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upper gastrointestinal tract Flashcards

1
Q

what anatomical landmark marks start of oesophagus

A

c5

coincides with upper oesophageal sphincter

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2
Q

what are some anatomical contributions to lower oesophageal sphincter

A
  • 3-4cm distal oesophagus within abdomen
  • diaphragm surrounds LOS ( L and R crux)
  • intact phrenosophageal ligament ( extension of inferior diaphragmatic fascia)
  • angle of his
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3
Q

what is stage 0/ oral phase of swallowing

A

chewing and saliva prepare bolus

both sphincters constricted

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4
Q

what happens during stage 1/ pharyngeal phase

A

pharyngeal musculature guides food bolus towards oesophagus
UOS opens reflexly
LOS opened by vasovagal reflex = receptive relaxation reflex

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5
Q

what happens during stage 2/ upper oesophageal phase

A

upper sphincter closes
superior circular muscle rings contract and inferior rings dilate
sequential contractions of longitudinal muscle

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6
Q

what happens during stage 3/ lower oesophageal phase

A

lower sphincter closes as food passes through

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7
Q

how to measure swallowing

A

manometry - tube passed through nose down into oesophagus and measure pressure of contractions

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8
Q

what is the pressure created by peristaltic waves

A

40 mmhg

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9
Q

what is the normal resting pressure of LOS

A

20mmHg

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10
Q

what is the pressure of the LOS during receptive relaxation

A

> 5 mmHg

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11
Q

what is the LOS receptive relaxation mediated by

A

inhibitory noncholinergic nonadrenergic (ncna) neurons of myenteric plexus

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12
Q

what are some functional disorders of oesophagus

A
  • first look for absence of stricture = commenest,
    then caused by abnormal oesophageal contraction(hyper/hypomobility and disordered coordination)
    or by failure of protective mechanisms for reflux (gord)
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13
Q

what is dysphagia

A 
difficulty in swallowing
localisation is important 
for solids/liquids
intermittent/ progressive
precise/vague
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14
Q

odynophagia

A

pain on swallowing

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15
Q

what is regurgitation

A

return of oesophageal contents from above an obstruction

can be functional/mechanical

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16
Q

what is reflux

A

passive return of gastroduodenal contents to mouth

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17
Q

what is achalasia

A

hyper-motility issue

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18
Q

what causes achalasia

A

loss of ganglion cells in aurebachs myenteric plexus in LOS wall
leads to decreased activity of inhibitory NCNA neurones

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19
Q

what is the aetiology of primary achalasia

A

unknown

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20
Q

what is the proposed model of achalasia pathophysiology

A

environmental trigger e.g infection combined with genetic predisposition ( DQb1,DQa1…) leads to non autoimmune inflammatory infiltrates -> extracellular turnover wound repair ->loss of immunological tolerance -> apoptosis of neurons ->humoral response

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21
Q

what are some other diseases which cause oesophageal motor abnormalities similar to primary achalasia

A

chagas disease - caused by parasite
protozoa infection
amyloid/sarcoma/eosinophilic oesophagitis

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22
Q

what does hypermobility do to the resting pressure of LOS

A

increases the pressure

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23
Q

what happens in oesophagus during achalasia

A

receptive relaxation sets in late and is too weak
during reflex phase, pressure in LOS in much greater than in stomach therefore food collects in oesophagus causing increases pressure throughout with dilation
- propagation of peristaltic waves cease over time

