Upper GI Flashcards
What is dyspepsia?
Inexact term used to describe collection of UPPER GI symptoms eg. heartburn, acidity, pain or discomfort, nausea, wind, fullness or bleching
Which symptoms of dyspepsia are suggestive of serious disease?
ALARM symptoms
Anaemia Loss of weight Anorexia Recent onset of progressive symptoms Melaena or Haematemesis (black, tarry faeces associated with upper GI bleeding)
What does faeculent vomit suggest?
Low intestinal obstruction or presence of gastrocolic fistula
Contraindications to OGD
Severe COPD, recent MI, severe instability of atlantoaxial joints
What is Behcets disease?
Rare condition causing inflammation of small blood vessels, aka small-vessel vasculitis
Often presents with mucous membrane ulceration and eye problems
Also ache, headache and joint problems
What is pemphigus vulgaris?
Pemphigus vulgaris - autoimmune blistering disease of skin and mucosa. Due to autoantibodies to desmogleins. Therefore attack desmosomes causing skin to blister.
What is pemphigoid?
Group of autoimmune skin blistering diseases but no acantholysis (targeting of desmosomes)
Believed to be IgG or IgA mediated. IgA rarely affect the mouth.
What is lichen planus?
Disease of skin and mucosal surfaces that resembles lichen – cause unknown (autoimmune?), no cure but can have symptomatic control
Treatment of mild aphthous ulcers?
Avoid trauma, avoid acidic food and drink
tetracycline or antimicrobial mouthwashes = chlorhexidine
Treatment of serious aphthous ulcers?
Corticosteroids (prednisolone)
Biopsy any ulcer not clearing after 3 weeks - query malignancy
What is oral hairy leucoplakia?
Shaggy white patch on side of tongue, benign
Seen in HIV with EBV
Risk factors for candidiasis?
Extremes of age
DM
Immunosuppressed
Antibiotics
Treatment of candidiasis?
Nystatin
Amphotericin
Fluconazole
All anti-fungals
What is chelitis - what caused by?
Also called angular stomatitis
Fissuring of mouth corners
Caused by denture problems, candidiasis, B12 or iron deficiency
What is gingivitis?
Gum inflammation and hypertrophy
Causes of gingivitis?
Poor oral hygiene Pregnancy Vit C deficiency Acute myeloid leukaemia Systemic sclerosis/scleroderma
What is microstomia and causes?
Small narrow mouth
Caused by thickening and tightening or perioral skin
Caused by:
- Burns
- Epidermolysis bullosa - connective tissue disease
- Scleroderma
What is Peutz-jeghers syndrome?
Hamaratmous polyps in GIT
Hyperpigmented macules on lips and oral mucosa
What are fordyce glands?
Creamy yellow spots at border of oral mucosa and lips - sebaceous cysts - common and benign
What is xerostomia? - causes?
Dry tongue
Dehydration, TCA’s, after radiotherapy, Crohn’s disease, Sjogren’s
What is glossitis? - cause?
Smooth, red, sore tongue
Caused by iron, B12 or folate deficiency
Causes of macroglossia?
Myxoedema (hypothyroidism)
Acromegaly
Amyloid
How does tongue cancer present?
On tongue edge, raised ulcer with firm edges
Main risk factors for tongue cancer? x2
Smoking and alcohol
Treatment of tongue cancer?
Radiotherapy or surgery
5year survival of early disease = 80%
What is odynophagia and what does it suggest?
