Upper GI Flashcards
Vitamin deficiencies
A: xerophthalmia, night-blind, hyperkeratosis;
D: rickets, osteomalacia (normal density, poor minerlisation - soft)
E: haemolytic anaemia, ataxia
K: coagulation disorder
B1 (thiamine): beri-beri; wernicke-korsakoff
B2 (riboflavin): glossitis, stomatitis
B3 (niacin): pellagra (derma, dd, dementia)
B6 (pyridoxine): polyneuropathy
B7 (biotin): dermatitis, alopecia, paraesthesia
B9 (folate): anaemia
B12 (cobalamin): anaemia, neuropathy
C: scurvy
vitamin excess:
A: liver damage, bone damage, terato
D: hypercalcaemia
NGT
empty stomach: pre-op, obstruction, ileus, GOO, panc, aspiration risk
intra-op: deflate/inflate stomach, decompress bowel, test anastamoses
irreversible dysphagia e.g. MND
feeding: fine bore tube
SE: pain, electrolytes, oesophagitis, necrosis, perf, intubation
undernutrition
increased requirement, increased losses, intake, treatment SE/D&V, NBM
immunity, healing, recovery, wasting/weakness, cardioresp function, psych/mood, fatigue
obesity
overweight 25-30; class I= 30-35; II= 35-40; III= >40 (surgery)
metabolic syndrome, liver, GORD, hernia, ventilation/OSA, OA, VV, cancer
Roux-en-Y (stomach bypass), banding (vert/adjust), bilio=panc diversion
ALARM SYMPTOMS (?cancer - scope!)
anaemia loss of weight anorexia and vomiting recent onset malaena/bleeding swallowing issues
age >55yo
abdo mass
Dyspepsia DDx
GORD: give PPI; risk of stricture, metaplasia
PUD: check H. pylori/CA; stop NSAIDs and smoking
Cancer: gastric, oesophageal
functional (non-ulcer) and non-erosive GORD
non-GI: heart, lungs, liver, GB, panc
drugs: NSAID, nitrates, CST, theo, Ca-agonist
scope +/- biopsy: accurate diagnosis
(normal = functional dyspepsia)
GORD presentation etc.
heartburn >2/w (retrosternal, positional, heat worse)
regurgitation (food and acid)
belching, acidbrash, waterbrash, odynophagia
worse asthma
RF: CREST, weight, diet, drugs (TCA, NSAID, CCB), H. Pylori, ZES
Tx if no red flags: life, antacid, alginates, PPI/anti-H
scope if ALARM, Tx fail, relapse, >4/52
Nissen Fundoplication: severe/refractory, young
complications: oesophagitis, ulcers, strictures, Barrett’s, AC/SqCC
Dysphagia DDx
oropharyngeal: higher; neuro; aspiration risk
lower oeso: localised; ‘stuck’ +/- regurg
mouth: tonsilitis, globus (functional)
neuromm: pharynx, bulbar palsy, MG/MS/CVA/PD
dysmotility: achalasia, SSc, spasm, DM
extrinsic: LA, goitre, AAA, L atrium, tumours
intrinsic: FB, stricture, webs (PWS), atresia, P-pouch
* PWS: IDA + webs + dysphagia
Dysphagia Hx + Ix
progressive (solids - liquids): Ca, stricture
solids + liquids: achalasia, neuro, pharyngeal
pain: Ca, ulcer, infection/inflam, spasm
intermittent = spasm; dry swallow = bulbar
Ix: bloods, CXR, scope + Bx,
oeso motility: manometry, barium swallow
orophary: videofluoroscopy + neuro testing
oeso cancer presentation
60-70yo; 30% lower (AC), 50% mid (SCC)
AC: metaplastic/stomach spread; earlier LN
SCC: drink/ciggs; later presentation, early LN
progressive persistent dysphagia
retrosternal pain, cough, aspiration,s anorexia/satiety
RF: ciggs/alc, diet, RDT, strictures, achalasia, Barrett’s/GORD
Oeso cancer treatment
staging: Barium, CXR, scope + Bx/EUS, CT/MRI
radical curative oesophagectomy: T1/2 (20-30%); transhiatal/3 stage open/ILO
neoadjuvant CTX (cisplatin + 5FU): morbidity risk
CTX + RDT if no operation
palliative: stent (risk of perf, bleed, stuck food bolus)
prognosis: poor but SCC better
<10% 5ys; mets in 25-30% at Dx (liver, lung, bone)
achalasia
tonic muscle contraction/peristaltic spasm
progressive megaoesophageus (prox dilatation)
RF for oeso CA
middle-aged, dysphagia, regurg, cramping, weight loss
OGD, barium swallow (rat’s tail), manometry (pressure)
Tx: small meals; balloon (recurs); cardiomyotomy; botulinum (last)
ZES
Gastrinoma: high fasting gastrin + secretin stimulation test
epigastric pain + diarrhoea
malabsorption
multiple duodenal ulcers
30% part of MEN1 (parathyroid, pit, panc
!!(DELETE)
To-DO
antibodies: ANA/anti-SM = AIH; PBC = anti-mito
* PSC = IBD-assoc
PUD
