Upper Gastrointestinal Flashcards by Tyler Wachtel

GORD definition

Reflux of acidic stomach contents into the oesophagus due to inappropriate transient or permanent relaxation of the lower oesophageal sphincter

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GORD can be classified into:

Erosive and non-erosive

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__-__% of patients with GORD have the non-erosive subtype

50-70%

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__-__% of patients with GORD have the erosive subtype

30-50%

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Risk factors for GORD include:

Smoking, alcohol, stress, obesity, pregnancy, scleroderma

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Clinical features of GORD include:

Retrosternal burning pain exacerbated with lying down, postprandially and triggered by certain foods/beverages. Regurgitation. Dysphagia. Bloating. Non-productive cough.

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Diagnosis of GORD is made:

Clinically

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Histopathological features of GORD include:

Superficial coagulative necrosis, basal cell thickening, elongation of papillae in lamina propria, inflammatory cell, squamous to columnar transformation

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Lifestyle changes indicated in the management of GORD include:

Weight loss, exercise and avoidance of triggers

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The first-line pharmacological treatment for GORD is:

Proton pump inhibitors

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Surgical management of GORD includes:

Fundoplication

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Fundoplication is only indicated in GORD which:

Is pharmacologically resistant to treatment

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Squamous cell carcinoma is most commonly found in which portion of the oesophagus?

The upper 2/3

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The most common subtype of oesophageal malignancy is:

Squamous cell carcinoma

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Adenocarcinoma is most commonly found in which portion of the oesophagus?

The lower 1/3

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Oesophageal malignancy can be classified by position according to:

The Siewert classification

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Risk factors for development of oesophageal carcinoma include:

Male sex, age 60-70yo, smoking, alcohol, past medical history of GORD/Barrett’s oesophagus

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The overall five year survival rate of oesophageal malignancy is:

20%

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Symptoms consistent with oesophageal carcinoma include:

Progressive dysphagia from solids to liquids, constitutional symptoms, dyspepsia, dyspnoea, retrosternal chest or back pain, persistent cough

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Signs of oesophageal carcinoma on physical examination include:

Vocal hoarseness, pallor, Horner’s syndrome, cervical lymphadenopathy

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Histopathological findings consistent with oesophageal adenocarcinoma include:

Metaplasia of oesophageal epithelium to columnar epithelium with goblet cells

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Histopathological findings consistent with oesophageal squamous cell carcinoma include:

Lymphocytic infiltration between carcinoma clusters

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Neoadjuvant chemoradiotherapy is indicated in oesophageal carcinoma in the following:

Locally invasive disease and Barrett syndrome high grade metaplasia

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Chemotherapy is indicated for oesophageal carcinoma in:

Advanced disease

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Operative treatment of oesophageal carcinoma includes:

Endoscopic submucosal resection

Operative management of oesophageal carcinoma is indicated in:

Superficial epithelial lesions

Barrett’s oesophagus definition

Intestinal metaplasia of the oesophageal mucosa where squamous epithelium transforms to columnar epithelium

Barrett’s oesophagus is induced by:

Chronic reflux of gastric contents

Risk factors for Barrett’s oesophagus include:

Male sex, age>50yo, obesity, GORD for >5years

Barrett’s oesophagus can be confirmed on:

Endoscopy

Conservative management of Barrett’s oesophagus includes:

Regular endoscopic monitoring

Pharmacological management of Barrett’s oesophagus includes:

Proton pump inhibitors

Operative management of Barrett’s oesophagus includes:

Radiofrequency ablation

Radiofrequency ablation of Barrett’s oesphagus is indicated in:

High-grade dysplasia

Eosinophilic oesophagitis definition

Chronic inflammatory disorder of the oesophagus characterised by eosinophilia and resultant oesophageal dysfunction

Eosinophilic oesophagitis affects _ in 100 adults

Eosinophilic oesophagitis affects _ in 10,000 children

Eosinophilic oesophagitis most commonly affects which patient group?

