Upper GI Flashcards by Eilish Irvine

Sx of dyspepsia

Epigastric pain or burning
Early satiety and post-prandial fullness
Belching
Bloating
Nausea
Discomfort in upper abdomen

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What leads to peptic ulcer disease?

Break in epithelial lining of stomach or duodenum
=>
damaged mucosa leads to ulcer formation
=>
increased H+ around ulcer leads to sx
=>
H. pylori, gastric acid, pepsin, NSAIDs make ulcers worse, also occurs more in men than women

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Signs and sx of peptic ulcer disease

Epigastric tenderness, pointing sign (points to where pain is)

Recurrent epigastric pain related to eating, early satiety, N&V, potential anorexia and wt loss

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Compare duodenal and gastric ulcers

Duodenal
- burning/gnawing sensation
- pain 2-3 hrs after eating
- often overeat/wt gain
- commonly wakes pts at night more than gastric ulcers

Gastric
- burning/gnawing sensation
- pain shortly after eating
- often avoid eating/wt loss

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RFs for peptic ulcer disease

H. pylori
NSAIDs
Smoking
Burns (leads to Curling ucler)
Head trauma (leads to Cushing ulcer)
Zollinger-Ellison syndrome

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How do NSAIDs cause ulcers?

Ibuprofen, aspirin, naproxen all inhibit COX-1, supprressing gastrin prostaglandin synthesis

Barrier properties of GI mucosa imparied so reduction of gastric mucosal blood flow, preventing repair

Insidious increased with age, look out for MI + stroke patients on aspirin treatment

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How do H. pylori cause ulcers?

Gram-neg. flagellate bacterium often found in developing countries that causes inflammation of stomach and duodenum

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What is Zollinger-Ellison syndrome?

Neuroendocrine tumour in pancreas producing gastrin thus an increase in gastric acid secretion, leading to hypertrophy of gastric mucosa and stimulation acid secreting cells, causing damaged mucosa and ulceration

Associated with MEN1 and 90% pts with this syndrome form ulcers

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Red flag signs

Vomiting
Early satiety
Dysphagia
Anaemia
Bleeding
Wt loss

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Ix for peptic ulcers

< 55 + no red flags
= breath test/stool antigen
= FBC*, stool occult blood, serum gastrin
*(only carry out if other causes/complications suspected)

> 55 + red flags or tx failed
= UGI endoscopy
(most specific and sensitive test)
= histology + biopsy urease testing
(is it neoplastic?)
= repeat endoscopy after 6-8 weeks
(confirm resolution and exclude malignancy)

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Mx for peptic ulcers

RF modification
- diet: less alcohol, avoid foods that cause sx
- smoking cessation

Pharmacological
- H. pylori +ve => triple therapy
- H. pylori -ve => PPI ‘-prazole’/H2 antagonist ‘-tidine’
- treat any anaemia => ferrous fumarate

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What’s triple therapy?

PPI
Clarithromycin
Amoxicillin or metronidazole

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Complications of ulcers

Perforate
- NBM, IV Abx, surgery (pneumoperitoneum on CXR)
Bleed
- endoscopy +/- therapy, IV PPI, +/- blood transfusion

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Signs and sx of gastric cancer

Palpable epigastric mass, Sister Mary Joseph node (metastatic nodule on umbilicus), Virchow’s node/Troisier’s sign (lympahdenopathy in left supraclavicular fossa)

Epigastric pain, wt loss, anorexia, N&V +/- blood

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RFs for gastric cancer

Smoking
H. Pylori
Chronic gastritis (i.e. peptic ulcer disease)
Male

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GORD sx

Oesophageal sx
- retrosternal burning after eating
- discomfort lying supine
- regurgitation into pharynx
- dysphagia (1/3 of pts)

Non-oesophageal sx
- cough/wheeze (aspiration of stomach contents into tracheobronchial)
- hoarseness/sore throat (irritation of focal chords)
- non-cardiac chest pain (oesophagus builds pressure)
- enamal erosion or other dental manifestations (HCl in mouth)

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RFs for GORD

Increased abdo pressure
- obesity, pregnancy
Lower oesophageal sphincter hypotension
- drugs: anti-muscarinics, CCBs, nitrates, smoking
- tx of achalasia, hiatus hernia
Gastric hypersecretion
- diet, smoking, Zollinger-Ellison syndrome

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Who is a hiatus hernia?

