The Digestive System - Upper GI Flashcards
1
Q
Foregut
A
Mouth to 2nd part of duodenum
2
Q
Midgut
A
2nd part of duodenum to distal 1/3 of transverse colon
3
Q
Hindgut
A
Distal 1/3rd of transverse colon to halfway down anal canal
4
Q
Radiological modalities used in upper GI
A
Endoscopy*
Fluroscopy - barium swallow
CT
Nuclear med
Angiography
Plain radiographs
MRI
5
Q
Parts of the stomach
A
Cardia
Fundus
Lesser curve
Greater curve
Incisura angularis
Antrum
Pyloris
Rugae
6
Q
Hiatus hernia
A
Abnormal bulging of a portion of the stomach through the diaphragm
7
Q
Achalasia
A
Failure of lower oesophageal sphincter to open in response to swallowing
8
Q
Odynophagia
A
Painful swallow w/ or w/out difficulty
9
Q
Indications for plain film
A
Dental/ trauma/ TMJ
Foreign body
Obstruction
Suspected perforation
Calculi?
10
Q
Indications for contrast swallow/ meal
A
Dysphagia and normal endoscopy
Not fit for endoscopy
Assess pharyngeal pouch
Clarify endoscopic findings
Perforation/ leak esp post-oesophagectomy
11
Q
Indication for CT
A
Staging malignancy
Surgical abdomen
Clarify anatomy e.g. extrinsic compression
Trauma
Unexplained sx
12
Q
Examples of gastric secretions
A
Gastric (hydrochloric) acid
Pepsinogen
Intrinsic factor
Gastrin
Leptin
Ghrelin
Somatostatin
Histamine
13
Q
What does the body of the stomach secrete
A
Mucus
Pepsinogen
HCl
14
Q
What does the antrum secrete
A
Mucus
Pepsinogen
Gastrin
15
Q
What is secreted by parietal cells
A
Acid
IF
16
Q
What is secreted by Chief cells
A
Pepsinogen
Leptin
17
Q
Which stomach cell secretes histamine
A
Enterochromaffin-like cell (ECL)
18
Q
Which cell secretes gastrin
A
G- cell
19
Q
Which cell secretes somatostatin
A
D-cell
20
Q
Specific stomach cells
A
Parietal cell
Chief cell
ECL cell
G-cell
D-cell
Epithelial cell
Progenitor cell
21
Q
Conventional phases of gastric secretion
A
Cephalic - stimulation
Gastric - stimulation
Intestinal - initial stimulation, later inhibition
22
Q
Overall integrators of cephalic phase of gastric secretion
A
Vagus nerve
23
Q
Overall integrators of gastric phase of gastric secretion
A
Neural - long vagus nerve
Gastrin
24
Q
Overall integrators of intestinal phase of gastric secretion
A
Hormones - gastrin, enteric inhibitors (enterogastrones)
25
What type of hormone is gastrin
Peptide
26
Types of gastrin
G-17 in gastric antrum
G17 and G-34 in duodenum
27
What is gastrin
Main physiological stimulant of gastric acid secretion
28
What can gastrin be directly stimulated by
Ca2+
Amines
29
When is gastrin release inhibited
pH <3 (-ve feedback)
Too much acid, turns off antral G cell
Less gastrin produced
Less HCl produced
30
Examples of spp gastric receptors
CCK2
CCKB
31
Main stimulants of acid secretion
ACh
Gastrin
Histamine
Activation of multiple pathways is synergistic
32
Where is ACh released from
Vagus nerve
33
Role of ACh in acid secretion
Stimulates release of gastrin and histamine
Directly activates parietal cell
Binds to muscarinic M3 receptor - elevates Ca2+
34
Role of gastrin in acid secretion
Stimulates histamine release
Directly stimulates parietal cells
Binds to CCK2 receptor - stimulates Ca2+
35
Role of histamine in acid secretion
Directly stimulates parietal cell
Binds to histamine H2 receptors - stimulates cAMP
36
Main inhibitors of acid secretion
Somatostatin
PGE2
37
Role of somatostatin in inhibition of acid secretion
Inhibits gastrin and histamine secretion
Inhibits parietal cell directly
38
Role of PGE2 in inhibition of acid secretion
Inhibits parietal cell directly
39
Gastrin effects on ECL cells
A/c - histamine release
Intermediate - histamine synthesis
C/c - hyperplasia of ECL cells
40
Parietal-ECL-D cell unit
Functional cellular unit of acid secretion
41
Where is the parietal-ECL-D cell unit located
Gastric body
42
Activation by the parietal-ECL-D cell unit
Direct activation of parietal cell
Indirect activation by ECL-cell secreted histamine
43
Inhibition of parietal-ECL-D cell unit
Paracrine inhibition by somatostatin
44
How does somatostatin secretion restrain gastrin
Immunoneutralisation
Receptor inhibition
45
At which pH does somatostatin secretion decline
pH >3
46
How can diseases w/ abnormal acid secretion be classified
Infl +/- atrophy of the gastric body e.g. AI gastritis, H. pylori gastritis
Iatrogenic..g drugs, vagotomy
47
Vagotomy
Surgical procedure to remove part of vagus nerve, typically to reduce rate of gastric secretion
48
What are diseases w/ too little acid secretion associated w/
Infectious diarrhoea
Gastric adenocarcinoma
49
Which spinal levels does the oesphagus run from
C5/6 to T10
50
Important muscles in the oesophagus
Cricopharyngeal/ upper oesophageal sphincter
Oesophagus
Lower oesophageal sphincter
51
Role of cricopharyngeus
Part of swallowing and preventing aspiration
52
Control of sphincters in oesophagus
Voluntary control - cricopharynxgeus
Involuntary - lower oesophageal sphincter
53
Layers of oepshageal wall
Mucosa
Submucosa
Muscualris - circular layer and longtudinal layer
Adventitia
NO serosa, unlike rest of intestinal tract
54
What is muscularis in the oesophagus involved in
Peristalsis
55
Role of squamous mucosa in oesophagus
Barrier, protective effect
56
