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.Year 3 > Upper GI > Flashcards

Upper GI Flashcards

1
Q

Sx of dyspepsia

A

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

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2
Q

What leads to peptic ulcer disease?

A

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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3
Q

Signs and sx of peptic ulcer disease

A

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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4
Q

Compare duodenal and gastric ulcers

A

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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5
Q

RFs for peptic ulcer disease

A

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

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6
Q

How do NSAIDs cause ulcers?

A

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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7
Q

How do H. pylori cause ulcers?

A

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

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8
Q

What is Zollinger-Ellison syndrome?

A

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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9
Q

Red flag signs

A

Vomiting
Early satiety
Dysphagia
Anaemia
Bleeding
Wt loss

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10
Q

Ix for peptic ulcers

A

< 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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11
Q

Mx for peptic ulcers

A

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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12
Q

What’s triple therapy?

A

PPI
Clarithromycin
Amoxicillin or metronidazole

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13
Q

Complications of ulcers

A

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

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14
Q

Signs and sx of gastric cancer

A

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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15
Q

RFs for gastric cancer

A

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

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16
Q

GORD sx

A

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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17
Q

RFs for GORD

A

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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18
Q

Who is a hiatus hernia?

A

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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19
Q

Ix pathway for GORD

A

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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20
Q

Ix and mx for hiatus hernia

A

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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21
Q

Mx for GORD

A

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

22
Q

Complications of GORD

A

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

23
Q

Mx of Barrett’s

A

Endoscopy:
High grade dysplasia => radiofrequency => PPI

Nodule => endoscopic mucosal resection => PPI

24
Q

Sx of oesophageal cancer

A

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

25
Q

Squamous cell oesophageal cancer summary card

A

Less common
Affects middle third
RFs: smoking, alcohol

26
Q

Ddx of dyspepsia

A

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

27
Q

Mx of dyspepsia

A

<55, no flags
=> lifestyle changes and drug review
=> trial of PPI/triple therapy

> 55 and/or red flags
=> UGI endoscopy
=> biopsy and histology

28
Q

Hx clues of dysphagia

A

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

29
Q

Functional causes of dysphagia

A

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

30
Q

Structural causes of dysphagia

A

Upper sx (neuromuscular disease)
- Cancer
- Pharyngeal pouch

Lower sx (obstruction)
- Cancer
- Stricture
- Plummer-Vinson syndrome
- Foreign body

31
Q

Neurological sx of dysphagia

A

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

32
Q

Achalasia summary card

A

‘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

33
Q

Ix for dysphagia

A

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

34
Q

Oesophageal cancer vs achalasia

A

Oes. cancer
- old
- new onset
- structural
- progressive
- red flag sx
- UGI endoscopy

Achalasia
- young
- old onset
- functional
- intermittent
- no red flags
- barium swallow + manometry

35
Q

How may Plummer-Vinson present?

A

Severe IDA
- cheilosis, atrophyicglossitis, koilonychia

36
Q

How may a pharyngeal pouch present?

A

Halitosis

37
Q

Mallory-Weiss tear summary card

A

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

38
Q

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

A

Pneumomediastinum

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

39
Q

What causes oesophageal varices?

A

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

40
Q

Presentation of oesophageal varices

A

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

41
Q

Ix and mx for oesophageal varices

A

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)

42
Q

Typical presentation of ruptured peptic ulcer

A

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

43
Q

Ix and mx of ruptured peptic ulcer

A

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

44
Q

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

A

b) Duodenal ulcer

45
Q

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

A

c) OGD endoscopy

46
Q

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)

A

e) Trial of PPI

47
Q

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

A

e) Barrett’s oesophagus

48
Q

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

a) Achalasia

49
Q

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

A

b) Oesophageal cancer

*old person with dysphagia, cancer until proven otherwise

50
Q

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

A

b) Mallory-Weiss tear

51
Q

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

A

d) Boerhaave syndrome

.Year 3 (32 decks)

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