RCSI: UPPER GI Flashcards
What is the definition of Gastro-Oesophageal Reflux Disease (GORD)?
A condition describing excessive reflux of gastric contents (acid, bile, and pancreatic enzymes) into the oesophagus, through a defective lower oesophageal sphincter (LOS), causing symptoms and/or oesophageal mucosal injury.
What can be observed at endoscopy in GORD?
Erosive and non-erosive disease.
What confirms the diagnosis of GORD?
An abnormal DeMeester score on pH monitoring.
What is the epidemiology of GORD?
- Most frequently diagnosed upper GI disorder
- Most commonly found in middle-aged adults
- About 25–40% of healthy adult Americans experience symptomatic GORD.
What are the risk factors for GORD?
- Family history of GORD
- Elevated BMI
- Heavy alcohol use
- Smoking
- Pregnancy
What are the pathophysiological mechanisms involved in GORD?
- Poor/inefficient oesophageal motility
- Reduced LOS tone
- Increased intragastric pressure and delayed gastric emptying.
What are common clinical features of GORD?
- Retrosternal discomfort or heartburn
- Acid reflux into pharynx
- Commonly worse at night and after large meals
- Dysphagia may occur if there is associated ulceration or a stricture
- Globus: Feeling of a lump in throat
- Pulmonary aspiration (nocturnal coughing; hoarse voice)
- Commonly associated with hiatus hernia.
What investigations are used to confirm GORD?
- Routine laboratory investigations
- 24 hours continuous pH monitoring
- Oesophageal manometry
- Oesophago-gastro-duodenoscopy (OGD) for patients over 45.
What lifestyle modifications can help manage GORD?
- Smaller meals at frequent intervals
- Avoid late-night food intake
- Avoid gastric irritants like coffee, chocolate, and spicy food
- Smoking cessation and moderation in alcohol intake.
What medical treatments are used for GORD?
- Proton pump inhibitors (PPIs)
- Antacids (e.g., Gaviscon).
What are the types of fundoplication surgeries for GORD?
- Nissen’s fundoplication
- Dor fundoplication
- Toupet fundoplication.
What are some complications of GORD?
- Oesophagitis and ulceration
- Peptic stricture
- Barrett’s oesophagus
- Increased risk of oesophageal adenocarcinoma.
What is Barrett’s Oesophagus?
The metaplastic change of stratified squamous epithelium of the distal oesophagus to columnar epithelium.
What are the classifications of Barrett’s Oesophagus?
- Long segment (>3 cm)
- Short segment (<3 cm).
What are the management strategies for Barrett’s Oesophagus?
- Lifestyle modifications
- Anti-reflux medications
- Eradication therapy for Helicobacter pylori
- Radiofrequency ablation and OGD surveillance
- Mucosal endoscopic resection
- Oesophagectomy.
What is the definition of a hiatus hernia?
The prolapse of the gastro-oesophageal junction (GOJ) and part or all of the stomach into the thoracic cavity through the oesophageal diaphragmatic hiatus.
What are the types of hiatus hernias?
- Type I: Sliding
- Type II: Paraoesophageal
- Type III: Combined
- Type IV: Complex.
What are common investigations for hiatus hernia?
- CXR
- Barium swallow
- OGD
- CT scan.
What are the management options for hiatus hernia?
- Conservative/medical: Reduce acid production, counteract acid secretion
- Surgical: Laparoscopic/robotic reduction of the hernia, excision of the sac, and gastric fixation (gastropexy).
What are complications associated with hiatus hernia?
- Oesophageal inflammation
- Ulceration
- Bleeding
- Iron deficiency anaemia
- Gastric volvulus.
What is the definition of Peptic Ulcer Disease?
Injury leading to the breakdown of the mucosal layer of the lower oesophagus, stomach, or duodenum, mainly occurring secondary to excessive acid production or damaged barrier mechanisms.
What are the key facts about Peptic Ulcer Disease?
- Lifetime prevalence: 11–14% in men, 8–11% in women
- Most common sites: First part of the duodenum, gastric antrum, lesser curve of the stomach
- H. pylori accounts for 90% of duodenal ulcers and 70–80% of gastric ulcers.
What are the clinical features of Peptic Ulcer Disease?
