Upper GI Flashcards
Common causes of upper GIT bleeding
Oesoph
- varices
- Mallory Weiss
Stomach
- ulcer
- erosive hemorrhagic gastritis
Duodenum
- ulcer
- erosive duodenitis
Uncommon causes of upper GI bleeding
- tumours
- stomal/anastomotic ulcers
- vascular malformations
- oesophagitis
- oesophageal ulcers
Most common causes of major GI bleeding
- PUD
- oesophageal varices
Clinical findings in major haemorrhage
- hypotension
- pallor
- weak and rapid pulse
- poor peripheral perfusion
- cool extremities
NB things to think of if a patient with upper GI bleeding has liver failure
- avoid Na-containing fluids
- give 5% dextrose
- octreotide to lower portal pressure
NB diagnostic investigations for upper GI
- endoscopy
- angiography
Forrest classification
1A = spurting blood 1B = oozing blood 2A = non-bleeding visible vessel 2B = adherent clot 2C = pigmented spot 3 = clean ulcer base
Risk stratificaiton score for upper GI rebleed
Roackall Risk score
- age
- haemodynamic status
- co-morbidities
- endoscopic Dx
- stigmata of recent Hg
Patients at risk of rebleeding
- age >60 yrs
- shock on admission
- endoscopic stigmata of recent bleed
- large ulcers (>2cm)
- lesser curvature gastric and post-duodenal bulb ulcer
Indications for surgery for upper GI bleeding
- exsanguinating Hg
- associated perforation
- failed endoscopy of active bleeding in shocked patient
- recurrent bleeding after endoscopic therapy
- patients at risk of rebleeding where endoscopy not avail.
Management of high risk upper GI patient
- resus
- admit to highcare
- endoscopic therapy
- commence IV PPIs
- oral intake of clear fluids 6 hrs after endoscopic haemostasis
- transition to oral PPIs
- test for HP and eradicate
Symptoms of duodenal ulcers
- upper abdo pain releived by food
- nocturnal pain
- heart burn, anorexia, vomiting and weight loss related to gastric outlet obstruction
Medical management of PUD
- PPI
- amoxicillin and metronidazole
When is surgery indicated for PUD
To fix complications
Complications of PUD
- haemorrhage
- perforation
- duodenal stenosis
Investigations for perforated peptic ulcer
- erect chest and abdo XRAY
- raised serum amylase
- gastrografin swallow if doubtful
NO ENDOSCOPY
Surgical management of perforated peptic ulcer
primary closure with omental patch
2 types of pathology of duodenal stenosis as a result of PUD
- large penetrating ulcers with inflammation and oedema
- healed ulcer with fibrosis
Compensatory muscular hypertrophy
Metabolic end results of duodenal stenosis
- severe dehydration
- raised urea and heamatocrit
- low serum Cl, Na, K
- serum alkalosis and intra-cellular acidosis
- decreased ionised calcium (tetany)
Clinical features of duodenal stenosis
- long history of dyspepsia and LOW
- anorexia, nausea and vomiting (undigested food)
- metabolic and nutritional derangements
Examination findings of duodenal stenosis
- dehydration
- upper abdo distension
- visible peristalsis
- succussion splash
Investigations of duodenal stenosis
- abdo XRAY
- barium meal
- endoscopy to exclude carcinoma
Treatment of duodenal stenosis
- rehydration and electrolyte correction
- enteral feeds
- stomach washouts
- ulcer therapy
- endoscopic dilatation
- often, surgery is necessary
3 types of gastric ulcers
- prepyloric
- combo duodenal and gastric
- > 2cm from the pylorus on the lesser curve
Symptoms of gastric ulcer
- pain precipitated by meals
- LOW
Complications of gastric ulcers
- bleeding
- perforation
- penetration into pancreas
- gastric outlet obstruction
4 layers of the small intestine
- mucosa
- submucosa
- muscularis
- serosa
Hormones produced by the small intestine
- gastrin
- cholecystokinin
- secretin
- motilin
- vasoactive intestinal polypeptide
Most common causes of small bowel obstruction
- adhesions
- hernias
Symptoms of small bowel obstruction
- abdo discomfort/pain
- abdo distension
- N + V (bile-stained)
- obstipation
Causes of small bowel perforation
- TB
- typhoid
- CMV
- malignancy
- Crohn’s disease
- steroids
- radiotherapy
Describe short bowel syndrome
- diarrhoea, steatorrhoea, malnutrition
- 100cm or less
- most need life-long TPN
Causes of small intestinal haemorrhage (excl. ulcers)
- vascular abnormalities
- Crohn’s
- Meckel’s
Mets that go to the small bowel
- melanoma
- renal
- breast
Risk factors for chronic atrophic gastritis
- autoimmune disorders
- chronic bile reflux
- H. pylori
- alcohol
- smoking
- poor nutrition
Describe Correa’s hypothesis
- nutritional defects cause gastritis
- cell damage leads to defective acid production and bacterial prolif
- bacteria produce nitrate reductase
- reduces dietary nitrate to nitrites which combine with amines
- nitrosamines are carcinogenic
Risk factors for gastric cancer
- H. pylori
- EBV
- gastric surgery
- abdominal radiation
- blood group A
- family history
- hereditary diffuse gastric cancer
- gastric polyps
- hypertrophic gastropathy (Menetiers)
- gastric ulcer
- pernicious anaemia
2 types of gastric cancer
- intestinal
- diffuse
Difference between intestinal and diffuse gastric adenocarcinomas
Intestinal
- ulceration
- acinar formation
- antrum
Diffuse
- constricting linitis plastica
- no acini
- fundus
- worse prognosis
Presentation of gastric carcinoma
- dyspepsia
- local complications
- insidious onset
- dysphagia (prox stomach)
- paraneoplastic manifestations
Differential diagnoses of dyspepsia
- functional dyspepsia
- PUD and gastritis
- GORD
- oesophagitis
- Drug SE
- biliary disease
- gastric Ca
Causes of gastric outlet obstruction
- Gastric carcinoma
- PUD
- pancreatic pathology
- corrosive stricture
- rarities (volvulus, bezoars)
Surgical decision making steps for gastric cancer
- confirm with endoscopic biopsy
- metastatic screen
- assess extent
- assess fitness for surgery
Operation for localised disease of gastric cancer
Billroth 2 (distal gastrectomy)
What are GI stromal tumours?
