Oesophagus, Stomach conditions Flashcards
Oesophagitis - causes, syx, ix, mx
Inflammation caused by:
- Reflux (most common cause)
- Infectious: more common in IMC pts (candida, herpes simplex virus, cytomegalovirus)
- Drug induced: if tablet not taken with enough liquid it can damage the tissues
- Eosinophilic: allergen exposure or GORD
- Chemical - occupational exposure to fumes/chemicals
Clinical features
- Asyx
- Epigastric pain +/- retrosternal burning pain especially when lying down or straining
- Odynophagia (painful swallowing)
- Cough
- N+V
Ix
Dx usually made clinical.
- Endoscopy (via referral) – allows for visualisation
Management
(1.) wt loss, smoking cessation, alcohol, avoid trigger foods, avoid eating larger meals
(2.) Medical - PPI, antacids
(3.) Treat underlying cause
Mallory-weis tear - what is it? RF? Syx? Ix? Mx?
Acute GI bleeding due to mucous mb lacerations at gastroesophageal junction
RF
- Excessive alcohol intake
- Predisposing conditions to vomiting/retching - gastroenteritis, bulimia, hyperemesis gravidarum
- Iatrogenic
Syx
- haematemesis after an episode of forceful or recurrent retching
- +/- epigastric pain, lightheaded, syncope, melena
Ix
- Bloods
- Endoscopy (dx)
Mx
Most are self-limiting
- Active GI bleeding: ABCDE, fluids, blood transfusion
- Endosocopy may be needed for Rx within 24hrs
- PPI, after endoscopy intervention + dx
Oesophagus Neoplasm
Adenocarcinoma most common in UK, SCC most common world-wide.
Rf
Ad: GORD, barret’s, smoking, achalasia, obesity
SCC: smoking, hi alcohol, achalasia
Syx
(1.) Progressive dysphagia from solids to liquids
(2.) Odynophagia
(3.) Anorexia
(4.) Wt loss
(5.) N+V
(6.) Hoarseness
Ix
- Endoscopy + biopsy
- Staging: CT/MRI/USS/PET
Rx
- Surgical resection (Ivor Lewis esphagectomy)
- Chemotherapy
2ww referral for endoscopy
(1.) Dysphagia regardless of age
(2.) >55y + wt loss PLUS
- Upper abdomen pain
- Reflux
- Dyspepsia
(3.) Dyspepsia
- Any age combined with 1 or more alarm syx (wt loss/proven anaemia/vomiting)
- >55y + with onset <1yr
- Combined with FH upper GI Ca, barret’s, pernicious anaemia, peptic ulcer surgery, jaundice, upper abdo mass or known dyplasia/atrophic gastritis/intestinal metaplasia
Dysphagia in ca vs spasm + achalasia
Ca has progressive dysphagia from solids to liquids
Differs from oesophageal spasm and achalasia which have dysphagia to solids and liquids from the start
Strictures - what are they and causes (7)? syx, ix, mx
Narrowing of the oesophagus can be benign or malignant.
Causes:
- GORD: acid damages lining + leads to peptic stricture
- Corrosive substance ingestion e.g. accidental ingestion/suicidal poisoning of household products
- Eosinophilic oesophagitis/ allergic reaction
- Drug-induced esophagitis e.g. NSAIDs
- iatrogenic post-endoscopy
- infectious
- malignant
Syx
- Progressive dysphagia (benign stricture follows a slow and insidious course, malignant stricture develops rapidly)
- food impaction
- odynophagia
- cp
- wt loss
- choking episodes
Ix
- Bloods: FBC, LFT
- Barium XR
Mx
- Urgent referral if malignancy
- Oesophageal dilation at endoscopy if benign strictures
Varices - what is it, causes, syx, mx
Abnormal, enlarged veins caused by portal HTN due to blocked liver flow from clot or scar tissue. This can rupture and cause life-threatneing bleeding
Causes
- Prehepatic: Portal vein thrombosis, splenomegaly
- Intrahepatic: Cirrhosis, schistomiasis
- Post hepatic: RSHF, hepatic vein obstruction (Budd-Chiari syndrome), constrictive pericarditis
Syx
- Haematemesis
- Melena
- Abdo pain
- Liver signs: jaundice, ascites
Mx: ABCDE
- Terlipressin/vasoactive drug
- Prophylactic Abx
- Urgent ENDOSCOPY: Oesophageal varices: band ligation (1st line) or TIPS. Gastric: N-butyl-2-cyanoacrylate or TIPS
Achalasia - what is it, presentation, ix, rx
Failure of the lower oesophageal sphincter to relax
Syx
- Gradual onset of dysphagia to solids + liquids
- Food regurgitation
- Aspiration
- Retrosternal CP/heartburn, does not respond to PPI
- Wt loss
Ix
- Endoscopy: shows dilated oesophagus, containing residual material
- Oesophageal manometry (Dx): shows hi pressure + incomplete lower oesophageal sphincter relaxation
- CXR: wide mediastinum + fluid level
- Barium swallow: shows classic ‘bird’s beak appearance’
Mx
Surgery
- oesophageal dilatation (1st line)
- ‘Heller’s Myotomy’ (surgical cleavage of the muscle) – if recurrent
Medical
- Botox or CCB/nittrates
GORD - what is it, causes, syx, ix, mx
- Acid from stomach reflexes through lower oesophageal sphincter and irritates lining of oesophagus. - Complications: oesophagitis, ulcers, stricture formation, iron deficiency, Barrett’s oesophagus
Causes
- Increased intra-abdominal pressure: pregnancy + obeisty
- Abnormal lower oesophageal sphincter - reduced tone or poor oesophageal peristalsis
- Defective Oesophageal dysmotility e.g. systemic sclerosis
- Gastric acid/function: Gastric acid hypersecretion or delayed gastric emptying
- HIatus hernia
- Smoking, alcohol, coffee, big meals
- Drugs e.g. tricyclics, anticholinergics, nitrates, CCB
Syx
- Heartburn/burning sensation: Related to meals, lying down, stooping and straining, relieved by antacids
- Belching (burping)
- Retrosternal discomfort
- Acid brash
- Odynophagia if severe oesophagitis or stricture
- other syx: CP, epigatric pain, bloating, nausea, chronic cough
Ix
If young, typical syx w/o worrying features (dysphagia/ wt loss /anaemia) can be treated empirically without ix.
