UGI Flashcards
You are asked to organise the staging investigations to help decide the treatment plan for a 65 year-old man who has been found to have an oesophageal cancer (adenocarcinoma) when he had an UGI endoscopy performed to investigate dysphagia. Biopsies taken at that investigation have confirmed that what looked like a cancer, is a cancer. What tests are needed?
What are they aimed at deciding?
Tests performed will be aimed to identify the stage of the adenocarcinoma which will then determine the most appropriate management.
CT chest/abdomen and USS can determine extent of spread and identify metastases. PET scan can be used if available.
The key decision is whether to start curative or palliative management.
You are asked to organise the pre operative assessment to help decide whether a 65 year-old man is fit for surgery for a locally confined oesophageal cancer (adenocarcinoma). He presented with dysphagia. His cancer has been proven, and staging complete. The best chance of cure is surgery. What issues are most important in this patient’s pre op work up?
The man’s smoking, alcohol and nutrition status are important to consider.
Investigate with bloods (FBC, UEC, LFT, coags, albumin, iron studies)
cardiopulmonary function with X-Ray, ECG,
You are a GP. A previously fit 65 year-old woman consults you and gives a history of three months of progressive dysphagia, initially she struggled to swallow large food boluses, eg bread or meat, now she can only swallow fluids. She is losing weight. What would you like to do to manage this lady?
Investigate with history, examination, investigation.
Hx -> initiating event, fever, malaise, night sweats, cold/heat intolerance, Lx, FHx
Ex -> palpate, swallow, CN exam
Ix -> FBC, UEC, LFT, T4, anti-TPO, USS, barium swallow, ECG, endoscopy
You are a GP. An otherwise fit 30 year-old man consults you. He has persistent gastroesophageal reflux disease, he is well maintained on 40 mg omeprazole per day, but gets bad symptoms very quickly if he stops taking the treatment. He is not keen on a lifetime of medication.
He wants to know if there are any other treatments, and what the risks are of them?
Conservative management -> weight loss, reduce exposure to trigger foods, reduce alcohol and smoking
Surgical -> Nissen fundoplication (laparoscopically dissect gastro-oesophageal junction and wrap gastric fundus around intra-abdominal oesophagus to improve sphincter control)
Side effects include: temporary dysphagia, gas-bloat syndrome (increased flatus due to decreased belching ability), slipped wrap (through hiatus hernia or onto the stomach. Presents with acute pain and dysphagia)
This patient with dyspepsia is having a gastroscopy. What does this show in the duodenum? (duodenal ulcer)
How might this be complicated?
What is the common cause of this?
How is this condition treated?
This gastroscopy shows a duodenal ulcer. Duodenal ulcers can haemorrhage (mostly posteriorly) or perforate (mostly anteriorly). Other complications include fistulation and gastric outlet obstruction
The main causes of duodenal ulcers include H. Pylori infection, NSAID overuse, excess alcohol intake, smokers, stress and FHx
Management includes removal of risk factors. Removal of proven H. Pylori infection is with triple therapy with PPI, amoxicillin and azithromycin
This is the endoscopic photo of a patient with a small sliding hiatus hernia. The photo is taken from just above the gastro-oesophageal junction.
Q1: What does this show.
Q2: What is the severity of the reflux in this case?
Q3: How should this be treated?
Q4: If this is a patient who has failed to respond to medical therapy, what is the next option.
Photo shows a hiatus hernia with fundus protruding above the diaphragm.
The severity of reflux in this case will be severe.
Patient should have conservative management (weight reduction, avoid trigger foods, avoid alcohol) and PPI (omeprazole).
Surgical therapy is a Nissen fundoplication. Wrap the stomach fundus around the gastro-oesophageal sphincter to improve tone
This is the endoscopic picture of a 65 year-old male with a history of chronic dyspepsia. The bottom two photos show an area of slough in the first part of the duodenum posteriorly.
Q1. What are the likely causes of this?
Q2. What complications can occur with this pathology?
Q3. What is the treatment?
Pathology is likely to be a duodenal ulcer. Most common causes of this are H. Pylori infection or NSAID use. Other causes include smoking, alcohol, spicy food, etc.
Complications that can arise include perforation (anterior), haemorrhage (posterior)
Treatment depends on cause. Stop NSAID use. Breath detection for H. Pylori. Treatment is amoxicillin, azithromycin and omeprazole.
This series of photographs shows a gastric tumour that is very close to the gastro-oesopgaheal junction at endoscopy.
Q1. What types of gastric tumours do you know?
Q2. How would you investigate this patient if the biopsy of this lesion proved to be an adenocarcinoma?
Q3. What treatment would be required for a lesion in this location?
Most common gastric tumour by far is adenocarcinoma. Other types include sarcoma, lymphoma or carcinoid.
Ix would be aimed at staging using TNM system. CT scan, endoscopic USS, PET scan
Palliative treatment is a stent. Curative treatment is radiotherapy, surgical resection, and chemotherapy for mets.
This photo taken at gastroscopy shows the area of the lower oesophagus just above the gastro-oesophageal junction.
Q1. What can you see?
Q2. What is the most likely cause of this process?
Q3. How would this be treated?
Most likely to be Barrett’s oesophagus.
The most likely cause of this process is persistent reflux, causing advancement of the Z line (columnar -> squamous epithelium).
This is a risk factor for developing an oesophageal adenocarcinoma.
Treatment will be appropriate management of reflux (PPI) and monitoring. Radiofrequency ablation is an option for high grade dysplasia
