Tutorial 6 - Upper GI symptoms

Question 1

Differentials of Dysphagia

Answer 1

Oesophageal wall 
Oesophageal carcinoma (adenocarcionma - barrets, squamous cell - smokers/drinkers) 
Peptic structure (chronic GORD)
Caustic stricture (strong acids)

Motility

• Achalasia (failure of pyloric sphincter relaxation)
• Oesophageal spasm
• nuerological (stroke, motor neuron disease)
• Scleroderma

External pressure on oesophagus

• lung cancer
• hilar lymphadenopathy
• paraoesophageal hernia

Question 2

Investigations for Dysphagia

Answer 2

Endoscopy 
Barium studies
Oesophageal manometry
CT (malignancy, staging) 
Endosonography (staging oesophageal cancer - T, N) 
Biopsy

Question 3

Management

• Oesophageal malignancy
• Achlasia
• Peptic stricture

Answer 3

Oesophageal malignancy - palliative, endoscopic stenting
Squamous - radiation
Surgery - lapartomoy and thoracotomy 
-Pre/post chemo
-Ivor-lewis oesophago-gaststrectomy 

Achlasia - laparoscopoic myotomy w partial fundoplication
-endoscopic balloon dilation, botox

Peptic stricture - ensdoscopic dilation of stricture, PPI (biospy)

GORD - weight loss, avoid coffe/spicey food, antacids, PPI

• -> complications - stricture, barrets eosophagus, adenocariconma
• surgery if severe

Question 4

Hiatal hernia

Answer 4

sliding - GORD associated, may require surgery
-stomach goes into mediastinum

Para-oesophageal hernia - stomach herniates alongside oesophagus

Question 5

Barrets change in epithelium and type of cacncer caused

Answer 5

Barrets - squamous cell –> columnar epithelium in esophagus
adenocarcionma

Question 6

Red flags - dyspepsia -

Answer 6

• unintentional weight loss, progressive dysphasia, persistent vomiting, pallor, lethargy, exertional dyspnea.
• further investigation - FBC, U+E, endsocopy

-may show - normal, reflux oesophagitis, ulceration, malignancy

Question 7

Peptic ucler

• 2 main causes
• 2 main areas
• Inv
• Tx
• Complciations

Answer 7

Common causes - h.pylori, NSAIDS.
-first part of duodenum, and lesser curvature of stomach
(less common - meckles diverticulum containing ectopic gastric mucosa)

Inv - endoscopy w biopsy
Tx - triple therapy (2abx + PPI)
PPI - gastric ulcer, need to check healing w PPI w gastroscopy

Complications - bleeding, perforation, stenosis, gastric outflow obstruction
-perforate - peritonitis (free air in peritoneum)
Tx - laparotomy, peritoneal wash out, excision of ulcer

Question 8

Haematamesis and melena differential

and Managagement

Answer 8

Peptic ulcer disease
gastric erosion
mallory weiss tear
oesophageal varicies
upper GI cancer
other 

1st - resus patient (ABCs, IV line, fluids, cross match, FBC, urinary catheter - shock)
2nd - Endoscopy (see source of bleeding)
3rd - treat cause
4th - Surgery if cannot treat bleed
5th - prevent rebleeding

-varacies - badning
Mallory weiss
Ucler - Full dose PPI, triple therapy, injection, diathermy, heat probe, clips
(always biopsy to rule out malignancy)