Circular vs longitudinal layer in muscularis
Circular muscle - contraction cause an increase in luminal pressure
Longitudinal muscle - contraction causes shortening
57
Control of muscle in oeophagus
Largely under parasympathetic control via vagus nerve
58
How does food travel down the oesphagus
As soon as food is past the cricopharyngeus its squeezed into a bolus and pushed down via peristalsis
Bolus pushed down in wave to LOS
LOS must relax to allow food into stomach then contract to prevent food coming up
59
Definition of peristalsis
Coordinated contraction and relaxation of muscles in oesphagus
60
Components of lower oesophageal sphincter components
These must all work together, neither on their own is effective
Internal - circular oepshageal muscle fibres, sling like oblique gastric muscle fibres
External - diaphragmatic crura
Angulation - angle of his between fundus and oesophagus
61
LOS function after swallowing
Inhibitory signals generated by peristalsis cause a reflex relaxation of the LOS for ~5secs
The diaphragmatic crura also relax
62
Transient LOS relaxation
TLESR
Gastric distension causes both the LOS and diaphragmatic crura to relax, allowing release of excess gas (burping)
63
Foods that increase LOS pressure
Protein
Carbs
(Refluxed) acids
64
Foods that decrease LOS pressure
Chocolate
Fat
Caffeine
Citrus
Garlic
Tomato
Decreased pressure causes acid reflux
65
Drugs that increase LOS pressure
Alpha-agoints
Beta-blockers
Cholinergics
Metoclopramide
Domperidone
66
Drugs that decrease LOS pressure
Alcohol
Anticholinergics
Beta-agonits
Calcium channel blockers
Dopamine (D2 receptors)
Nicotine
Nitrates
TCAs
67
Stomach as a provider of storage capacity
Small amounts can be fed into small intestine where it is broken down more efficiently
Pylorus opens 3x/min to allow small amounts through
68
How is the grinding motion of the stomach caused
By 3 muscle layers: longitudinal, circular & oblique causes food to be broken down physically
69
Function of stomach rugae
Make acid
These folds increase SA of stomach
70
Where is stomach rugae found
Body of stomach, not antrum
71
Processes involved in gastric acid secretion
Neural
Endocrine (gastrin)
Paracrine (histamine and SST)
72
Which cells are found in the gastric body
Parietal cell
ECL cell
73
Examples of diseases w/ too much acid
Zollinger-Ellison syndrome
74
What substances does the gastric gland secrete
Gastric acid
Proteolytic pepsin(ogen)
75
When does pepsinogen --> pepsin
Once pepsinogen meets an acidic environment
76
Why is the canalicular membrane of the PC partially internalised
Increase SA for secretion
77
Where do the contents of PC secretions go
Into canaliculi --> gastric gland --> lumen
78
Features of proton pump in canalicular membrane
Active pump - pumps H+ OUT and K+ IN PC
Requires a lot of ATP
Cl- diffuse across membrane and combines w/ H+ to form HCl
79
Stimulation of protein pump
3 receptors on basolateral membrane of PC - one ACh, one histamine (H2) and one gastrin
ACh is neurotransitter - stimulates proton pump
Gastrin travels in blood (endocrine effect)
Histamine travels directly to PC (paracrine effect)
80
Cephalic phase of acid secretion
Thought, taste, smell, sight, swallowing
Vagus nerve sends signal to stomach to prepare for food
Done through release of ACh
81
What is gastrin secreted in response to
Gastric distention - stomach stretched by a meal
AA/ peptides - foods high in this increase gastric production
Low acidity (i.e buffering by food)
82
Feedback loop in gastric phase of gastric acid secretion
Low acidity causes astral G cell to make gastrin
PC produces acid
High acidity switches on D cell to create SST
Switches OFF antral G cell
83
Intestinal phase of gastric acid secretion
Least important (5-10%)
Stimulation via duodenal distension (neural) and chyme (gastrin)
Inhibition via enetroendocrine cells secreting various gastric inhibitory peptides
84
In which fashion does SST work
Paracrine
85
Main gastric acid treatment
Antacids - simplest way (neutralise)
Surgery
Anti-secretory drugs
86
Surgery to help with gastric acid treatment
Vagotomy - inhibits cephalic phase
Antrectomy - inhibits gastric phase
87
Main anti-secretory drugs used in gastric acid treatment
Anticholinergics
H2 receptor antagonise
PPIs
Potassium- competitive acid blockers
88
Pyloric stenosis
Narrowing of the pylorus leading to intestinal obstruction in infants
Usually 2-8 weeks
89
Cause of pyloric stenosis
Hypertrophy and hyperplasia of pylorus
Mechanical obstruction to outflow of gastric contents into duodenum
90
Px of pyloric stenosis
Non-bilious vomiting
Regurg
91
O/E seen in pyloric stenosis
Visible peristalsis
Palapable mass after feeding in RUQ/ epigastrium
92
How is diagnosis of pyloric stenosis made
Abdominal ultrasound
93
Mx of pyloric stenosis
Appropriate fluid rests and correction of electrolyte abnormalities
Ramstedt pyloromyotomy
94
Pyloromyotomy
Open procedure that involves cutting thickened muscle to release stenosis
95
Complications of pyloromytomy
Mucosal perforation
Haematoma
Wound infection
96
Risk factors for pyloric stenosis
Fhx
Maternal smoking
Bottle feeding
Macrolide use in first 2/52 of life?
