Upper gastrointestinal tract Flashcards
Define hiatus hernia with regard to anatomical type
Hiatus herniae allow part of the stomach into the thoracic cavity. They are usually asymptomatic.
The two types are:
- Sliding hiatus hernia:
- The gasto-oesophageal junction slides through the hiatus to lie above the diaphragm
- Occurs in 30% of adults over 50
- Para-oesophageal/rolling hernia
- A small part of the fundus rolls up through the hernia alongside the oesophagus, but the sphincter remains competent below the diaphragm
What are the anatomical and physiological factors predisposing gastro-oesphageal reflux disease (GORD)?
Anatomical:
- Hiatus hernia
Physiological:
- Raised IAP (pregnancy/obesity)
- Large meals, eaten late at night
- Smoking
- High caffeinated drink intake
- High fatty foor intake
- Drugs (anticholinergics, nitrates, tricyclics and calcium channel blockers)
Name the 3 typical symptoms of GORD
- Heartburn/indigestion
- Aka ‘dyspepsia’
- Worse on bending/lying down, when drinking hot liquids or alcohol
- Relieved by antacids
- May experience odynophagia (pain when swallowing)
- Regurgitation of food/acid
- Passive process (not like vomiting)
- More common when bending/lying
- Aspiration may occur
- Waterbrash
- Sudden filling of the mouth with dilute saliva
What investigations are used to confirm a diagnosis of GORD?
- GORD can generally be diagnosed clinically without further investigations
Although:
- Endoscopy is able to establish malicious causes and consquency of GORD such as malignancy, hiatus hernia, oesophagitis and Barrett’s oesophagus.
- Barium swallow/meal can diagnose any anatomical problems such as hiatus hernia
- 24 hour luminal pH monitoring and manometry (measures competence of sphincter) to diagnose GORD if endoscopy is normal
All patient with GORD should be treated empirically with a PPI unless there are any red flag symptoms that would indicate a need for endoscopy.
What are those red flag symptoms?
(not an objective)
ALARM55
- Anaemia (iron deficiency)
- Loss of weight
- Anorexia
- Recent onset, progressive symptoms
- Melaena or haematemesi
- Swallowing difficulties
- 55 years of age or older
What is the difference between dysphagia and odynophagia?
Dysphagia is difficulty swallowing
Odynophagia is pain upon swallowing
What are the common causes of dysphagia?
-
Diseases of the mouth tongue:
- E.g. tonsillitis
-
Neuromuscular disorders:
- Myasthenia gravis
- Motor neurone disease
- Bulbar palsy
-
Oesophageal motility disorders:
- Achalasia (lower esophageal sphincter fails to open during swalling)
- Scleroderma (an autoimmune, rheumatic, and chronic disease that affects the body by hardening connective tissue)
- Diabetes mellitus
-
Extrinsic pressure:
- Goitre
- Lymph nodes
- Enlarged left atrium
-
Intrinsic lesion:
- Forgein body
- Benign/malignant stricture
- Pharyngeal pouch
- Oesophageal web (Plummer-Vinson syndrome)
What are the main investigations for dysphagia?
Establishing time course and differences in passage of liquids and solids can help narrow down DDx.
Is it oropharngeal dysphagia (difficulty initiating swallow +/- choking/aspiration) or oesophageal dysphagia (food ‘sticks’ after swallowing, +/- regurgitation)?
Endoscopy and barium swallow are the main investigations.
What is the typical history of a patient with a malignant lesion of the oesophagus? (who and symptoms)
- Generally occur in over 60s, although becoming more common in younger age groups
Symptoms:
- Progressive dysphagia, starting with solids and progressing to liquids and eventually difficulty swallowing saliva
- Weight loss and anorexia
- Retrosternal chest pain
- Coughing/aspiration
- Occasional lymphadenopathy
Describe the pathology of oesophageal malignancy
(location and type)
- Most are now in the lower third
- Most are adenocarcinomas and the remainders are mainly squamous cell carcinomas
Adenocarcinoma:
- Increasing incidence, arise from areas of epithelial metaplasia in the lower oesophagus (Barrett’s oesophagus-refers to an abnormal change (metaplasia) in the cells of the lower portion of the esophagus. It is characterized by the replacement of the normal stratified squamous epithelium lining of the esophagus by simple columnar epithelium with goblet cells - usually caused by GORD)
- Risk factors are thus those related to GORD
Squamous cell carcinoma:
- Mainly occur in heavy smoking and drinking males
- Usually present late when the tumour is early enough to compromise the lumen and cause dysphagia
- Regional lymph node spread is early and common
What are the main causes of peptic ulcer disease?
- Helicobacter Pylori infection (90% duodenal, 70% gastric ulcers)
- NSAIDs (around 30% of ulcers)
- Zollinger-Ellison syndrome (excessive acid secretion due to non-insulin secreting islet cell tumour of pancreas secreting gastrin-like hormone, often leading to excessive ulceration)
Other risk factors: are smoking, coffee cosumption, and hepatic/renal failure
How does H. Pylori cause peptic ulceration?
- H. Pylori produces gastritis, mainly in the gastric antrum, leading to activation of an inflammatory infiltrate
- There is also increased acid secretion in the presence of H. Pylori (increased gastrin and decreased somatostatin), and abnormal mucus production, leading to epitheal damage
- H. pylori is also causally associated with duodenal ulcers
How does smoking cause peptic ulceration?
- Impairs gastric mucosal healing
- Nicotine increases acid secretion
How do NSAIDs cause peptic ulceration?
- NSAIDs inhibit cyclo-oxygenase enzymes, which has anti-inflammatory properties as the COX-2 isoform normally causes inflammatory prostaglandin synthesis
- Adverse GI effects generally occur due to inhibition of COX-1 in the stomach, which is responsible for synthesis of prostaglandins that inhibit acid secretion and protect the mucosa
(given PPIs can diminish gastric damage caused by these agents)
What are symptoms of a peptic ulcer?
- Epigastric pain, related to food intake, relieved by antacids
- Pain classically relieved by eating in duodenal ulcers
- Worse on eating in gastric ulcers
- Nausea
- Anorexia and weight loss
- Haematemesis/melaena ( dark sticky faeces containing partly digested blood)
