Upper GI

Question 1

What is achalasia?

Symptoms?

Answer 1

Failure of the lower oesophageal sphincter to relax and failure of peristalsis.
Due to degenerative loss of ganglia from Auerbach’s plexus.

Dysphagia of solids and liquids.
Heartburn
Regurgitation of food.

Question 2

Achalasia

Investigations and treatment?

Answer 2

Oesophageal manometry
Barium swallow
CXR

Balloon dilation
Surgical intervention
Intrasphincteric injection of botulinum toxin

Question 3

GORD

Investigations

Answer 3

Oesophagitis due to refluxed gastric acid.
Do upper GI endoscopy if > 55, symptoms > month, dysphagia, relapsing symptoms, weight loss.

If endoscopy is -ve consider 24 hour oesophageal pH monitoring.

Question 4

GORD

Management

Answer 4

PPI e.g. omeprazole. If no response try doubling dose for a month.

Question 5

Barrett’s oesophagus
What is it?
Treatment?

Answer 5

Metaplasia of lower oesophageal mucosa.
Squamous epithelium -> columnar epithelium.
Increased risk of adenocarcinoma.

Short < 3cm and long >3cm.

Endoscopic surveillance every 3-5 years, high dose PPI.
Dysplasia -> mucosal resection/radiofrequency ablation.

Question 6

Causes of acute upper GI bleeding?

Scoring systems?

Answer 6

Oesophageal varices
Duodenal peptic ulcer
Cancer
Diffuse erosive gastritis

Blatchford score and then Rockall score after endoscopy.

Question 7

Acute GI bleed management

Answer 7

ABCDE
2 x wide bore IV access
Cross match and transfuse with O negative if haemodynamically unstable.
FFP if fibrinogen level < 1g/L.
Prothrombin complex if on warfarin.
Endoscopy within 24 hours.

Variceal -> terlipressin, antibiotics, band ligation/sclerotherapy, TIPS 2nd line.
Propranolol for prevention.
Non-variceal -> endoscopic clipping of ulcers, adrenaline,

Question 8

Peptic ulcer disease
Risk factors
Symptoms

Answer 8

H pylori infection
NSAIDs, SSRIs, corticosteroids

Epigastric pain
Nausea
Duodenal- pain worse when hungry, relieved by eating.
Gastric ulcers- pain made worse by eating.

Question 9

Peptic ulcer disease
Investigation
Management
Complications

Answer 9

Endoscopy
H pylori test- urea breath test/stool antigen test.

H pylori eradication
Stop exacerbating drugs
PPIs

Perforation- do erect CXR to show air under diaphragm.

Question 10

Helicobacter pylori
Associations
Management

Answer 10

Peptic ulcer disease
Gastric cancer
B cell lymphoma of MALT tissue
Atrophic gastritis

7 days of PPI + amoxicillin + clarithromycin/metronidazole.
If penicillin allergic clarithromycin + metronidazole.

Question 11

Oesophageal cancer
Most common type?

Risk factors?

Answer 11

Adenocarcinoma with history of GORD. In the lower 1/3.
Other types: SCC in the upper 2/3rds.

GORD, smoking, alcohol, achalasia, obesity.
Plummer Vinson syndrome- dysphagia, iron deficiency anaemia and oesophageal webs.

Question 12

Oesophageal cancer
Investigations
Treatment

Answer 12

Upper GI endoscopy.
Staging- CT TAP

Surgical resection- Ivor Lewis oesophagectomy: intrathoracic oesophagastric anastomosis.
Biggest risk of anastomotic leak and mediastinitis.
Adjuvant chemotherapy.