97
Causes of acquired pyloric stenosis
Ulcer
Antral tumour
Pancreatic tumour (head)
98
Causes of a/c gastritis
Irritants
Drugs
Severe stress
Radiation
Chemo
99
Irritants as a cause of a/c gastritis
Smoking
Alcohol
100
Drugs as a cause of a/c gastritis
Aspirin
NSAIDs
Oral steroids
101
Severe stress as a cause of a/c gastritis
Burns
Trauma
Surgery
Shock
Sepsis
102
Complications of a/c gastritis
Erosions
A/c stress ulcers
103
Erosions as a result of a/c gastritis
Small ulcers in which depth is limited to Lamina propria
Tend to bleed
104
A/c stress ulcers as a complication of a/c gastritis
Penetrate muscular mucosa
Particularly associated w/ stress - Curling's ulcers and Cushing's ulcers
Associated w/ drinking and smoking
Tend to bleed
105
Curling ulcer's
Occurs following severe burns
Reduced plasma volume --> iscahemia and necrosis of stomach
106
Cushing ulcers
Occur secondary to raised ICP e.g. intracranial tumour, trauma etc
107
HP associated c/c gastritis
Spirochetes found at surface of gastric epithelium causing infl
C/c infl is host immune repose to HP but improves after eradication of bacteria
108
What is HP associated gastritis associated w/
DU
GU
Gastric MALT lymphoma and cancer
109
Features of chemical/ relative c/c gastritis
Due to bile reflux
Usually HP -ve
Hx is important
Reactive change in surface epithelium w/out significant a/c infl
110
Features of AI c/c gastritis
AI destruction of specialised glands of the body mucosa
Autoantibodies to IF and PCs
HP rare
A/c and c/c infl of body mucosa
Dysplasia --> increased risk of cancer
111
What can loss of PCs in AI gastritis cause
Achlorhydria
112
Achlorhydria
Loss of HCl in stomach
113
What can loss of IF in AI gastritis lead to
B12 deficiency and pernicious anaemia
114
Natural protective factors against ulcers
Surface ,luscious secretion
Bicarb secretion into mucous
Mucosal blood flow
Epithelial barrier function
Epithelial regenerative capacity
115
Examples of injury to mucosa that can cause peptic ulcers
HP infection
NSAID
tobacco
Alcohol
Gastric hyperacidity
Duodenal-gastric reflux
Ischaemia
NSAIDs
116
Peptic ulcer disease
Umbrella term for development of gastric ulcers and duodenal ulcers
117
Epidemiology of gastric ulcers
Incidence increases w/ age
Gender distribution is closer to equal (1:1 to 2:1)
118
Epidemiology of duodenal ulcers
Mean ages 30-40
M > F 4:1
119
A/c stress ulcers vs c/c peptic ulcers - penetration
A/c doesn't penetrate musuclaris propria
C/c does
120
A/c stress ulcers vs c/c peptic ulcers - scarring
A/c has no scarring ulder ulcer
C/c does
121
A/c stress ulcers vs c/c peptic ulcers - endarteritis obliterates
A/c has no endarteritis obliterans
C/c does
122
Endarteritis obliterans
Infl of intimacy which proliferates and ultimately plugs lumen of artery
123
A/c stress ulcers vs c/c peptic ulcers - healing
A/c heals w/ regeneration
C/c heals by repair w/ fibrous scar
124
A/c stress ulcers vs c/c peptic ulcers - number & location
A/c is multiple and can be anywhere
C/c is single and usually antral
125
Aetiology of peptic ulcer disease
H. pyloric* - 95% of DU and 75% of GU
Medication
Zollinger-Ellison
A/c stress
Malignancy
Infl e..g Crohn's
126
Medication causing peptic ulcer disease
NSAIDS*
Corticosteroids
Alcohol
127
Symptoms of peptic ulcer disease
Epigastric pain
Dyspepsia (e.g. distension, bloating)
Heartburn
128
Signs of peptic ulcer disease
Mild epigastric tenderness
129
DU vs GU - pathophys
DU - high acid eroding a normal mucous membrane
GU - low or normal acid eroding mucous membrane w/ reduced resistance
130
DU vs GU - pain
DU - ulcer pain relived by eating
GU - ulcer pain worsens by eating
131
DU vs GU - genetic factors
DU - important genetic component
GU - no genetic component
132
How is dx of peptic ulcer disease made
Endoscopic examination
133
Genetic factors in c/c DUs
2x increase in 1st deg relatives
37% increase in blood group O
HLA B5
134
DU disease associations
H pylori c/c gastritis
Hyperparathyroidism (increased serum Ca stimulates gastric --> acid ++)
Alcoholic cirrhosis
C/c renal failure
135
Where do DUs typically px
90% in 1st part
Ant > post
136
Where do GUs typically px
Lesser curve, antrum/ upper body
137
What does heaping up of a peptic ulcer suggest
Malignancy
138
Histology of peptic ulcers - 4 zones
Surface layer of necrotic debris
Cellular infl layer rich in neutrophll polymorphs
Granulation tissue layer
