Upper GI Flashcards
Oesophagitis Los Angeles grading
Grade A - one or more mucosal breaks <5mm, none of which extends between tops of mucosal folds
Grade B - one or more mucosal breaks >5mm, none of which extends between tops of mucosal folds
Grade C - mucosal breaks extending between the tops of mucosal folds, <75% mucosal circumference
Grade D - mucosal breaks involving >75% of mucosal circumference
Dysphagia - types
Intermittent/episodic - Schatzki rings
Liquids then solids, lack of pattern, non-progressive - achalasia
Solids then liquids - mechanical obstruction (e.g. stricture, Ca)
Blood supply - targets for embolisation
a) Posterior duodenum
b) Anterior duodenum/head of pancreas
c) Pylorus and proximal duodenum
a) Posterior superior pancreaticoduodenal artery
b) Anterior superior pancreaticoduodenal artery
c) Gastroduodenal artery (gives off the above 2 branches)
Achalasia
a) diagnosis
b) management
a) - Definitive test is oesophageal manometry showing high resting oesophageal tone, weak or absent peristalsis and a non-relaxing LOS
- OGD necessary to exclude Ca
- Barium swallow shows distal tapering (bird’s beak)
b) - Surgical: Heller’s cardiomyotomy (surgical division of LOS), pneumatic dilatation (endoscopic division of LOS)
- Non-surgical: CCBs, botulinum
NSAIDs and risk of peptic ulcer
a) Which NSAIDs carry the lowest risk?
b) What is the average increase in RR of patients on NSAIDs vs those without
c) Gastric erosions vs ulcer presentation
a) - Coxibs carry lowest risk (e.g. celecoxib) as they are COX-2 specific (still 1.5x placebo)
- Ibuprofen lower risk than other NSAIDs (2x placebo)
- Aspirin and diclofenac intermediate risk (3-4x placebo)
- Naproxen and meloxicam/piroxicam carry highest risk (5-10x placebo)
c) - Gastric erosions- generally painless, small volume bleed
- Ulcers - painful, larger volume bleeds
K+/H+/ATPase channel
a) Significance
b) PPI action
a) Parietal cells: production of HCl
- Target for anti-parietal cell antibodies in PA
- Target for H2RA and PPI
b) PPI binds to it irreversibly
Pernicious anaemia
a) Associated conditions
b) 2 common antibodies and associated pathology
c) Presentation
d) Schilling test
e) Management
f) Complication
a) Other autoimmune conditions
- Also, 20% have family history
b) - Anti-parietal cell antibodies - cause gastritis (which causes iron deficiency anaemia), and HCl deficiency which also causes B12 deficiency as not enough freed up from the diet
- Anti-intrinsic factor antibodies: causes B12 deficiency due to malabsorption in terminal ileum
- Note: 50% also positive for anti-thyroid antibodies
c) - Anaemia (macrocytic usually, though may be normocytic/microcytic if anti-parietal cell antibodies)
- Brittle nails, dry skin, angular stomatitis, glossitis
- Neuropathy - peripheral, SCDC (75% SCDC patients have PA)
- Jaundice due to raised unconjugated bilirubin
d) - If neurological symptoms, give B12 injections on alternate days until resolution of symptoms
- If no neurology, give 3x weekly B12 injections for 2 weeks
- Maintenance B12 supplementation needed for life, 3-monthly
e) Schilling test measures B12 before and after intrinsic factor is given. B12 levels should rise in PA as there is an issue with intrinsic factor production
f) Gastric carcinoma in 3%
Zollinger-Ellison syndrome
a) what is it?
b) presentation
c) diagnostic tests
d) associated condition in 25%
e) management
a) Gastrinomas usually of the pancreas or duodenum, causing excess HCl production
b) Leads to GORD, peptic ulcers (often presents as recurrent PUD in absence of other risk factors), diarrhoea, GI bleeding.