- sub-epithelial neoplasms found usually in the stomach
- symptoms only really occur when large
Mutation found in GIST
CD 117Ag (part of tyrosine kinase receptor)
- responsive to Imatinib (blocks tyrosine kinase receptor)
What type of lymphoma is gastric lymphoma usually?
- non-Hodgkin
- most are aggressive and treated with CHOP chemo
Benign disease of the pharynx/oesophagus
- GORD
- Para-oesoph hernia
- motility disorders
- achalasia
- diverticula
- oesoph perforation
- dysphagia
Possible investigations for benign oesophageal diseases
- chest and abdo XRAY
- barium swallow and meal
- endoscopy
- CT
- endoscopic US
- manometric studies
- 24 hr pH monitoring
What is the pathology in GORD?
Incomplete/inappropriate relaxation of the LOS
- many have sliding hiatus hernia
Symptoms of GORD
- burning substernal/epigastric distree
- acid regurg after meals or when lying down
- associated aspiration, asthma and hoarseness
Complications of GORD
- oesophagitis
- ulceration (stenosis and bleeding)
- Barrett’s oesophagus
Complications of para-oesophageal hernia
- gastric volvulus
- obstruction
- incarceration
- strangulation
- pulmonary complications
Types of achalasia
- hypofunctional
- hyperfunctional
What causes hypofunctional achalasia
- destruction of Auerbach’s nerve plexus
- oesoph gradually dilates
- test with manometry
Management of hypofunctional achalasia
Heller’s myotomy
Causes of hyperfunctional achalsia
- diffuse oesophageal spasm
- nutcracker oesophagus
3 types of oesophageal diverticulae
- pharyngo-oesophaegeal (Zenkers)
- Traction diverticula
- Epiphrenic diverticula
Types of oesophageal perforation
- instrumental
- non-instrumental
Causes of non-instrumental perforation
- post-emetic
- foreign body
- penetrating injury
- anastomotic leak
Severe result of oesophageal perforation
Virulent necrotising mediastinitis
Benign causes of dysphagia
- GORD
- caustic
- Webs
- Schatzki ring
- motility disorders
- drug-induced
- post-Nissen
- eosinophilic oesophagitis
Malignant causes of dysphagia
- squamous carcinoma
- adenocarcinoma
- metastases
Causes of odynophagia
- hypermobility disorders
- candidiasis
- herpes simplex
- drugs
Two types of oesophageal cancer
- squamous cell (upper)
- adenocarcinoma (glandular cells at junction)
Risk factors for oesophageal cancer
- race
- sex (M)
- age
- smoking
- alcohol
- GORD
- other (HPV, PlummeriVinson, tylosis, achalasia)
What is Plummer- Vinson
association of postcricoid dysphagia, upper esophageal webs, and iron deficiency anemia
What is tylosis?
A genetic disorder characterized by thickening (hyperkeratosis) of the palms and soles, white patches in the mouth (oral leukoplakia), and a very high risk of esophageal cancer
Local symptoms of oesophageal cancer
- dysphagia
- cough and regurg
- odynophagia
- weight loss
- upper GI bleeding
Symptoms of oesophageal cancer caused by surrounding invasion
- resp fistula
- hoarseness
- hiccups
- pain
Symptoms of oesophageal cancer caused by distant disease
- mets
- hypercalcaemia
Contraindications to oesophagectomy for oesophageal cancer
- mets to N2 nodes
- local structure invasion
- severe comorbidities
Possible interventions for oesophageal cancer
- surgery
- radiotherapy (palliative)
- intubation (and stenting)
- chemo (limited)
- other (laser, photodynamic therapy)