Men aged <40yo

Eosinophilic oesophagitis pathophysiology

Exposure to allergens → chronic inflammation and eosinophilic infiltration of the oesophagus → subepithelial fibrosis, oesophageal remodelling and dysfunction

Symptoms of eosinophilic oesophagitis include:

Dysphagia, dyspepsia refractory to acid suppression therapy, vomiting, food ‘sticking’ while swallowing, cough, melaena

Histopathological findings in eosinophilic oesophagitis include:

Eosinophilia and subepithelial fibrosis

Features of eosinophilic oesophagitis on endoscopy include:

Trachealisation of the oesophagus (circumferential mucosal lesions), longitudinal furrows, mucosal fragility

Non-operative management of eosinophilic oesophagitis includes:

Avoidance of trigger allergens

Pharmacological management of eosinophilic oesophagitis includes:

Proton pump inhibitors and topical glucocorticoids (e.g. fluticasone)

Operative management of eosinophilic oesophagitis includes:

Oesophageal dilation

In the setting of eosinophilic oesophagitis, oesophageal dilation is indicated:

In oesophageal strictures or disease refractory to conservative therapy

Oesophageal varices definition

Dilation of the submucosal veins of the distal oesophagus as a complication of portal hypertension

__% of cirrhotic patients have concurrent oesophageal varices

30%

__% of patients with oesophageal varices will experience bleeding

50%

__% of variceal bleeds are fatal

30%

Risk factors for the development of oesophageal varices include:

Alcohol consumption, increased variceal size, advanced Child-Pugh classification

Oesophageal varices pathophysiology

Liver cirrhosis → cannot accommodate blood flow → resultant retrograde portal hypertension → collateral enlargement → congestion of submucosal veins in the oesophagus → potential rupture +/- haemorrhage

Symptoms of ruptured oesophageal varices

Sudden onset haematemesis, melaena, haematochezia (if rapid-transit bleed), abdominal discomfort

Physical examination signs of oesophageal varices

Caput medusae, gynaecomastia, palmar erythema, testicular atrophy, splenomegaly, shifting dullness

CBE in the setting of liver cirrhosis may show:

Normocytic normochromic anaemia and thrombocytopaenia

LFTs in the setting of liver cirrhosis may show:

Increased AST/ALT and hypoalbuminaemia

Endoscopy in the setting of oesophageal varices is useful to:

Identify active bleeding sites and provide treatment

Non-operative management of bleeding oesophageal varices includes:

Resuscitation and stabilisation

Pharmacological management of bleeding oesophageal varices includes:

Octreotide and erythromycin

Octreotide is indicated for what time period in the setting of bleeding oesophageal varices?

3-5 days.

Operative management of bleeding oesophageal varices includes:

Endoscopic band ligation, injection sclerotherapy and balloon tamponade

Mallory Weiss syndrome definition

Longitudinal lacerations of the mucous membrane in the oesophagus

Risk factors associated with Mallory Weiss syndrome include:

Prolonged severe vomiting, alcoholism, blunt abdominal trauma and GORD

Mallory Weiss syndrome pathophysiology

Acute excessive rise in oesophageal intraluminal pressure, resulting in tearing of the oesophageal mucous membrane and submucosal arteries/veins leading to bleeding

Endoscopic findings consistent with Mallory Weiss tear include:

Longitudinal tear limited to the mucosa and submucosa around the GOJ

Operative management of Mallory Weiss syndrome includes:

Endoscopic adrenaline and endoscopic electrocoagulation

Hiatus hernia definition

Abnormal protrusion of any abdominal structure, usually the stomach, into the thoracic cavity through a laxity in the diaphragmatic oesophageal junction

Risk factors for the development of hiatus hernia include:

Obesity, increasing age, smoking and increased abdominal pressure

Type I hiatus hernia may be associated with which symptom?

Retrosternal burning pain

The following symptoms may be associated with type II or III hiatus hernia

Epigastric or substernal pain and early satiety

Non-operative management of hiatus hernia includes:

Avoidance of triggers, smaller meals, weight loss and PPIs

Operative management of hiatus hernias includes:

fundoplication

Achalasia definition

Oesophageal motility disorder characterised by inadequate relaxation of the lower oesophageal sphincter and non-peristaltic contractions in the distal 2/3 of the oesophagus due to the degeneration of inhibitory neurons

Achalasia commonly affects which age group?

25-60yo

Clinical features of achalasia include:

Dysphagia progressing from solids to liquids, regurgitation, retrosternal pain and weight loss

Pathophysiology of achalasia

Atrophy of inhibitory neurons → deficiency in inhibitory neurotransmitters → imbalance in excitatory vs inhibitory neurotransmitters → lack of relaxation and increased LOS resting pressure with dilation proximal to LOS

Manometric findings in achalasia include:

Absence peristalsis in the lower 2/3 of the oesophagus, absent LOS relaxation and increased LOS resting pressure

Signs of achalasia on barium swallow include:

Rats tail sign and widened proximal oesophagus

Operative management of achalasia includes:

pneumatic dilatation

Pharmacological management of achalasia includes:

Botox injection (indicated in poor surgical candidates)