Can also be cancerous tumours that metastasise to lymph nodes and liver
c) - Gastrin blood test (fasting). May give IV secretin which increases gastrin levels in gastrinomas
- Gastric pH level
- OGD
d) MEN1
- suspect if hypercalcaemia (hyperPTH) or pituitary adenomas
e) Surgery to remove tumours
PPI if surgery not possible or in MEN1 where there are often multiple small tumours
Gastric Cancer
a) Risk factors - modifiable, non-modifiable, diseases
a) - Modifiable: Smoking, alcohol, low vit C, high salt
- Non-modifiable: Japanese ethnicity, family history
- Diseases: Pernicious anaemia, H. pylori, Gastric surgery (particularly biliary diversion into stomach)
Barrett’s oesophagus
- Surveillance
a) No dysplasia
- repeat OGD every 3-5 years if <3cm
- repeat OGD every 2-3 years if >3cm
Low-grade dysplasia
- Re-biopsy after intensive PPI in 6-8 weeks
- repeat OGD every 6 months until non-dysplastic on 2 consecutive OGDs (then can go back to 2-yearly)
High-grade dysplasia
- Refer to UGI MDT - 30% risk of invasive adenocarcinoma, so likely need endoscopic resection or oesophagectomy
Hiatus hernia
a) Distance from diaphragmatic hiatus to GOJ
a) >2cm
H. pylori
a) How C13-breath test works
b) Other diagnostic tests
c) Complications of h. pylori
d) Who should have h. pylori testing?
e) Indications for re-testing after eradication therapy
f) What should you advise in terms of PPI pre-testing?
a) - Ingestion of drink with C-13 + urea
- If h. pylori present, it will produce urease and will convert the urea to ammonium and this will be detected on the breath test
b) - Stool antigen test (very specific, but less sensitive)
- Campylobacter like organism (CLO) test - performed during OGD, also detects presence of urease (but less sensitive after PPI use)
c) Duodenal ulcer (90% have h. pylori), gastric ulcer (80% have h. pylori), gastric cancer, MALToma
d) - Dyspepsia without any red flag features in whom symptoms are not resolved in 2 weeks of PPI treatment
e) MALToma, recurrent dyspepsia or complicated PUD
f) Stop PPI 2 weeks pre-test
Dumping syndrome
a) What is it?
b) Risk factors
c) 2 types and symptoms/signs
d) Diagnosis
e) Treatment
a) Rapid gastric emptying into the duodenum
Tends to be worse with sugary foods or liquids
b) - Gastric surgery
- Pyloric incompetence
- Diabetes
c) Early dumping syndrome
- Occurs within 30 mins of meal
- Causes nausea, vomiting, bloating, pain, diarrhoea, distension, tachycardia, flushing
Late dumping syndrome:
- Occurs 2-3 hours post-meal
- Results in rapid increase in intestinal glucose, causing insulin release and resultant hypoglycaemia and flushing
d) - Oral glucose tolerance test - hypoglycaemia, tachycardia
- Gastric emptying scintigraphy
e) Conservative: eat 5-6 smaller meals in the day, delay liquids until 30 mins post-food, avoid sugary or very starchy foods, lie down post meals
Medical: octreotide (slows gastric emptying)
Surgical
GAVE
a) What is it?
b) Risk factors
c) Presentation
d) Diagnosis
e) Management
a) Gastric antral vascular ectasia
b) Systemic sclerosis (esp anti-RNA polymerase III antibodies), CKD, liver cirrhosis, autoimmune disease, malignancy
c) GI bleed, IDA, portal HTN
d) Endoscopy - “watermelon” appearance of stomach
e) - Endoscopic argon photocoagulation/thermal ablation
- Surgical antrectomy
Oesophageal webs
a) Presentation
b) Associated condition causing IDA
c) Differential
a) Dysphagia - often intermittent
b) Plummer Vinson (Patterson-Kelly) syndrome - risk of oesophageal SCC in 3%
c) Schatzki rings - tend to be lower oesophageal vs webs which tend to be upper oesophageal