- Nonspecific symptoms: dyspepsia, nausea, epigastric pain
- Heartburn and acute chest pain
- Hematemesis/melaena for bleeding ulcers
- Symptoms of anaemia
- Duodenal ulcers: hunger pains, nocturnal pain, relieved by food.
What investigations are used for Peptic Ulcer Disease?
- Urease test for H. pylori
- Urea breath test
- Stool antigen testing
- Serology
- Fasting serum gastrin levels
- OGD.
What is the management for Peptic Ulcer Disease?
- Eliminate H. pylori infection with triple therapy
- Diminish irritant effects of acid-pepsin
- Use mucosal protective agents
- Reduction of acid secretion with PPIs and H2 receptor-blocking drugs.
What are the complications of Peptic Ulcer Disease?
- Bleeding
- Perforation and sepsis
- Gastric outlet obstruction.
What is the definition of upper gastrointestinal bleeding?
Bleeding from the oesophagus, stomach, or duodenum (above the ligament of Treitz).
What are the key facts about upper gastrointestinal bleeding?
- Hematemesis indicates vomiting of blood
- Melaena refers to black ‘tarry’ stools
- PUD is the most common cause.
What are the clinical presentations of upper gastrointestinal bleeding?
- Haematemesis and melaena
- Abdominal pain
- Heartburn, reflux, dyspepsia
- Symptoms of chronic liver disease
- Features of anaemia.
What symptoms suggest oesophagitis or ulceration?
Burn, reflux, dyspepsia
These symptoms may indicate inflammation or ulceration of the esophagus.
What are the features of chronic liver disease?
Jaundice, ascites, spider naevi, gynecomastia, caput medusae, hepatomegaly
These features may indicate the presence of liver dysfunction or cirrhosis.
What are common medications associated with upper gastrointestinal bleeding?
Aspirin/Plavix, warfarin/NOAC, NSAIDs, steroids
These medications can increase the risk of bleeding due to their anticoagulant or irritant properties.
What vital signs indicate instability in a patient with upper GI bleeding?
Tachycardia, hypotension, tachypnoea, reduced urine output
These signs suggest significant blood loss and potential shock.
What is the differential diagnosis of upper gastrointestinal bleeding?
- Oesophageal Varices
- Malignancy
- Ulcer
- Oesophagitis
- Mallory-Weiss tear
- Gastric Varices
- Gastritis
- Dieulafoy lesion
- Duodenal Ulcer
- Vascular malformation (such as aorto-enteric fistula)
Each of these conditions can lead to bleeding in the upper gastrointestinal tract.
What blood tests are essential in the investigation of upper GI bleed?
- FBC
- U&E
- Coagulation screen
- LFTs
- Group and crossmatch
- ABG
These tests help assess blood loss, kidney function, liver function, and bleeding risk.
What is the purpose of IV PPI infusion in the management of upper GI bleeding?
To reduce gastric acid secretion
This helps prevent further erosion of the gastric mucosa and promotes healing.
What is the Rockall Score used for?
To estimate the risk of rebleeding or death in an upper GI bleed
It helps guide management decisions based on the patient’s risk profile.
Define dysphagia.
Difficulty swallowing
This can be a symptom of various underlying conditions affecting the esophagus.
What are the causes of odynophagia?
- Trauma
- Foreign body
- GORD
- Infective causes
- Neoplasia
- Motility-related issues
- Other (e.g., scleroderma)
Odynophagia is painful swallowing, which can arise from various etiologies.
What is achalasia?
A condition characterized by a loss of esophageal peristalsis and failure of the lower esophageal sphincter to relax
This leads to swallowing difficulties and can result in food accumulation in the esophagus.
What is the primary investigation for dysphagia?
Upper GI Endoscopy
This allows direct visualization and potential biopsy of the esophagus.
What is the characteristic appearance of achalasia on barium swallow?
Bird’s beak appearance
This appearance is due to the narrowed esophago-gastric junction and dilated esophagus.
What are the key complications of achalasia?
- Nocturnal aspiration
- Bronchiectasis
- Lung abscess
- Carcinoma (3% risk)
These complications arise from chronic obstruction and stasis in the esophagus.
What is the most common histological type of esophageal cancer?
Squamous Cell Carcinoma (SCC)
SCC is prevalent in specific regions, while adenocarcinoma is more common in Western countries.
