Upper GI Flashcards
How does Achalasia happen
failure of the LOS to relax and aperistalsis - degeneration of the myenteric plexus which produce NO and VIP for relaxation
Which one of these diseases can be a secondary cause of achalasia?
Buerger’s disease
Chagas disease
Lyme disease
Behcets disease
Crohn’s disease
Chagas diseas (trypanosoma cruzi)
Achalasia presentation
dysphagia - both solid and liquids
regurgitation - due to food trapped in oesophagus
gradual weight loss - due to lack of food ingestion
Achalasia investigations
gold standard:
high resolution oesophageal manometry - will demonstrate incomplete relaxation and aperistalsis
others:
1st line: upper GI endoscopy - can show retained food debris with dilated wall
barium swallow - “bird beak” appearance
Achalasia differentials and complications
differentials:
oesophageal cancer
benign stricture
complications:
aspiration pneumonia
GORD
oesophageal cancer
A 58 year old man presents to the GP. He complains of retrosternal chest pain after eating meals. His wife has noticed his breath is foul smelling and he often experiences a bitter taste in his mouth. What is the most likely diagnosis?
Barrett’s oesophagus
Plummer Vinson syndrome
Zenker’s diverticulum
GORD
Acute gastritis
GORD
GORD definition
symptoms or complications resulting from reflux of gastric contents into the oesophagus or beyond
GORD risk factors/causes
LOS hypotension
hiatus hernia
obesity
gastric acid hypersecretion
alcohol
smoking
pregnancy
LOS tone reducing drugs (TCAs, nitrates, anticholinergics)
GORD presentation
++ heartburn (pain in chest) usually after meals
++ acid regurg leaving bitter taste in mouth
+ increased salivation
+ odynophagia if oesophagitis or ulceration
+ chronic cough or nocturnal asthma
GORD investigations
gold standard:
- resolution of symptoms after 8 week PPI trial
other:
- OGD - will detect erosions and ulcerations (oesophagitis)
- oesophageal manometry with pH monitoring is useful if OGD shows nothing
GORD management
lifestyle:
weight loss
smoking cessation
small regular meals
avoid certain foods (acidic fruit, coffee, alcohol)
medical:
continue PPI that was working
consider adding H2 blocker
antacids may be useful for symptom relied
surgery:
Nissen fundoplication
all forms of surgery aim to increase LOS pressure
GORD differentials and complications
differentials:
ACS
stable angina
complications:
ulceration/perforation
barrett’s oesophagus
oresophageal cancer
Peptic ulcer disease definition
break in lining of stomach with obvious depth through the submucosa
duodenal ulcers > gastric ulcers
peptic ulcer risk factors
H.pylori
NSAIDs
smoking
increased/decreased gastric emptying
gastric specific ulcers
Cushing and Curling ulcers
peptic ulcer disease - presentation
epigastric pain that the patient can point towards
key difference is gastric directly after meals while duodenal manifests couple hours later
nausea and vomiting
mild weight loss
complications of peptic ulcer disease
haemorrhage, perforation or obstruction
peptic ulcer disease investigation
gold standard:
upper GI endoscopy - reveals ulcerations and can perform a biopsy of the tissue
other:
- h.pylori tests - most common are urea breath tests and stool antigen test (retest after 6-8 weeks)
- serum fasting gastrin level
peptic ulcer disease management
lifestyle:
reduce smoking and alcohol
medical: h.pylori +ve
triple therapy: ppi + 2 abx (normally amoxicillin or clarithromycin unless CI, then metronidazole) - 7 day eradication
medical: h.pylori -ve (maybe drug induced)
stop drug causing ulcer immediately
offer 4-8 weeks of ppi therapy
gastritis definition
histological presence of mucosal inflammation
gastritis risk factors
h.pylori
NSAIDs
alcohol
Zollinger Ellison syndrome
Menetrier disease
autoimmune
gastritis investigations
mainly h.pylori tests
other tests needed for other causes
gastritis management
tailor treatment towards each condition
hiatus hernia types
sliding (80%) and rolling (20%)
risk factors for hiatus hernia
obesity
anything increasing intra-abdominal pressure
hiatus hernia presentation
most are asymptomatic
GORD symptoms may be the only reveal
GORD usually worse when lying flat
palpitation or hiccups indicate pericardial irritation
hiatus hernia investigations
gold standard:
upper GI endoscopy
other:
CXR - retrocardiac bubble
hiatus hernia management
lifestyle and medical:
similar to GORD - weight loss and PPI
surgery:
only refractory to medical therapy
involves pushing the hernia back into the abdomen
the stomach is also wrapped around the oesophageal junction to help tighten it
hiatus hernia differentials and complications
differentials:
GORD
complication:
gastric volvulus
Barrett’s oesophagus
Barrett’s oesophagus definition
metaplasia of normal stratified squamous epithelium to columnar epithelium
Barrett’s oesophagus risk factors
GORD
