sphincter
What is a hernia?
When an organ or tissue protrudes through the confines of the cavity it should be in into another cavity
What is the definition of a hiatus hernia?
Protrusion of an abdominal organ from the abdominal cavity into the thorax from the oesophageal hiatus
What are the 3 types of Hiatus hernia?
Sliding
Rolling
Mixed
What is a sliding hiatus hernia?
When the stomach follows the oesophagus upwards
What is a rolling hiatus hernia?
Stomach appears next to oesophagus
What vertebral level is the oesophageal hiatus?
T10
What are the risk factors for hiatus hernia?
Age
Chronic cough
Larger diaphragmatic hiatus
Pregnancy
Obesity
Ascites
Previous oesphageal or stomach surgery
How do hiatus hernia present?
Typically asymptomatic
GORD
Mild Epigastric pain
May get swallowing difficulties
How is hiatus hernia managed?
Same as GORD
Lifestyle (weight loss, smoking cessation, cease alcohol)
PPIs
Surgery (fundoplication, cruroplasty)
How does oesophageal cancer present?
(Red flags)
Progressive Dysphagia
Weight loss
Cancer related anorexia
Odonyphagia
Hoarse voice
What are some potential causes/ differentials for Dysphagia?
Oesophageal cancer
Stroke
Oesphageal strictures
Oesophagitis
Anaphylaxis
Thyroid cancer
Foreign body obstruction
Pharyngitis
Tonsillitis
Achalasia
What are the 2 types of oesphageal cancer and where do they occur in the oesophagus?
Squamous cell carcinoma = upper 2/3s oesophagus
Adenocarcinoma = lower/distal 1/3 oesophagus
What is the typically pathophysiology of developing adenocarcinoma of the oesophagus?
Metaplastic changes of the distal 1/3 of the oesophagus likely due to GORD lead to changes from the normal stratified squamous cells to columnar epithelial cells
What are the risk factors for oesophageal cancer?
Male
Smoking
Alcohol
GORD
Obesity
Hot foods + drinks
What maybe present on examination in a patient with oesphageal cancer?
Cachexia
Weight loss
Supraclavicular lymphadenopathy
Signs of metastasis (jaundice, Ascites)
What imaging should be done if suspecting oesphageal cancer?
Urgent OGD (2 wks) with biopsy sent for histology
Can also take a fine needle aspirate of any palpable lymph nodes
Barium swallow or endoscopic ultrasound
If cancer confirmed:
CT CAP IV contrast or CT PET for staging the cancer
What is the management of squamous cell carcinoma of the proximal 2/3s of the oesophagus?
Chemoradiotherapy
Since typically hard to operate on
Some can have endoscopic resection (very few)
What is the management of lower 1/3 oesophageal adenocarcinoma?
Neoadjuvant chemoradiotherapy:
-endoscopic submucosal or mucosal resection
-OESOPHAGECTOMY
What is the rough outline for how an oesphagectomy for a lower 1/3 adenocarcinoma is treated?
What is the procedure called?
Ivor-Lewis
Midline abdominal incision + right thoracotomy (lung deflated)
Oesophagus removed and stomach pulled up and attached to remaining oesophagus (artificial hiatus hernia)
What is the main issue post oesophagectomy in terms of management?
Feeding
How should a patient receive nutrition following an oesophagectomy?
No oral foods just fluids POD 5
Insert jejunostomy tube (alternatives are Central Venous catheter for TPN or Nasojejenal tube)
Those that have the best outcomes are those who start receiving oral foods as soon as its safe to do so
What are the nutritional requirements for maintenance of a patient?
30kcal/kg
1g/kg protein
25-30ml/kg water
1mmol/kg Na+/Cl-/K+
50-100g glucose
What condition may a patient develop following an oesophagectomy once they start eating again?
Refeeding syndrome
What are the 2 types/classes of oesophageal tears?
Superficial mucosal tears
Full thickness tear
What is the name given to superficial oesophageal mucosal tears?
Mallory-Weiss tears.
How does a Mallory Weiss tear typically present?
Haematemesis following an episode of vigorous vomiting
What is the name of the condition where there is full rupture of the oesophagus/oesophgeal perforation occurs due to severe forceful vomitting?
Boerhaave syndrome
How can an oesophageal perforation be caused?
Severe forceful vomiting (boerhaave syndrome)
Endoscopy
How does a patient with oesophgeal perforation present?
Retrosternal chest pain
Respiratory distress
Subcutaneous emphysema
Critically unwell (septic)
Dull to percussion, reduced air entry
What investigations are done for a patient with suspected oesophgeal perforation?
CXR (pneumomediastinum)
The URGENT CT CAP with IV and oral contrast (contrast should be water soluble to not worsen inflammation in thoracic cavity)
Urgent endoscopy if high clinical suspicion and imaging confirms
How is an oesophgeal perforation managed?
Fluid resus
High flow 02
Broad spec antibiotics and. Anti-fungals
Drain intrathoracic contamination (large bore chest drain)
What are the principles to managing an oesophageal perforation?