Stomach prolapses through diaphragmatic oesophageal hiatus, predispoing to reflux/worsening existing reflux
Cause: increased intraabdo pressure, defect in wall
RFs: abdominal ascites, obesity, pregnancy, loss w/ age, muscle weakening of elasticity

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Ix pathway for GORD

Clinical diagnosis (unless red flags)
=>
PPI trial (diagnostic + therapeutic)
=>
UGI endoscopy (if persists)
=>
Biopsy (if oesophagitis/Barrett’s)
=>
Consider other tests (barium swallo, oesophageal capsule endoscopy, oesophageal manometry, ambulatory pH monitoring)

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Ix and mx for hiatus hernia

Ix = barium swallow (shows outpouchings of barium at lower end of oesophagus), CXR, endoscopy

Mx = RF modification -> PPI/H2 antagnoist -> Nissen fundoplication (laprascopic)

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Mx for GORD

Conservative
- diet, avoid precipitants and lose wt
- sleep with head of bed elevated
- smoking cessation
Pharmacological
- PPI (H+/K+ ATPase inhibitor)/H2 antagonist (decrease gastric secretion)
Surgical
- Endoluminal gastroplication
- Nissen fundoplication if hiatus hernia cause

Complications of GORD

Barrett’s => Adenocarcinoma (oesophageal cancer)
- squamous epithelium changes to columnar epitherlium
- need regular surveillance; endoscopy and biopsy
- cancer affects lower third

Mx of Barrett’s

Endoscopy:
High grade dysplasia => radiofrequency => PPI

Nodule => endoscopic mucosal resection => PPI

Sx of oesophageal cancer

Red flags = anaemia, wt loss
Burning chest pain
Progressive dysphagia from solids -> liquids

Squamous cell oesophageal cancer summary card

Less common Affects middle third RFs: smoking, alcohol

Ddx of dyspepsia

PUD, gastric cancer, GORD, oesophageal cancer, biliary/pancreatic pathology, non-ulcer dyspepsia

Mx of dyspepsia

<55, no flags => lifestyle changes and drug review => trial of PPI/triple therapy >55 and/or red flags => UGI endoscopy => biopsy and histology

Hx clues of dysphagia

Intermittent/progressive => motility issue/neurological suggests structural blockage Solids + liquids => functional, solids progress to liquids suggest structural (i..e cancer growths) Red flag => cancer Sx of underlying disease => MS

Functional causes of dysphagia

Upper sx (neuromuscular disease) - Stroke - Parkinson's - Myasthenia gravis - MS - MND Lower sx (obstruction) - Achalasia - Oesophageal spasm - Limited cutaneous scleroderma (CREST); corkscrew oesophagus on barium swallow

Structural causes of dysphagia

Upper sx (neuromuscular disease) - Cancer - Pharyngeal pouch Lower sx (obstruction) - Cancer - Stricture - Plummer-Vinson syndrome - Foreign body

Neurological sx of dysphagia

Stroke + Parkinson's: Coughing immediately on swallowing Choking implies problem with swallow process Slow eating Early dysphagia for liquids (functional problem)

Achalasia summary card

'Reverse GORD' due to failure of LOS to relax + absence of oeseophageal peristalsis (loss of ganglion cells in myenteric plexus) - dysphagia of solids and liquids, regurgitation, dyspepsia, wt loss - bird's beak appearance on Ba swallow

Ix for dysphagia

Endoscopy ! Barium swallow Videofluroscopy Manometry if ba swallow/endoscopy unremarkable to distinguish motility disorder

Oesophageal cancer vs achalasia

Oes. cancer - old - new onset - structural - progressive - red flag sx - UGI endoscopy Achalasia - young - old onset - functional - intermittent - no red flags - barium swallow + manometry

How may Plummer-Vinson present?

Severe IDA - cheilosis, atrophyicglossitis, koilonychia

How may a pharyngeal pouch present?

Halitosis

Mallory-Weiss tear summary card

Hx: blood streaked in vomit, vomit preceded bleeding, severe vomiting (i.e. alcohol, bulimia) Ix: diagnosis via endoscopy Mx: resolves within 24-48 hrs

Pt has chest pain, severe vomiting and subcutaenous emphysema, what would you see on their CXR?

Pneumomediastinum This is Boerhaave syndrome, a complication of MWT that requires surgical managements within 24 hrs

What causes oesophageal varices?