Layer of fibrosis - vessel walls in this zone
139
H. pylori testing
Invasive - urease test (CLO), histology, culture
Non-invasive - breath test, serological test, stool antigen test
140
HP breath test
Pts must be off PPIs
Can be used for both dx and testing for eradication
141
Mx of PUD
Lifestyle modification
Abx
PPIs
142
Lifestyle modifcation for PUD
Avoid triggers
Obesity
Smoking and alcohol
143
Treating PUD associated w/ HP
No association w/ NSAIDs - 1st line eradication
Association w/ NSAIDS - 2/12 full dose PPIs then 1st line eradication
144
Treating PUD w/ no association to HP
4-8 wk full dose PPIs
145
Follow up in PUD
Gastric ulcers require bx in 6-8 weeks due to possibility of malignancy
146
1st line eradication of HP
7/7 course of PPIs, amoxicillin, clarithromycin if no penicillin allergy
If penicllin allergy - PPIs, clarithromycin, metronidazole
147
Complications of PUD
Penetration
Perforation
Haemorrhage
Gastric outlet obstruction (pyloric stenosis)
148
Perforation as a complication of PUD
Pts px w/ signs of infection and severe abdominal pain
Mx is supportive care, abx and laparoscopic repair
149
Possible perforation zone in PUD
Posterior ulcers ---> pancreas
Anterior DU --> peritoneal cavity
GU in lesser curve ---> lesser sac
Less common is common bile duct and transverse colon
150
Haemorrhage as a complication of PUD
Can cause UGIB
Typically posterior DU eroding into gasproduodenal artery
Bleeding can be mild and c/c infl --> IDA
151
Gastric outlet obstruction as a compciaton of PUD
Pts px w/ nausea and vomiting, abdominal pain and distension
152
Zollinger Ellison syndorme
Occurs secondary to increased gastrin secretion by hyper-secreting gastrinoma in pancreas
153
Features of ZE syndrome
Recurrent DUs - multiple ad in atypicla sites
1/3 have diarrhoea due to increased gastric acid
Ulceration/ eriosn of stomach rare
154
ZE syndrome and MEN
1/3 of gastronomes in ZE are associated w/ MEN/ Werner's synd
Gene located on chromosome 11
Hyperplasia/ neoplasia of 1+ endocrine gland
50% of pts w/ MEN have ZES
155
MEN
Multiple endocrine neoplasia
156
Examples of primary gastric neoplasia
Adenocarcinomas
Malignant gastrointestinal stromal
Lymphoma (MALT lymphomas associated w/ HP may resolve w/ HP eradication)
157
Polyp
Any lesion raised above mucosa
158
Epidemiology of gastric adenocarcinomas
4th most common malignancy
Age - 50+
Sex - M > F 2:1
Geography - Japan/ Central & S america
159
Anatomical classification of gastric adenocarcinoma
Epicentre of the tumour <2cm from the GOJ - oespheageal
Epicentre of the tumour >2cm from the GOJ - gastric
160
Histological classification of gastric cancer
Intestinal - most common, gland-forming
Diffuse - less common, formed of discohesive cells
161
Intestinal gastric cancer features
More commonly seen in males
Affects older ages
Better prognosis
162
Diffuse gastric cancer features
Equal sex prevalence
Seen in younger pts
Worse prognosis
If involves major portion of stomach may be referred to as 'linitus plastica' - leather bottle stomcah
Stomach unable to inflate properly
163
Genetic predisposing factors for gastric adenocarcinomas
Fhx
Increased risk w/ blood group A
164
Predisposing factors for gastric adenocarcinomas - diet
Carcinogens
Polycyclic hydrocarbons in smoked food
Increased starch - decreased fat, fresh fruit, green, leafy veg
165
Predisposing factors for gastric adenocarcinomas - premalignant condns
Pernicious anaemia
Operated stomach
Atrophic gastritis (dysplasia)
Adenomas (dysplasia)
166
Gastric cancer types
Type 1 - polypoid
Type 2 - fungating
Type 3 - ulcerated
Type 4 - infiltrative
167
What % of gastric malignancies is made up by gastric lymphoma
15%
Commonest site of GIT lymphoma
168
Causes of a/c epigastric pain
A/c pancreatitis
Perforated peptic ulcer
Peptic ulcer
A/c cholecystitis
Biliary colic
Mesenteric vascular disease
Perihepatitis
Supradiaphragmatic
169
Causes of dyspepsia
Functional
GORD
Pepetic ulcer
Oesophageal cancer
Gastric cancer
Other causes incl colon cancer, c /c pancreatitis, pancreatic cancer etc
170
Associated features of dyspepsia that may help w/ dx
Dysphagia
Wt loss
Physical signs
Anaemia/ thrombocytois
171
Assumptions based on risk factors for dyspepsia
Young pts w/out dysphagia, NSAIDs or H.pylori are v unlikely to have organic pathology
Young pts w/ NSAIDs or HP MIGHT have PUD
Older pts (esp w/ alarm sx) are at higher risk of cancer
