Treatment

Question 1

How to treat Barrett’s oesophagus?

Answer 1

For non-dysplastic with intestinal metaplasia or any Barrett’s oesophagus >3cm in length, treat GORD symptoms and perform endoscopic surveillance every 3-5 years.

Question 2

How to treat when there’s dysplasia or neoplasia?

Answer 2

When confirmed on an endoscopy, treatment options include endoscopic mucosal resection or radiofrequency ablation.

Question 3

What is the immediate management of Barrett’s oesophagus?

Answer 3

• Symptom control of GORD with non-pharmacological and pharmacological measures.
• Long term endoscopic surveillance to detect progression to dysplasia and oesophageal adenocarcinoma

Question 4

What is the long term management of Barrett’s oesophagus?

Answer 4

• Long term PPI therapy
• Ablative therapy - destroys Barrett’s epithelium to a sufficient depth to eliminate intestinal metaplasia and allow regrowth of squamous epithelium
• Oesophagectomy - when severe dysplasia confirmed

Question 5

What is the treatment for stage T1N0 or T2N0 oesophageal cancer?

Answer 5

Immediate surgery

Question 6

What is the treatment for stage T3N0, T1N1 or T2N1 oesophageal cancer?

Answer 6

Preoperative chemoradiation then reevaluate for surgery.

Question 7

What are the treatment options for oesophageal cancer?

Answer 7

• Surgery - open vs laparoscopic
• Chemotherapy - neoadjuvant/definitive/palliative (OEO2/MAGIC etc)
• Radiotherapy - SCC
• Endoscopic - EMR/ESD
• Combination
• Palliative - stenting/PEG/PEJ/jejunal feeding/drugs etc

Question 8

What are the treatment options for peptic ulcers?

Answer 8

• Lose weight
• Avoid trigger foods such as coffee, chocolate, tomatoes, fatty or spicy foods
• Eat smaller meals and eat 3-4 hours before bed
• Stop smoking
• Reduce alcohol consumption
• H.pylori eradication
• PPIs
• Stop drug for drug-induced ulcers

Question 9

What is the 1st line treatment for H.pylori?

Answer 9

7 day, twice daily course of:

• PPI
• Amoxicillin
• Clarithromycin or metronidazole

Question 10

What is the 2nd line treatment for H.pylori?

Answer 10

If previous exposure to clarithromycin and allergy to penicillin:

• PPI
• Bismuth
• Metronidazole
• Tetracycline

Question 11

What is the treatment for NSAID caused peptic ulcers?

Answer 11

Stop NSAID and give 4-8 week course of full dose PPIs.

Question 12

What is the management for gastric bleeds?

Answer 12

ABATED
ABCDE
Bloods: FBC, cross match, clotting, U+E, LFTs, ABG
Access: 2X large bore cannula
Transfuse: consider major haemorrhage pathway
Endoscopy: banding (oesophageal), sclerotherapy (gastric), TIPS
Drugs: stop NSAIDs + anticoagulants, start IV PPI, consider terlipressin (varices)
Prophylaxis: beta blockers for varices

Question 13

What is the management for oesophageal varices?

Answer 13

• IV terlipressin
• Prophylactic antibiotics
• Band ligation during endoscopy
• TIPS procedure if band ligation fails