- ECG
- FBC, CRP, Cardiac enzymes, UE, LFT
- CXR
- Barium swallow may show hiatus hernia
- Endoscopy (ix of choice)
- 24hr pH-monitoring/manometry
Mx
Conservative:
- wt loss
- smoking cessation
- diet: small regular meals, reduce hot drinks/alcohol /spicy /caffeine.
- avoid eating/ heavy meals <3hrs before bed
- raise head in bed
- stay upright after meal
Medical
- Antacids or alginates e.g. Gaviscon - for syx relief
- PPI for 1m
Surgical
- Laparoscopic fundoplication (tightens lower oesophagus sphincter) or laproscopic insertion of magnetic bead band
WHat is barrets - RF, Syx, mx
Normal distal squamous epithelial lining has been replaced by metaplastic columnar epithelium above gastro-oesophageal junction.
RF: GORD, hiatus hernia, obesity, smoking, excess alcohol intake
Presentations
- Asyx
- GORD or stricture syx
Management:
- Low grade dysplasia: high dose PPI and FU with endoscopic surveillance at 6m intervals
- High grade dysplasia: endoscopic ablation or esophagectomy
Gastritis - complications, causes, syx, ix, mx
Inflammation of gastric. Complications: ulcer disease, gastric carcinoma, gastric lymphoma
CAuses: H.pylori infection (most common), NSAIDs, alcohol, stress, AI, mucosal ischaemia.
Syx
- ASyx
- Dyspepsia
- Bleching
- Epigastric pain - food makes pain worse
- Other syx: N+V, bloating, retching, early satiety
Ix
Gastritis is a histological dx.
- Bloods: FBC (?anaemia), CRP, FT, UE, B12 (?pernicious anaemia).
- Test for hpylori: faecal antigen or urea breath test
- Endoscopy if suspicious features
Mx
Conservative
- Eat smaller, more frequent meals
- Avoid irritating foods (spicy, acidic/juices, fried/fatty)
- Avoid alcohol
- Smoking cessation
- Reducing Stress
- Reduction of NSAIDs
Medical (depends on aetiology)
- Antacid
- If hpylori: eradication therapy: PPI + amoxicillin/metronidazole + clarithromycin
PUD - causes, clinical features, ix, mx
Causes
- Helicobacter infection (80-95%)
- Zollinger-Ellison Syndrome
- Mucosal ischaemia
- Bile reflux
- Smoking, NSAIDs/aspirin, stress
Syx
- EPigastric pain: relieved with food (duodenum), worse with food (gastric)
- N+/-V
- Bloating
- Dyspepsia
- Early satiety
- Upper GI bleed: aneamic, meleana etc
Ix
- Obs, abdo ex
- Bloods: FBC (?IDA), Clotting, CRP, LFT, UE, amylase
- Stool Antigen Test or Carbon-13 urea breath test
- OGD (confirms Dx): only consider if this is 1st presentation, alarm syx present, >55y + prev PUD/gastric surgery/ perc anaemia/ NSAID, FH Ca
Mx
Conservative
- Stop NSAIDs/ alendronate/ aspirin
- Avoid smoking, alcohol, caffeine, stress, wt loss, spicy food, triggers
- Eat smaller meals, 3-4hrs before bed
- FU endoscopy following PUD 6-8w after tx, to confirm healing.
Medical
- Hpylori eradication therapy for 7-10d
- Biopsy if hypylori -ve, nsaid -ve, and suspect zolllinger
- Endoscopic ablation for bleeding ulcers
Gastric Neoplasm
Adenocarcinoma most common, other types of gastric tumour include lymphomas and GIST.
RF: age, male, poor-socioeconomic, pernicious anaemia, H. pylori, FH, FAP, smoking
Clinical features
- dyspepsia, wt loss, vomiting, dysphagia, anaemia, early satiety
- signs: epigastric mass, hepatomegaly, jaundice, ascites, Troisier’s sign (enlarged Virchow’s node), acanthosis nigricans
Ix
- FBC (?IDA), LFT
- Endoscope + biopsy (Ix of choice)
- CT for TNM staging
- Barium meal
Mx
- Screen for nutritional deficiency + support
- Syx control: pain, nausea, constipation, depression
- Endoscopic surgery
- chemo + radiotherapy
Pyloric stenosis - signs + syx, Ix, Mx
Hypertrophy + narrowing of pylorus
Clinical features
(1.) Baby will appear: hungry, thin, pale, failing to thrive.
(2.) Projectile vomiting: 30-60mins after food, with every feed there is vomitting
(3.) infrequent or absent bowel movement
O/e
- Peristalsis may be visible after feeding
- Firm, round mass in RUQ (‘olive’)
IX
- UE: hypokalaemic from dehydration
- ABG: hypochloric metabolic alkalosis due to vomiting stomach acid
- Abdo USS (dx)
Mx
- IV fluids + electrolyte replacement
- Laparoscopic pyloromyotomy (Ramstedt’s operation) - incision made in smooth muscle of pylorus which allows widening of canal and food to pass.