172
Investigations for dyspepsia
Endoscopy
Barium swallow/ meal
H. pylori tests
Oesophageal pH/ pH-impedance
Anti-tag Ab/ Ig
Gastric emptying
173
Pain modulators given for dyspepsia
Amitriptyline
Mirtazipin
Buspirone
174
Mx of GORD
Lifestyle measures
Lowest dose required to control sx - PPI/ H2RA/ antacid (except Barrett's)
Surgical intervention
175
Surgical intervention for GORD
Laparoscopic fundoplication
Magnetic sphincter augmentation
(Bariatric surgery: Roux-en-Y)
176
Other terms for functional dyspepsia
Post-prandial distress syndrome
Epigastric pain syndrome
177
Rx for functional dyspepsia
HP eradication
PPI
Prokinetics
Amitriptyline/ imipramine
Buspirone
Mirtazipine
Sulpiride
Behavioural intevrenyions e.g. diaphragmatic breathing, psych rx
178
Theoretical ways to reduce acid secretion
H2 antagonist
Gastrin antagonist - none clinically available
Muscarinic antagonist - atropine, pirenzepine
Block H+ secretion - PPIs
Inhibits PC secretion physiologically - misoprostol, SST
Neutrralisation - antacids
179
Onset of antacids
Rapid but transient
180
What can large, regular doses of antacids heal
Duodenal ulcers
181
What do antacids provide symptomatic relief for
GORD
Indigestion
182
What are examples of compounds found in antacids
Mg, Ca, Na or Al
Al --> constipation
Mg ---> diarrhoea
183
Adverse effects of antacids
Systemic alkalosis in v high doses
Carbonate containing compounds release CO2 --> belching
184
Adverse effects of antacids - Al
Osteodystrophy and encephalopathy in c/c renal failure
Al chelates tetracyclines and levodopa
185
Adverse effects of antacids - Ca
Calcium stimulates gastrin --> counterproductive
186
Examples of H2 receptor antagonists
Cimetidine
Ranitidine
Nizatidine
Famotidine
187
Where do H2RAs act
PCs
Cardiac atria
188
Actions of H2RAs
Reduce basal and stimulated acid secretion
Reduce pepsin secretion by about 60%
189
What is the rate of peptic ulcer healing dependent on
Degree of acid suppression
190
Time frame for healing ulcers using H2RAs
DU: 4/52 - 6-52
GU: 6/52 - 8/52
191
H2RAs for GORD
Provides symptomatic relief
Healing requires much higher doses
192
Metabolism of H2RAs
Cimetidine and ranitidine rapidly absorbed
Short half lives
Cimetidine excreted renally but other renal and liver
193
Adverse effects of H2RAs - uncommon
Diarrhoea
Headache
Confusion in elderly
Cimetidine - anti androgen (gynaecomastia)
Cimetidine - inhibits P450 (enhances warfarin, theophylline, tolbutamide)
194
Examples of PPIs
Omeprazole
Lansoprazole
Rabeprazole
Esomeprazole
195
Actions of PPIs
Inhibits acid secretion by 90%
Covalently inhibit PP
Some PPIs may inhibit clopidogrel activation
196
Metabolism of PPIs
All via P450 system
Mild inhibition of P450 isoforms
197
Adverse effects of PPIs
Diarrhoea
Headache
Infectious gastroenteritis
Hypergastrinaemia and acid rebound
Impaired Ca and Mg - osteoporotic fractures
198
Adverse effects of PPIs
Diarrhoea
Headache
Infectious gastroenteritis
Hypergastrinaemia and acid rebound
Impaired Ca and Mg - osteoporotic fractures
199
Why is infectious gastroenteritis an adverse effect of PPIs
Reduces bacterial killing
200
Why is diarrhoea an adverse effect of PPIs
Idiosyncratic
Bacteria overgrowth Microscopic colitis
201
Uses of acid suppression
GORD
Prevention of NSAID-induced peptic ulcer
Helaing of peptic ulcer
HP eradication
Stress ulcer and aspiration prevention
202
Indications for parenteral therapy for acid suppression
Prevntion of aspiration during anaesthesia
Stress ulcer prophylaxis in certain critical ill pts
Peptic disease and inability to take oral ex for 5/7
Post-endoscopic rx in selected GI haemorrhage pts
Non-responsive ZE syndrome
203
Alarm features of dyspepsia
Anorexia
Loss of weight
Anaemia
Recurent vomiting
Dysphagia
204
Acid suppression in peptic ulcer
Remove etiological factors
Use PPIs to help prevent
Maintenance high doses fr ZES
205
Cytoprotective agents used in GIT
Misoprostol
Sucralafte
Bismuth
206
Misoprostal as 'gastroprotection'
PGE1 analogue
Inhibits acid secretion
Increases duodenal bicarb secretion, gastric mucous production, mucosal blood flow
207
Misoprotsol features
Heals peptic ulcers
Reduces NSAID-induced ulcers AND complications
Rapidly absorbed from gut - extensive 1st pass metabolism
208
Adverse features of misoprostol
Diarrhoea - 30%
Uterine contractions - avoid in pregnancy and young women
Menorrhagia and pots-menopausal bleeding