What are the risk factors for adenocarcinoma of the esophagus?
- Barrett’s esophagus
- GORD
- Obesity
- High fat intake
- Cigarette smoking
- High alcohol intake
These factors contribute to the development of metaplasia leading to cancer.
What is the management strategy for esophageal cancer?
- Chemotherapy
- Radiotherapy
- Surgery
Multidisciplinary approaches are essential for effective treatment.
What are some risk factors for oesophageal cancer?
Cigarette smoking, high alcohol intake, nitrosamines in diet, vitamin A and C deficiency, coeliac disease, strictures and webs, achalasia, peptic ulcer disease.
What clinical features indicate the need for urgent referral for endoscopy in patients over 45?
Any new symptoms of dysphagia, especially with weight loss.
What is the significance of high-grade dysplasia in Barrett’s metaplasia?
It is associated with occult adenocarcinoma in 30%.
List symptoms of disseminated oesophageal cancer.
- Cervical lymphadenopathy (including Virchow’s node)
- Hepatomegaly due to metastases
- Epigastric mass due to para-aortic lymphadenopathy.
What are symptoms of local invasion in oesophageal cancer?
- Hoarseness in recurrent laryngeal nerve palsy
- Cough and haemoptysis in tracheal invasion
- Neck swelling in superior vena cava (SVC) obstruction
- Horner’s syndrome if sympathetic chain invasion.
What investigations are used for local staging of oesophageal cancer?
Endoluminal ultrasound scan to assess depth of invasion and paraesophageal lymph nodes.
Which imaging technique is used to evaluate local invasion and locoregional lymphadenopathy in oesophageal cancer?
CT Thorax Abdomen Pelvis (TAP).
What is the role of PET scan in the management of oesophageal cancer?
It is used to exclude metastases.
What is the management approach for early-stage oesophageal cancer without nodal involvement?
Surgery can be a single modality treatment.
What is the Ivor Lewis procedure?
A 2-stage oesophagectomy performed for distal tumours.
What type of cancer is classified through the Siewert classification?
OGJ (oesophagogastric junction) tumours.
What are the key facts about gastric cancer?
- Sixth most common cancer
- Third most common cause of cancer-related deaths
- Most patients present with advanced disease
- 5-year survival is 31%.
What are common subtypes of gastric cancer?
- Gastric adenocarcinoma
- Adenocarcinoma of the GOJ
- Gastrointestinal stromal tumours (GISTs)
- Neuroendocrine tumours (carcinoid tumours)
- Lymphoma (associated with H. pylori).
What are the risk factors for gastric adenocarcinoma?
- Chronic gastric ulceration related to H. pylori
- Diet rich in nitrosamines
- Epstein-Barr virus (EBV)
- Family history of gastric cancer
- Blood type A.
What are the common symptoms of gastric cancer?
- Dyspepsia
- Weight loss, anorexia, lethargy
- Hematemesis, melena
- Dysphagia
- Gastric outlet obstruction and projectile vomiting.
What are some signs of gastric cancer?
- Anaemia
- Palpable epigastric mass
- Palpable supraclavicular lymph node (Troisier’s sign)
- Malignant pleural effusion and ascites
- Hepatomegaly and jaundice.
What is the first step in the diagnosis of gastric cancer?
Gastroscopy and biopsy.
What is the purpose of neoadjuvant chemotherapy in gastric cancer?
To improve surgical outcomes in locally advanced disease.
List early complications of partial or total gastrectomy.
- Haemorrhage
- Acute pancreatitis
- Anastomotic leak
- Duodenal stump disruption
- Respiratory compromise.
What are late complications of gastrectomy?
- Dumping syndrome
- Bile reflux and vomiting
- Diarrhoea
- Recurrent stomal ulceration
- Metabolic abnormalities.
What is the overall prognosis for gastric cancer?
Overall prognosis remains poor with a five-year survival of 66% for stage I disease and 10% for stage III disease.
What should patients be informed about before oesophago-gastro-duodenoscopy?
The procedure involves inspection of the upper GI tract with a flexible endoscope, and they can choose sedation or local anaesthetic.
What are the risks associated with oesophago-gastro-duodenoscopy?
- Perforation
- Bleeding
- Damage to teeth
- Risks associated with sedation
- Aspiration.