aetio: H. pylori (D > G), NSAIDs, cigg/alc, stress, ZES, acid/caff
burning epigastric pain, food-related (gastro worse, duo better)
nausea, anorexia/satiety, weight loss
haematemesis and melaena
?perf: severe, persistent, back pain
clinical Dx unless ALARM/>55 (scope)
test for H. pylori if refractory and no PMH
(ulcer PMH = assume infection)
Tx: antacids +/- anti-reflux +/- ABx (H. pylori)
comps: hge, perf, stenosis; (operate)
PUD - Duo vs. gastric
duo: commoner, pain pre-meal + night, +/- back pain, melaena more likely, more complications
gastro: older (55-65yo), post-food worse, haematemesis more likely, cancer more likely if not lesser curve
GI Hge DDx
PUD: 45-50% (PPI, ligate, adr, diathermy)
Mallory-Weiss tear:15%
gastroduo erosions: 10%
reflux oesophagitis: 10%
inflammation: gasto, duo, oeso (pain + vom)
varices: 7% (banding + BB/terlipressin)
gastric CA: usually small bleeds
post-PCI: 2% of PCI
Boerhaave’s: oeso rupture (pneumo-m’stinum)
rare: gastric AVM, portal HTN, GIST, angiodysplasia
Glasgow-Blatchford score (pre-endo)
decide need/urgency of scope
0 low risk; higher = likely intervention; 6 = >50% need
*urgent scope: <4h if ?varices; 12-24h if shock/co-morbid
urea (2/3/4/6) Hb (F = 1/6, M = 1/3/6) SBP (1-3) tachycardia (1) melaena (1) syncope/hepatic disease/heart failure (2)
Rockall score (post-endo)
prognosis: rebleed and mortality
age shock comorbidity diagnosis: Mallory vs. other vs. CA recent hge signs on scoping
pre-endo 7 = 50% mortality
post-endo 7 = 27% mortality
post-endo 8 = 41.1%
Lower GI Hge DDx (HAND CrAC)
Haemorrhoids Angiodysplasia Neoplasm Diverticular Crohn's Anal fissure Colitis (ischaemic, inflammatory, infective)
GI Hge: Sx2
haematemesis, melaena, haematochezia (PR)
postural hypoTN/dizzy, syncope
abdo pain
shock (HR, BP), low JVP, cold and clammy
CLD stigmata, purpura
low UO, Urea (»Cr), lactate
jaundice (biliary colic + jaundice + melaena = ?haemobilia)
GI Hge management
1) assess for shock
* not shocked: IV access, bloods, vitals, UO, ?transfuse (Hb >8)
2) protect airway + NBM
3) access + bloods (FBC, UE, LFT, BM, clotting, XM 6)
4) O2 + fluid resus (MAP 65) + monitor UO (>30/h)
5) correct clotting: vit K, FFP, plt (<50), terlipressin (varices)
6) monitor 15mins until stable (then hourly)
7) urgent scope (consult surgeons)
8) ?IV omeprazole (stabilise clot, prevent re-bleed)
9) ?anti-emetic (gastric emptying), transexamic acid
Gastric Cancer Sx2
RF: male, H. pylori/gastritis, diet, ciggs/alc, group A, pernicious, polyps, FHx
epigastric pain (food better), N&V, dysphagia
anorexia, satiety, weight loss
anaemia, dyspepsia (>1/12 + >55yo UPO)
palpable mass (50%; late stage)
hepmeg, ascites, jaundice
Virchow’s node/ Troisier’s sign
acanthosis nigricans/dermatomyositis
Gastric Cancer Mx (Ix + Tx)
<10% 5ys (20% if radical surgery)
FBC, UE, LFT gastroscope + biopsies barium meal (filling defect, irregular rolled ulcer) EUS + CT/MRI (staging) staging laparoscopy if ?M0
partial/total gastrectomy (distal/proximal)
chemotherapy (advanced disease)
endoscopic mucosal resection (early disease)
palliation CTX/RDT: obstruction, pain, hge
Gastrectomy complications
ulceration, gastric tumour
abdo fullness, loop obstruction
bilious vomiting, diarrhoea
dumping syndrome: osmosis - faint + sweat
weight loss, anaemia, malabsorption, osteomalacia
Gastric Ca pathology
mostly antral and AC (90%)
local + lymph spread: malignant ascites, Krukenberg, umbilical nodule
intestinal TI: commonest; metaplasia; polyp/ulcer; well/mod-diff
intestinal TII: signet ring, linitus plastica, poor-diff
other CA: stromal, GIST, lymphoma, carcinoid, polyps
Gastric Ca staging (Borrmann classification)
1: polypoid
2: excavating
3: ulcerated and raised
4: infiltrative
5: early - limited to mucosa/submucosa
early disease/Dx rare; usualyl late stage
Acute Abdomen: Ix/Tx
FBC, UE, LFT, CRP, ABG/lactate, UA
MUST DO AMYLASE AND b-HCG
erect CXR; ECG if >50yo/PMH
USS, AXR, CT, ERCP/MRCP
laparoscopy
laparotomy: ruptured organ, peritonitis
*remember: AAA, panc, DKA, gynae, testicular, heart, lungs, haemo