Cirrhosis leads to decreased clotting factors and increase extrahepatic blood shunting This causes increased bleeding risk and portal HTN respectively, increasing the risk of ruptured oesophageal varices Continued alcohol use also irritates the oesophagus, contributing to the rupture of oesophageal varices

Presentation of oesophageal varices

Extreme haematemesis May be unconscious/shock Malaena Signs of alcohol/cirrhosis

Ix and mx for oesophageal varices

Ix: FBC (low Hb + MCV + plts), LFTS (high GGT, bilirubin and low albumin), U&Es (high urea) Mx: fluids, regular monitoring, endoscopy (band ligation first line), reduce portal HTN (IV terlipressin)

Typical presentation of ruptured peptic ulcer

Coffe-ground emese Malaena Background of PUD; H. Pylori infection, long-term NSAID use

Ix and mx of ruptured peptic ulcer

Ix: obs (low BP), FBCs + LFTs (normal) => exclude hepatic causes, i.e. o varices Mx: endoscopy (IM adrenaline at site of ulcer) => triple therapy if H pylori/PPI after ulcer treated to prevent recurrence

A 45 year old woman presents with a 2 month history of upper abdominal pain, occurring 2 – 3 hours after meals. The GP orders some blood tests, with the relevant results shown below: RBC low, HCT low, MCV low, normal LFTs Which of these is the most likely diagnosis? a) GORD b) Duodenal ulcer c) Gastric ulcer d) Biliary colic e) Cholecystitis

b) Duodenal ulcer

A 61 year old man presents to his GP with a 3 month history of upper abdominal pain following meals. On questioning, he describes this pain as burning and is able to point to the pain on his abdomen. He reports having noticed his clothes have been looser recently, and has a long standing history of headaches. Which of these is the most important investigation to arrange? a) H. Pylori breath test b) Full Blood Count c) OGD Endoscopy d) Trial of Proton pump inhibitor (PPI) e) Abdominal X-ray

c) OGD endoscopy

A 40 year old lady presents to her GP with heartburn and problems swallowing. She reports that the heartburn worsens at night, and is often accompanied by a ‘funny taste’ in her mouth and cough. She reports no change in weight or systemic symptoms. Which of these should be the next step? a) OGD endoscopy b) Barium Swallow c) Manometry d) Serum gastrin levels e) Trial of Proton pump inhibitor (PPI)

e) Trial of PPI

A 59 year old man presents with severe retrosternal burning pain. Upper GI endoscopy shows ‘metaplastic changes within the epithelium’. Which of these is the most likely diagnosis? a) Gastric ulcer b) Gastric carcinoma c) Oesophageal carcinoma d) GORD e) Barrett’s oesophagus

e) Barrett's oesophagus

A 28 year old lady presents with a 2-year history of mild dysphagia to both solids and liquids. She has no weight loss, but symptoms of heartburn and nocturnal cough. PPIs and bronchodilators haven’t helped. She is systemically well, and her examination is unremarkable. A “bird’s beak” appearance is noted on barium swallow. What is the most likely diagnosis? a) Achalasia b) Benign stricture c) Plummer-Vinson syndrome d) Oesophageal spasm e) Stroke

a) Achalasia

A 76-year old retiree visits her GP with difficulty swallowing solids. She says this has been getting progressively worse over 1 month. There is no coughing, choking or heartburn. She reports food getting “stuck” 2-3 seconds after swallowing. She attributes her weight loss to not eating properly, and also thinks this has caused loose, brown-black stools. She feels tired. Bloods show a microcytic anaemia. Select the likely diagnosis: a) Stroke b) Oesophageal cancer c) Pharyngeal pouch d) Plummer-Vinson syndrome e) Benign stricture

b) Oesophageal cancer *old person with dysphagia, cancer until proven otherwise

A 53-year old man staggers into A&E having vomited 6 times in 2 hours. He is intoxicated and jaundiced. His friend said his vomit was initially “normal”, but after the first couple of episodes had fresh blood in it. His blood pressure is 120/90 and HR 70 bpm. What is the most likely diagnosis? a) Ruptured oesophageal varices b) Mallory-Weiss tear c) Ruptured peptic ulcer d) Boerhaave syndrome e) Oesophagitis

b) Mallory-Weiss tear

A 47 year old man is brought into A&E having vomited blood. His wife reports he developed food poisoning 2 days ago. Suddenly this morning he experienced extreme chest pain and began to vomit blood. His HR is 110 and BP 85/60. On auscultation of his chest you hear a crackling sound and his CXR shows pneumomediastinum. What is the most likely diagnosis? a) Ruptured oesophageal varices b) Mallory-Weiss tear c) Ruptured peptic ulcer d) Boerhaave syndrome e) Myocardial Infarction

d) Boerhaave syndrome