Control leak (repair)
Eradicate mediastinal and pleural contamination (drainage and/or washout)
Decompress oesophagus drain or NG tube)
Nutritional support (jejunostomy)
How is a Mallory Weiss tear investigated?
OGD
What is peptic ulcer disease?
Break in the lining of the gastrointestinal tract extending through to the muscular layer
Where are peptic ulcers most often located?
Less curvature of proximal stomach (gastric ulcer)
Proximal duodenum (duodenal ulcer)
What normally leads to formation of peptic ulcers/risk factors?
H-pylori infection
NSAIDs
How can H-pylori lead to peptic ulcer formation?
They can survive in gastric and duodenal mucosa by producing an alkaline environment (urease enzyme) this leads to inflammatory response in mucosa leading to ulceration
Inhibit parietal cells gastric acid production
Can migrate to duodenum causing duodenal ulcers
How does NSAID use lead to peptic ulcers?
NSAIDs inhibit COX enzymes inhibiting the production of protective prostaglandins. This decreases the amount of blood flow and production of the protective alkaline gastric mucosa
What are the risk factors for peptic ulcers?
H-pylori infection
Prolonged NSAIDs
Corticosteroids (when used with NSAIDs)
Severe burns
Head trauma
Zollinger-Ellison syndrome
What is the type of peptic ucler that can occur with severe burns?
Curlings ulcer
How does peptic ulcer disease present?
Epigastric pain (associated with eating)
Nausea
Bloating
Early satiety
Haematemesis if leads to perforation
How might you be able to clinically differentiate between a gastric ulcer and duodenal ulcer?
Gastric ulcer = pain immediately after eating
Duodenal ulcer = pain a few hours after eating
How are patients with peptic ulcers managed?
H-pylori testing (urea Breath test)
If upper GI red flags endoscopy with CLO test for H-pylori and histology
Conservatively:
Cease NSAIDs
Smoking cessation
Reduce alcohol
Weight loss
PPIs if have peptic ulcers
What is the medication given for peptic ulcer disease?
PPI
What is the treatment for patients with H-pylori infection?
Triple therapy
PPI + x2abx
Lansoprazole + amoxicillin + clarithromycin or metronidazole for 14days
What are the main major complications of peptic ulcer disease?
Upper GI bleeding/perforation
What is the likely diagnosis with this presentation?
51y/o male
20pack year
20 units a week
6hr Epigastric tenderness radiating to back
Haematemesis
Opened bowels fine
Takes regular ibuprofen
Perforated peptic ulcer
What Ix would you do for a patient with potential perforated peptic ulcer/bleeding?
FBC
U+E
LFTS
Clotting
G+S and cross match if bleeding
CRP
ECG
VBG
Serum amylase
What imaging should be done for a potential perforated peptic ulcer?
CXR (air under diaphragm)
URGENT OGD
CT angiogram if patient cant undergo endoscopic procedure
What is the management for a perforated peptic ulcer/bleed?
A-E
2222 (MHP)
Give blood
Fluids
OGD (adrenaline injection and cauterisation at the site of the bleed)
Analgesia
Antiemetics
IV PPI
How is a perforated peptic ulcer definitively managed?
Surgically:
Defect < 2cm repair
Defect > 2cm resect area
Address risks of developing peptic ulcers
What artery is most commonly at risk with gastric ulcers?
Splenic artery (posterior gastric ulcers)
What blood vessel is. Most at risk with posterior duodenal ulcers?
Gastroduodenal artery
What are some post op respiratory complications from treating perforated peptic ulcers?
PE
Atelectasis
Aspiration pneumonia
Pneumothorax
How does ruptured oesophageal Varices present?
Haematemesis
Melaena
Hypotension
(SHOCK symptoms)
What is the definition of shock?
Abnormality of circulatory system that results in inadequate organ perfusion and tissue oxygenation
What is the management of oesophageal Varices?
A-E
2222 (MHP)
Fluid bolus
Blood transfusion
Terlipressin (to reduce splanchnic blood flow and reduced portal blood pressure)
ABG and bloods
Endoscopic banding and ligation
What blood vessels does oesophageal Varices occur between?
What is the pathophysiology?
Portal hypertension leads to shunting of blood between portosystemic anastomoses between the left gastric vein and the azygous vein
What drug can help reduce bleeding?
TXA
What drug can help reduce bleeding?
TXA
What is a CLO test?
Sample of tissue taken and assessed to see if urease enzyme is present and so if h-pylori has infected the tissue
What investigations would you do for a patient who you think might have peptic ulcer disease?
FBC
LFTs
U+Es
Serum amylase
G+S
Clotting
CRP
Troponin
Urine dip
CXR
OGD
ECG
What is gastric outlet obstruction?
Mechanical obstruction between pyloric sphincter and proximal duodenum
What is the management of gastric outlet obstruction?
What Ix / imaging is done?
FBC, CRP, U+Es, LFTs, G+S, clotting
Abdominal plain film radiograph
CT abdominal-pelvis IV contrast
IV fluids
NG tube (DECOMPRESS STOMACH)
PPIs
Endocscopy can dilate structuring
Further surgery may be. Required if fails or its malignant cause
