Upper GI Flashcards
How long is the Oesophagus
27cm
Where does the oesophagus start and end?
C6 to T10, where it enters the diaphragm at the oesophageal hiatus
How can the oesophagus be split
Upper third mucosa - non keratinising squamous epithelium
Columnar cells lower down
What does the upper sphincter split?
What is it composed of?
What is its function?
Upper oesophagus and pharynx
Mainly composed of thyropharyngeal and cricopharyngeal muscle pressing against the cricoid
Function - prevent acid reflux going into your mouth and things gong into your airway
What are the normal constrictions during the course of the oesophagus and when can you see this?
Bariums swallow
-Level of the cricoid
-Level of the left main bronchus/left atrium
-When the oesophagus enters the diaphragm at T10
Anatomy of Lower Oesophageal Sphinter?
-Angle of His - Angle at which oesophagus enters the diaphragm at T10
-Lt and Mainly Rt Crux of diaphragm forming a circular muscular ring
-Apposition of the mucosal folds
-Phrenoesophageal ligament, which is connective tissue
3-4cm distal oesophagus within abdomen
Intra-abdominal pressure acting against the abdominal component of oesophagus
Describe the phases of swallowing
Oesophageal phase - autonomic
How is motility of oesophagus measured?
Manometry - probe passed into oesophagus and pressure readings taken
Peristaltic waves ~ 40 mmHg
LOS resting pressure ~ 20 mmHg
↓<5 mmHg during receptive relaxation
Mediated by inhibitory noncholinergic nonadrenergic (NCNA) neurons of myenteric plexus
Functional Disorders of the Oesophagus
What is dysphagia?
Red flag symptom for oesophageal cancer if type changes
What is odynophagia?
pain on swallowing
What is regurgitation?
refers to return of oesophageal contents from above an obstruction
-May be functional or mechanical
What is reflex?
passive return of gastroduodenal contents to the mouth
Symptoms vs signs
Symptoms - What the patient reports
Signs - What you illicit from examination
What is achalasia?
What are the causes?
Hypermotility
-Failure of LOS to relax ; increased resting pressure
What is this?
Barium Swallow
-Radio opaque liquid to drink and pacifies the entire oesophagus
-Bird’s beak appearance - tapering of distal oesophagus
-Dilated oesophagus proximally to this
(Shows achalasia- later feature though so clinically manometry diagnoses it)
What is achalasia a risk factor or?
Squamous oesophageal cancer
Increases risk 28 fold
What else happens in achalasia?
Disease course of achalasia?
Has insidious onset - symptoms for years prior to seeking help
Without treatment → progressive oesophageal dilatation of oesophagus.
What is pneumatic dilation ?
Risk of perforation
What surgical treatment is available for achalasia?
What are the risks?
Second procedure prevents acid reflux
What is Scleroderma?
What treatment is available?
What is diffuse oesophageal spasm?
Treatment?
Disordered coordination
Where are oesophageal perforations?
Cricopharyngeal constriction
Aortic and bronchial constriction
Diaphragmatic
Aetiology of oesophageal perforations?
Iatrogenic (OGD) >50%
Spontaneous (Boerhaave’s) - 15%
Foreign body - 12%
Trauma - 9%
Intraoperative - 2%
Malignant - 1%
How does Iatrogenic Oesophageal perforation occur?
How does Boerhaave’s Oesophageal perforation occur?
Someone has been drinking a lot etc then…
How does Foreign Body Oesophageal perforation occur?
How does Trauma Oesophageal perforation occur?
What is the presentation of Oesophageal perforation?
Pain 95 %
Fever 80 %
Dysphagia 70 %
Emphysema 35 %
What investigations are done for oesophageal perforation?
CXR
CT
Swallow (gastrograffin)
OGD
Pneumo-mediastinum
Black shows air
What is the initial management for oesophageal perforation?
NBM
IV fluids
Broad spectrum A/Bs & Antifungals – due to high burden of fungi in oesophagus
ITU/HDU level care
Bloods (including G&S)
Tertiary referral centre
What is the definitive management for oesophageal perforation?
Chest drain, stent and then ITU
Why is the LOS usually closed?
As a barrier against reflux of harmful gastric juice (pepsin & HCL)
What is LOS pressure increase by ?
What is LOS decreased by?
When does sporadic reflux occur
Is normal
-pressure on full stomach
-swallowing
-transient sphincter opening
What are 3 mechanisms protect following reflux
Volume clearance - oesophageal peristalsis reflex
pH clearance - saliva
Epithelium - barrier properties
What is chronic acid reflux a risk factor for?
Oesophageal Adenocarcinoma
What are failures of protective mechanisms in GORD?
What are failures of protective mechanisms in GORD?
What is sliding hiatus hernia?
Stomach is herniating through the hiatus of the diaphragm
What is a hernia?
Protrusion of a viscous of a defect of its walls of its containing cavity in abnormal position
What is a rolling/paraesophageal hiatus hernia?
GOJ is in the correct position but a portion of stomach that is herniated alongside that
Theoretical risk that is can strangulate - therefore surgery
In a GP, if a patient comes in with acid reflux and no red flags, what do you do?
Treat them there
If referred to secondary care, what investigations do you do for acid reflux?
OGD
—To exclude cancer
—Oesophagitis, peptic stricture & Barretts oesophagus confirm ∆
Oesophageal manometry
–Important for those with difficult to control reflux to check whether achalasia first
24-hr oesophageal pH recording
(Last two are standard investigations for those considering anti acid surgery)
What are the treatments for acid reflux?
Medical
—Lifestyle changes (wt loss, smoking, EtOH)
—PPIs
Surgical
—Dilatation peptic strictures
—Laparoscopic Nissen’s fundoplication
What are the functions of the stomach?
Breaks food into smaller particles (acid & pepsin)
Holds food, releasing it in controlled steady rate into duodenum
Kills parasites & certain bacteria
Anatomy of Stomach
cells?
What is erosive & haemorrhagic gastritis?
Numerous causes
Acute ulcer – gastric bleeding & perforation
What is Atrophic (fundal gland) gastritis?
Fundus
Autoantibodies vs parts & products of parietal cells
Parietal cells atrophy
↓acid & IF secretion
What is reactive gastritis?
What is Nonerosive, chronic active gastritis?
Antrum
Helicobacter pylori - Triple Rx (amoxicillin, clarithromycin, pantoprazole) for 7-14/7
How is gastric secretion stimulated
How is gastric stimulation inhibited?
What is the natural mucosal protection composed of?
What can non-steroidal drugs like ibroprofen do?
-They can inhibit bicarbonates so they should be taken with an acid suppressant
What are the mechanisms for epithelial repair and wound healing?
What is the biggest reason for ulcer (break in epithelium) formation?
What are the treatment of ulcers?