209
Features of sucralfate
Coats ulcer base
Increases prostaglandins secretion
Prevents diffusion of acid
210
What can sucralfate be used to prevent
Sclerotherapy-induced oesophageal ulcers
Stress ulceration in critically ill pts
211
Features of bismuth
Bind to base of ulcers
Enhances locals protective mechanism
Anti H pylori action
212
Adverse effects of bismuth
Black stool
Black tongue
Can produce encephalopathy in renal failure
213
Adverse effects of sucralfate
Constipation
214
Bismuth uses
Commonly used in 2nd and 3rd line HP eradication regimens
Widely used OTC - pepto-bismol, indigestion, diarrhoea
215
Barrett's oesphagus
Normal distal oesophageal squamous epithelial lining replaced w/ metaplastic columnar epithelium
216
Transformation to cancer from Barrett's
Non dysplasie Barrett's oesophagus
Low-grade dysplasia
High grade dysplasia
Oesophageal adenocarcinoma
217
Clinical px of oesophageal cancer - alarm sx
Progressive dysphagia
Change to liquid diet
Wt loss
Regurg
Persistent reflux NOT responding to PPI
Others e.g.g food bolus obstruction
218
Dx of oesophageal cancer
Upper GI endoscopy and biopsies is the ix of choice
Mucosal visualisation
Biopsies x8
Other modalities incl CT and barium swallow (obsolete)
219
Barium swallow to dx oesophagela cancer
Only for v frail pts who ca tolerate OGD
220
OGD
Oesophagogastro dudodenoscopy
221
Staging pathways for oesophageal carcinoma
Staging is assessment of the extent of disease of a cancer
CT and PET scan to excl distant mets
Other specialised tests e.g. endosocpic ultrasound
222
Treatment pathways for oeosphageal carcionma
Curative treatment = chemo +/- surgery
Palliative treatment = chemo +/- stent
223
Ideal curative pathway for oesophageal xcarcinoma
3 cycles of chemo - eradicate systemic disease, prevent disease progression
surgery
Adjuvant chemo = 3 further cycles (75% doses)
224
Surgery for oesophageal cancer
Ivor Lewis oesophagectomy
Oesophagus joined to stomach
225
How may gastric cancer px as
IDA
Early satiety
Wt loss
Abdominal pain/ mass
Reflux
Non-healing gastric ulcer
225
How may gastric cancer px as
IDA
Early satiety
Wt loss
Abdominal pain/ mass
Reflux
Non-healing gastric ulcer
226
How can gastric cancer px as an emergency
Haematemesis/ melaena
Gastric outlet obstruction
Perofrated gastric ulcer
Disseminated disease e.g. ascites
227
Treatment for gastric cancer
Endoscopy
Biopsies/ histology
Urgent CT san (chest/ abdo/ pelvis)
Book for oesophagogastric MDT
Inform pt - need CNS
Discuss in MDT
Decide if curative or pallitive
228
Curative intent for gastric cancer
Period chemo then gastrectomy
Straight to gastrectomy (age > 80, co-morbidities ++)
229
Palliative intent for gatsric cnacer
Palliative care
Stents e..g pyloric stent for obstruction
Best supportive care
Drain e.g. ascites etc
Palliative chemo +/- Herceptin
230
Total gastrectomy for proximal cancer
Oesphagus joined to jejunum
Functionally v debilitating
Causes wt loss and nutritional deficiencies
NEVER as a palliative option
231
Obesity stigma
Highly stigmatised disease
Amongst the public, medical professionals, and healthcare commissioners
Obesity is 'self-inflicted'
232
Consequences of pts' experiences of obesity
Depression gets worse
Anxiety
Suicidal thoughts
Disordered eating
Decreased self esteem
Avoidance of physical activity
Shaming themselves
Decreased QoL
233
Obesity - surgery vs non-surgical
Surgery produces sustained wt loss
Ultimately, improved long-erm survival compared to those w/out surgery
234
Effects of bariatric surgery
Acts through restrictive or malabsprptive effect
Acting centrally within the hypothalamus to control appetite , hunger and satiety
Gut hormonal changes
Alterations in bile acids
235
Bariatric MDT
Core members incl
Obesity physician
Specialist surgeon
Dietitian
Psychologist
Anaesthetists
236
Tired structure of obesity mx in the NHS
Tier 1 - universal interventions
Tier 2 - lifestyle interventions, diets, pharmacology
Tier 3 - specialist services
Tier 4 - surgery
237
Main bariatric surgery operations
Sleeve gastrectomy
Roux en Y bypass
Laparoscopic Adjustable Gastric Band (LAGB)
238
Features of sleeve gastrectomy
One of the most common procedures
Majority of stomach excised
Faster, less technically demanding, fewer post-op complications
239
In which pts is a sleeve gastrectomy contraindicate din
Pts who suffer from GORD
240
Mechanism of sleeve gastrectomy