anything modulating GORD
Barrett’s oesophagus presentation
symptoms of GORD
Barrett’s oesophagus investigations
gold standard:
upper GI endoscopy WITH BIOPSY
Barrett’s oesophagus - management
non-dysplastic:
maximise PPI therapy and surveillance every 2 years
therapeutic intervention:
radiofrequency ablation or endoscopic mucosal resection for nodular growths
Barrett’s oesophagus differentials and complications
differentials:
oesophagitis
GORD
complications:
oesophageal cancer
oesophageal stricture
oesophageal cancer definitions and types
cancer originating from the epithelial lining of the oesophagus
split into two types:
squamous (upper 2/3rd)
adenocarcinoma (lower 1/3rd)
risk factors for squamous oesophageal cancer
alcohol
smoking
strictures
achalasia
nitrosamines
risk factors for adenocarcinoma oesophageal cancer
GORD
Barrett’s
obesity
achalasia
oesophageal cancer presentation
dysphagia - first solids then liquids (progressive)
rapid weight loss
hoarseness if recurrent laryngeal pressed
oesophageal cancer investigations
gold standard:
upper GI endoscopy WITH BIOPSY
other:
CT/MRI for staging - important for treatment
oesophageal cancer differentials and complications
differentials:
benign stricture
achalasia
complications:
aspiration pneumonia
fistulas
Gastric cancer definition
neoplasm originating in any portion of stomach most commonly adenocarcinoma
others include lymphoma, GI stromal tumours, carcinoid
types of gastric cancers
intestinal - H.pylori associated
diffuse - e-cadherin mutation associated
risk factors for gastric cancers
pernicious anaemia
h.pylori
nitrosamines
smoking
high salt/ low vit C
blood type A
gastric cancer presentation
vague but usually epigastric abdominal pain
weight loss
lymphadenopathy
gastric cancer investigations
gold standard:
upper GI endoscopy with biopsy showing signet ring cells
other:
CT/MRI for staging
EUS with FNA - for staging
*EUS- endoscopic US
*FNA- fine needle aspirate
gastric cancer differentials and complications
differentials:
PUD
benign stricture
complications:
haemorrhage
obstruction
perforation
Mallory-Weiss tear definition
longitudinal lacerations in mucosa and submucosa near GOS
usually self-limiting and resolves spontaneously
Mallory-Weiss tear risk factors
persistent retching. coughing, vomiting or straining
found in alcoholics and bulimics
Mallory-Weiss tear presentation
haematemesis
lightheaded/dizziness
postural hypotension
may experience dysphagia, odynophagia and melaena
Mallory-Weiss tear Ix
Gold standard:
upper GI endoscopy to visualise tears
points to note:
risk assessments
rockall score
glasgow-blatchford score
other:
FBC- may show anaemia
urea- elevation may indicate upper GI bleed
CXR- to rule out perforation
Mallory-Weiss tear management
1st line:
with endoscopy inject adrenaline or conduct band ligation to stop bleeding
adjuncts:
give anti-secretory therapy (PPIs) before endoscopy to reduce bleeding
give anti-emetics to prevent recurrence
2nd line:
Sengstaken-Blakemore tube
Mallory-Weiss tear differentials and complications
differentials:
oesophageal varices
oesophagitis
complications
Boerrhave’s perforation
re-bleeding
which one of these investigations would be used initially in achalasia?
- colonoscopy
- CXR
- Upper GI endoscopy
- Oesophageal manometry
- Transoesophageal MRI
- Upper GI endoscopy
Although oesophageal manometry is the gold standard for diagnosing achalasia, with any new onset dysphagia, especially in older patients, an endoscopy to rule out insidious growths is needed
PPIs are often trialled and used as 1st line for GORD. which is an example of PPI
- ketoconazole
- albendazole
- riluzole
- Carbimazole
- Omeprazole
- Omeprazole
ketoconazole is a commonly used antifungal
albendazole is a commonly used anti-helminth
riluzole is used for motor neurone disease
carbimazole is used in Cushing’s disease
A 50 yr old male presents to a+e with excruciating epigastric pain. the pain is also felt in his right shoulder. it is later revealed that he has been suffering from recurrent gastric ulcers lately. What sign is observed in CXR?
- Rigler sign
- McBurney’s sign
- Dome sign
- Haemoperitoneum
- Sail sign
- Dome sign
When gastric ulcers burst, free air is released into the peritoneum. Air will naturally rise on an erect CXR displacing the diaphragm causing a dome shape
A 60 yr old female presents with severe epigastric pain and retching without vomiting. Small bowel obstruction is suspected and a ‘drip and suck’ protocol is initiated. The NG however is unable to be passed into the stomach. What is the likely diagnosis?
- large bowel obstruction
- gastric cancer
- oesophageal spasm
- gastric volvulus
- achalasia
- gastric volvulus
a gastric volvulus is a classic complication of a hiatus hernia. the triad is severe epigastric pain, retching without vomiting and not being able to pass ng tube into stomach