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24
Q

what symptoms can achalasia form

A 
weightloss
trouble swallowing 
pain
regurgitate food
retrospective pain
can cause oesophagitis and pneumonia
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25
what is the risk of oesophageal cancer in those with achalasia
increased 28x fold | annual incidence approx 0.34%
26
how to treat achalasia
pneumatic dilatation - | pd weakens LOS by circumferential stretching and in some cases tearing of muscle fibres
27
how effective if pneumatic dilatation
71-90% of patients respond initially but many patients subsequently relapse
28
what is the more effective treatment for achalasia
surgery
29
whats is hellers myotomy
continuous myotomy performed for 6cm on oesophagus and 3cm onto stomach
30
what is dor fundoplication
follows myotomy and | anterior fundus folded over oesophagus and sutured to right side of myotomy
31
what are the risks of hellers myotomy and dor fundoplication
oesophageal and gastric perforations (10-16%) division of vagus nerve - rare splenic injury
32
what is scleroderma
autoimmune disease causing hypomotility due to neuronal defects
33
what does neuronal defects in scleroderma cause
``` atrophy of smooth muscle in oesophagus peristalsis in distal portion stops decreased pressure in LOS GORD develops often associated with CREST syndrome ```
34
what is the treatment for scleroderma
exclude organic obstruction improve force of peristalsis with prokinetics - cisapride once peristalsis failure occures usually irreversible
35
what is an example of disordered coordination
corkscrew oesophagus
36
what is corkscrew oesophagus
``` incoordinate contractions dysphagia chest pain pressure of 400-500 marked hypertrophy of circular muscle ```
37
treatment for corkscrew oesophagus
may respond to forceful PD of cardia | results not as predictable as achalasia
38
what are the 3 areas of anatomical constriction in oesophageal perforation
cricopharyngeal constriction aortic and bronchial constriction diaphragmatic and sphinter constriction
39
what causes pathological narrowing in oesophageal perforation
cancer foreign body physiological dysfunction
40
what is the aetiology of oesophageal perforation
``` iatrogenic >50% spontaneous (boerhaaves) -15% foreign body - 12% trauma - 9% intraoperative - 2% malignant - 1% ```
41
what is boerhaaves
spontaneous perforations | increase in intra oesophageal pressure with negative intra thoracic pressure - vomitting again closed glottis
42
how does oesophageal perforation present in patients
pain - 95% fever - 80 % dysphagia - 70 % emphysema - 35%
43
what investigation can be done if oesophageal perforation suspected
chest x ray ct swallow -gastrograffin ogd - Oesophago-Gastro-Duodenoscopy
44
primary management for oesophageal perforation
surgical emerygency - 2x increase in mortality if 24h delay
45
what is the initial management for oesophageal perforation
``` nbm iv fluids broad spectrum antibiotics and antifungals itu/hdu level care bloods - including g and s referred to tertiary centre ```
46
definitive management for oesophageal perforation
conservation management with metal stent operative management should be default: - primary repair is optimal - oesophagectomy - definitive solution
47
what is the stomachs protective mechanisms against reflux
LOS usually closed as barrier against reflux of pepsin and hcl
48
sporadic reflux is normal but what can it be caused by
pressure on full stomach swallowing transient sphincter opening
49
what are the 3 mechanism to protect following reflux
volume clearance - oesophageal peristalsis reflex ph clearance - saliva epithelium - skin barrier
50
what are the cause of failure of protective mechanisms
``` GORD decreased sphincter pressure increased transient sphincter opening decreased saliva production and buffering abnormal peristalsis hiatus hernia defective mucosal protective mechanism decreases volume and ph clearance ```
51
what does failure of protective mechanisms lead to
reflux oesophagitis epithelial metaplasia leading to carcinoma
52
what is a sliding hiatus hernia
stomach slides up within chest
53
what is a rolling/paraoesophageal hiatus hernia
stomach slips up the side | = emergency
54
investigations for gord
ogd - to exclude cancer oesophagitis,peptic strictutre and barretts oesophagus confirmed oesophageal manometry 24hr oesophageal ph recording
55
treatment for gord
lifestly echanges - diet, smoking | ppis
56
surgery that can be used for gord
dilation of peptic strictures | larascopic nissens fundoplication
57
what is the function of the stomach
break food into smaller particles using acid and pepsin | holds food, releasing in controlled, steady state into duodenum
58
whats found in cardia and pyloric region
mucus only
59
what is found in body and fundus of stomach
mucus, hcl, pepsinogen
60
what is found in antrum of stomach
gastrin
61
what is erosive and haemorrhagic gastritis
numerous causes - | acute ulcer - gastric bleeding and perforation
62
what is nonerosive, chronic active gastritis
takes place in antrum | caused by helicobacter pylori - amoxicillin, clarithromycin and pantoprazole for 7-14 days
63
what is atrophic (fundal gland) gastritis
``` takes place in fundus autoantibodies vs parts and products of parietal cells parietal cells atrophy decreased acid - increased gastrin decreased if secretion ```
64
what is reactive gastritis
long term contact with substances that irritate lining
65
what do parietal cells produce
H ions
66
what is the role of chief cells
enrich secretion with pepsinogen
67
what is the neural stimulation of stomach
ach - post ganglionic transmitter of vagal parasympathetic fibres
68
what is the endocrine stimulation of stomach
gastrin - g cells of antrum
69
what is the paracrine stimulation of stomach
histamine - ecl cell and mast cells of gastric walls
70
what causes inhibition of stomach gastric secretions
endocrine - secretin in small intestine paracrine - somatostatin (sih) paracrine and autocrine pge2 and pgi2, tgf alpha and adenosine
71
what are the mechanisms for repairing epithelial defects
>migration - adjacent epithelial cells flatten to close gap via sideward migration along basement membrane > gap closed by cell growth- stimulated by egf, tgf alpha, igf1,grp and gastrin > acute wound healing - attraction of leukocytes and macrophages: phagocytosis of necrotic cells, angiogenesis, regeneration of ecm after repair of bm epithelial closure by restitution and cell division
72
how does ulcer form?
``` helicobacter pylori? - disturbs mucosal barrier secretion of gastric juice hco3 secretion cell formation blood formation ```
73
treatment for ulcer
``` ppi/h2 blocker all 3 antibiotics elective surgical rare - most ulcers heal within 12 weeks change meds if see no change check serum gastrin ogd and biopsies ```
74
what are some surgical indications
intractability - after medical therapy continuous use of NSAIDs complication - haemorrhage, obstruction, perforation

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