Produces neurohormonal changes in GLP-1 and PYY as well as reduced gherkin production due to removal of gastric fundus
241
Features of Roux en Y gastric bypass
A loop of jejunum is brought up and anastomosed to the gastric pouch to form the Roux limb, allowing the passage of ingested food bypass the duodenum, preventing it form mixing w/ binary secretions
2nd anastomosis is created 100-120cm down Roux line, joining the biliary limb to allow mixing of food w/ bile within common channel
242
Gastrojejunostomy
Anastomosis between stomach and jejunum
243
Jejunojejunostomy
Anastomosis between two parts of jejunum
244
Complications of Roux en Y bypass
Anastomotic leaks - can be life threatening
Internal herniation - can be life threatening
245
What does a Roux en Y bypass allow for in the future
Access to gastric remnant for gastric cancer
Access to duodenum for ERCP
246
Laparoscopic Adjustable Gastric Band
Gastric band placed over small portion of stomach and is attached to a port
The band can be adjusted by inserting fluid in a balloon around the band - this is controlled by the port
247
Example of an bariatric emergency
Slipped band
248
Sliped band as a bariatric emergency
Distal stomach herniates upward through the band, causing proximal pouch dilatation
Left untreated, this can result in ischaemia and necrosis
249
Px of slipped gastric band
Upper abdominal or chest pain, dysphagia and regurg of all fluid
250
Mx of slipped band
Urgent deflation of band
Can be deflated on the ward via an abdominal port w/ a Huber needle
251
How may regurg px in children
FTT
252
GORD
Gastro-oesophageal reflux disease
Reflux of stomach contents in oesophagus
253
Pathophys of GORD
Lower Oesophageal Sphincter (LOS) relaxes inappropriately
254
Risk factors for GORD
High BMI
Smoking
Genetic associations
Pregnancy
NSAIDs, alcohol
255
Sx of GORD
Heartburn - postprandial and worse lying down
Chest pain
Regurg
Acid brash
Hoarse voice
Dysphagia
256
Atypical sx of GORD
'Laryngopharyngeal reflux'
Cough
Throat clearing
Dental issues
257
Oesophageal syndromes of GORD
Reflux (erosive) oesophagitis
Reflux stricture
Barrett's oesphagus
Oesophageal adenocarcinoma
258
Things to ask in hx of GORD
Sensitivity to PPIs
How they are using PPIs
How do they sleep
Do they eat a heavy meal within few hrs of going to sleep
259
Red flags for GORD - ALARM
Gastroscopy is required
Anaemia
Loss of wt
Anorexia
Refarctoru to med
Maelena & haemetesis
Swallowing difficulties
New onset dyspepsia (>55 yrs)
260
Ddx of GORD
Functional heartburn
Achalasia (failed relaxation of LOS)
Eosinophilic oesophagitis
Cardiac causes of chest pain
Malignancy
261
Ix in GORD
pH monitoring - when dx is uncertain. 24hr pH monitoring can be combined w/ high res manometry
Gastroscopy
262
Manometry
Assesses motor abnormlaities of the oesophagus
263
Gatsroscopy for GORD
Done for pts w/ red flag sx, suspected complications and being considered for surgery
Up to 50% of pts w/ GORD have normal gastroscopy
264
Steps in mx of GORD
Lifestyle changes
Pharmacological treatment
265
Conservative mx of GORD
Wt loss
Smoking cessation
Reducing stress
Reducing caffeine (lowers LOS pressure)
Elevating head of bed
Stop eating within 2hrs of bed
266
Pharmacological mx of GORD
PPis (2/52 trial) - best for treating erosive disease
Ranitidine
Over counter meds e.g.g gaaviscon
Prokinetics e.g. domperidone
Baclofen
Amitriptyline
267
Anti-reflux surgery
NIssen fundoplication - wrapping fundus around lower oesophagus
Constructs new anti-reflux barrier
268
Who is anti-reflux surgery reserved for
Pts who fail to respond to medical tx
Pts who cannot tolerate med due to side effects
Pts who wish not to be on meds lifelong
269
Endoscopic treatment for reflux
Stretta radio frequency
Endoscopic suturing
Endoscopic fundoplication
270
Complications of GORD
Erosive oesophagitis
Stricture
Barrett's oesophagus
271
Erosive oesophagitis
Infl of oesophagus --> ulcers, bleeding, peptic stricture formation
272
Stricture
Scarring and narrowing of oesophagus due to repeated damage
273
Barrett's oesophagus
Premalignant condn due to columnar metaplasia (seen in stomach) of the normal squamous mucosa of oesophagus
274
Oral ulcers 'stomatitis'
AKA apthous ulcers
Caused by HSV (aciclovir) or candida (fluconazole)
275
Bacterial causes of pharyngitis
Strep tonsillitis (peritonsillar abscess)
Diphtheria
Vincent's angina
Ludwig's angina