Pain during swallowing and suggests oesophagitis
eg. due to reflux
Infection
Chemical oesophagitis due to drugs such as bisphosphonates, or slow-release potassium
Causes of GORD
Lower oesophageal sphincter hypotension
Hiatus hernia
Loss of peristalsis function
Gastric acid hypersecretion
Obesity, overeating, smoking, alcohol and pregnancy
Surgery for achalasia
Drugs - TCAs, anticholinergics, nitrates
Helico bacter pylori
Symptoms of GORD
Heartburn - retrosternal burning discomfort - worse on stooping, eating, lying down or straining
Belching
Acid brash
Waterbrash (increased salvation)
Odynophagia
Asthma, nocturnal cough, laryngitis, voice hoarseness
Complications of GORD
Oesophagitis
Ulcers
Benign stricture
Malignancy
Iron-deficiency
Tests in GORD
Endoscopy if ALARM signs or symptoms persisting despite treatment, or >55
Barium swallow may show hiatus hernia
Oesophageal manometry
Conservative treatment of GORD
Raise bed head
Loose weight, stop smoking, reduce alcohol
Regular meals and avoid trigger food/drink
Avoid eating 3 hours before bed
Avoid drugs which affect GI motility - nitrates, anticholinergics, Calcium channel blockers
Avoid drugs that damage mucosa - NSAIDs, K+ salts, bisphosophonates
Medical treatment of GORD
Antacids - neutralise stomach acid eg. alginate containing - Gaviscon
PPI - lansoprazole
H2 receptor antagonists - cimetidine, ranitidine, famotidine
When is surgery implicated in GORD?
If drugs not working, concern of long-term side effects
Recurrent hiatus hernia
What is the surgery for GORD?
Fundoplication - tighten the crura in diaphragm
Nissen - 360 degree wrap and others are less
Done laparoscopically
What is Barrett’s oesophagus?
When normal oesophageal squamous epithelium is replaced by metaplastic columnar mucosa
Almost always a hiatus hernia present
From acid exposure by GORD
Diagnosis of Barrett’s oesophagus? Treatment?
Endoscopy and biopsies
Can do mucosectomy or oesophageal resection
Risk with Barrett’s oesophagus?
Oesophageal adenocarcinoma - quantity of increased risk is debated
What is achalasia?
Impaired peristalsis of oesophagus and impaired relaxation of lower oesophageal sphincter
How does achalasia present?
Long history of intermittent dysphagia
Both liquids and solids from onset
Regurgitation of food - especially at night
Chest pain + heartburn
Weight loss but not loads of marked weight loss
Difficulty belching
Investigations in achalasia
Chest x ray - dilated oesophagus and widened mediastinum
Barium swallow - lack of peristalsis and failure of sphincter to relax
CT scan - exclude distal cancer
Treatment of achalasia?
Drug therapy rarely effective (nifedipine, sildenafil)
1) Endoscopic dilatation of LOS with a balloon - needs redoing as wears off after a few years
2) Botox injections into sphincter - wears off after a few months - less chance of perforation than balloon
3) Surgical division of LOS - Heller’s operation - surgical treatment of choice
What is diffuse oesophageal spasm?
Oesophageal dysmotility - bizarre contractions of oesophagus without normal peristalsis when swallowing
- Causes chest pain and dysphagia
Nutcracker oesophagus - variant of this - very high amplitude peristalsis
- Chest pain more common than dysphagia
Treatment - antispasmodics, nitrates, Calcium channel blockers and GABA agonists (baclofen)
What is pharyngeal pouch?
Oesophageal diverticulum just above upper oesophageal sphincter - dysphagia and regurgitation
May see visible pouch
Also get diverticulum in middle of oesophagus or just above lower sphincter
What is most common cause for benign oesophageal stricture?
Peptic stricture secondary to reflux
Also after ingestion of corrosives, after radiotherapy, after sclerosis of varices, prolonged NG tube intubation
2 types of hiatus hernia
Sliding - 80% - where gastro-oesophageal junction slides up into the chest through the diaphragm
acid reflux common
Rolling - 20% - gastro-oesophageal junction in the abdomen but bulge of stomach herniates into chest alongside oesophagus
as GO junction remains intact - gross acid reflux is uncommon
When are hiatus hernia more common?
Obesity
Imaging in hiatus hernia
Barium swallow
Treatment of HH
Lose weight, treat reflux symptoms
Surgery if intractable symptoms - rolling HH may strangulate therefore surgery advised
Which is more common duodenal ulcer or gastric ulcer?