Chlamydia
HIV
276
Viral causes of pharyngitis
Common cold
Enteroviral pharyngitis
Herpangina
Infectious mononucleosis
277
Epidemiology of diphtheria
Common disease in 19th century
10,00 death/ yrs
Seen in children < 5 (immunisation introduced in 1942)
278
Dipheriae definition
URTI characterised by sore throat, low grade fever, adherent membrane of tonsils, pharynx, nose
279
Causative organism of diphtheria
Corynebacterium diphtheria
280
Local px of diphtheria
Tough pseudomembrane
Grey, semitransparent necrotic area
Pain, bleeding if scraped
281
Systemic effect of diphtheria
Eraly, cardiac damage - myocraditis, heart failure, heart block
Late, neuro damage - demtylination, palate palsies
Late, nephritis
282
Mx of diphtheria
Abx - benzylpenicillin, erythromycin
Antitoxin
Tracheostomy if oedema threatens airway
Prevention/ control - vaccine
283
Causative organisms of oesphagitis
Candida
CMV
HSV
VZV
284
Sx of oepshagitis
Difficulty swallowing
Odynophagia
Retrosternal discomfort
Anorexia
Fever
285
Common risk factors for oesophagitis
Abx use - candida spp
AIDS - CMV, HSV, candida
Leukaemia, lymphoma - candida, HSV
Corticosteroids - candida
286
Dx of oesphagitis
Flexible endoscopy, X-ray (barium)
Swab or brushings
Tissue bx (histology culture)
287
Features of oesophageal candiasis
Typical white plaques, nodules
Causes severe odynophagia
Seen in pts w/ MM and HIV
288
Features of Herpes simplex oesophagitis
Usually seen in immunocompromised pts
Numerous small ulcerations
Fever and odynophagia
289
Treatment for herpes simplex oesophagitis
Candida spp - azoles (fluconozaole, intraconozole), amphotericin B
HSV, ZVZ - aciclovir, foscarnet if resistant to acyclovir
CMV - ganciclovir, foscarnet
290
How can we prevent acid rebound in pts on PPIs
Step down before stopping
291
Mx of achalasia
Botox injections/ dilation
CCBs
Nitrates
292
Can you give omeprazole to patients on clopi
No
293
Surveillance for Barrett's oesophagus
Every 3-5 yrs
294
Mx of high grade Barrett's
Oesophagectomy
295
Mx low grade Barrett's
Ablation to encourage new normal cell growth
296
Risk of oesophagectomy
Issues w/ aperistalsis and bloating
Worse when combined w/ fundoplication
297
Side effects of PPIs
Nausea
Abdo pain
Rash
Dizziness
Constipation
298
Types of dysphagia
Low vs high
Oropharyngeal - can't initiate swallow
Oesophageal - blockage or irritation
299
Key gastro ddx of difficulty swallowing
Adenocarcinoma
SCC
Pharyngeal pouch
Epiglottitis
Hiatus hernia
Rare - achalasia, corkscrew oesophagus
300
Drugs as risk factor for GORD
Nitrates
CCBs
TCAs
Anticholinergics
301
Presentation of gastritis
Dyspepsia
Anorexia
Nausea and vomiting
Haematemesis or maleana
Many cases resolve spontaneously
302
Ix for gastritis
Endoscopy
Bx
H pylori test
303
Risk factors for oesphageal cancer
Older age, M gender
GORD, Barrett's
Smoking and chewing tobacco
Obesity and Poor diets
Alcohol
Previous head and neck cancer or RT
304
Classification of oesophageal cancer
Adenocarcinomas tend to arise in distal third oesipahgus
SCC in upper or middle, more prevalent WW
305
Clinical px of oesophageal cancer
Sx tend to arise when lumen < 2cm
Progressive, painless dysphagia
Dyspepisa, regurg - reistant to PPI
Lymphadenoathy
Mediastinal inasion - chest pain
306
Ix for oesophageal cancer
Upper Gi endoscopy w/ 8 separate bx
Barium swallow for pts who can't tolerate gastroscopy
307
Hiatus hernia definition
Herniation of part of stomach through diaphragmatic oesophageal hiatus
308
Risk factors for hiatus hernia
Older age
Male sex
Obesity
Increased intra-ab pressure
309
Classification of HH
Type I - sliding
Type II to IV - para-oesophageal
310
Type I HH
Displacement of GOJ above diaphragm
Usually asymptomatic
311
Type II HH
Dislocation of fundus
GOJ unchanged
312
Type III HH
Dislocatiom of BOTH HH and fundus
Most common para-oesophagela type
313
Type IV HH
Presence of other organs within hernia sac
May lead to gastric volvulus
314
Sx of HH
Mainly asymptomatic
Heartburn
Regurg
Dysphagia
Bowel sounds in L chest
If volvulus - post-pradial pain and distension
315
Ix for HH
Usually incidental finding
Upper GI endoscopy >2cm separation form z-line
Barium swallow
CT may be used for gastric volvulus
CXR - small air fluid levels
316
Mx of HH
Usually nothing
PPIs for symptomatic Type I
317
Complications of HH
Gastric volvulus
Strangulated hernias
Uncontrolled bleeding
Gastric outlet obstruction