Duodenal = 4x more common
2 x major risk factors for duodenal ulcer
H.pylori - 90%
Drugs - NSAIDs, steroids, SSRI
Minor risk factors for duodenal ulcer
Increased gastric acid secretion, increased gastric emptying (lower duodenal ph), blood group 0, smoking
Symptoms/signs of duodenal ulcer
Epigastric pain - before meals or at night
Relieved by eating or having milk
Worse several hours later
Epigastric tenderness
50% asymptomatic
Mean age 30s
Diagnosis of DU
Upper GI endoscopy
Test for h.pylori - C-Urea breath test
IgG antibody against H.pylori confirms exposure but not eradication
What is Zollinger-Elson syndrome and how do you test for it if suspected?
Gastrin secreting tumour of pancreas
Stimulates stomach parietal cells
Causes GI mucosal ulceration
Measure gastrin concentrations when off PPI for diagnosis - Secretin test (IV Secretin causes a rise in serum gastrin in ZE patients but not normal)
Treatment of duodenal ulcer
PPI
Where do gastric ulcers most commonly occur?
Lesser curvature of stomach - if elsewhere, often malignant
GU mostly in elderly
Risk factors for GU
H pylori - 80% Smoking NSAIDs Delayed gastric emptying Stress
Presentation of GU
Pain - epigastric - relieved by antacids
Weight loss
Mean age 50s
Worse soon after eating
Diagnosis of GU
Endoscopy - exclude malignancy
Biopsy of ulcer
Treatment of ulcers
Purge stress, avoid aggravating foods
Decrease smoking and drinking
Treatment of h-pylori
Triple therapy
PAC500 regimen - PPI, amoxicillin, clarithromycin
PMC250 regimen - PPI, metronidazole and clarithromycin
Medical treatment of ulcers
PPIs H2 blockers (ranitidine)
When do you do surgery for ulcers?
Only really for complications - haemorrhage, perforation
Or if don’t respond to medical therapy
Emergency surgery for ulcer haemorrhage
Adrenaline injection, laser coagulation, heat probe
What is pyloric stenosis
Late complication of duodenal ulcers - vomiting large amounts of food some hours after meals
Treat with endoscopic balloon dilatation
What type of oesophageal carcinomas occur where?
Squamous cell carcinoma can occur throughout
Adenocarcinoma only in distal third
20% in upper, 50% in middle, 30% in lower
Risk factors for oesophageal carcinoma?
Smoking and alcohol Diet (nitrosamines) Vitamin A & C deficiency Achalasia Coeliac disease
Barrett’s oesophagus + GORD (adeno)
Presentation of oesophageal carcinoma
Often insidious
Dysphagia, solid and then liquid
Weight loss
Coughing or choking after food
upper 1/3 - hoarseness (may indicate recurrent laryngeal nerve palsy)
Diagnosis of O carcinoma
Barium swallow
Endoscopy - biopsy
CT scan
Treatment of O carcinoma
25% of patients are operable - can do radical oesophagectomy
Can do early endoscopic mucosal resection
SSC more radiosensitive than adenocarcinoma
Pre-op chemotherapy may be useful but morbidity
Palliation - stent or dilation
Prognosis of o carcinoma
5% have 5 year survival
What type of cancer is stomach cancer normally?
85% = adenocarcinoma 15% = lymphoma
Risk factor for stomach cancer
Nitrites
Nitrosamine exposure
H.pylori exposure
Lower social class
Smoking
Alcohol
Diet - high nitrate, low vit c
Presentation of stomach cancer
Insidious
Early satiety
Nausea, weight loss, anorexia, fatigue, anaemia (bleeding) - haematemesis
Dyspepsia
Presentation from stomach cancer mets
Transperitoneal - ascites
Ovarian masses - Krukenberg tumour
Virchow’s node - Troisiers sign
Acanthosis nigrans - hyperpigmentation of skin
Diagnosis of stomach cancer
Barium and endoscopy
Gastroscopy and biopsy
Endoscopic ultrasound - depth of invasion
CT/MRI - staging
Treatment of stomach cancer
30% - surgery for potential cure - gastrectomy (can be partial - Bilroth 1 and 2 partial gastrectomy)
Chemotherapy - 30% partial response - therefore combine with surgery
Endoscopic mucosal resection - for early tumours confined to mucosa
Prognosis for stomach cancer
5 year 5% survival
Prevalence of small intestine tumour
Rare
