Upper GI Flashcards
What is dyspepsia
A combination of symptoms indicating an upper GI problem
Typically:
- epigastric pain
- early satiety and post-prandial fullness
- Belching
- bloating
- nausea
- discomfort in the lower abdomen
What is peptic ulcer disease
Break in the epithelial lining of the stomach or duodenum
What are the symptoms of peptic ulcer disease
- Recurrent epigastric pain related to eating (described as gnawing or burning)
- early satiety
- nausea and vomiting
- potential anorexia & weight loss
What are the signs for peptic ulcer disease
- epigastric tenderness
2. pointing sign (pts are able to point to where the pain is)
How is the pain of duodenal ulcers described
the abdominal pain may be severe and radiate through to the back as a result of penetration of the ulcer posteriorly into the pancreas
Difference between gastric and duodenal ulcers: Pain
Duodenal ulcers: 2-3 hours after eating
Gastric ulcers: immediately after eating
Difference between gastric and duodenal ulcers: Antacid relief
duodenal ulcers: yes
gastric ulcers: minimal
Difference between gastric and duodenal ulcers: eating
duodenal ulcers: overeating - weight gain
gastric ulcers: avoids eating - weight loss
A 45 year old woman presents with a 2 month history of upper abdominal pain, occurring 2 – 3 hours after meals. The GP orders some blood tests, with the relevant results shown below:
[reduced RBC, HCT, MCV]
Which of these is the most likely diagnosis?
GORD Duodenal ulcer Gastric ulcer Biliary colic Cholecystitis
Duodenal ulcer
What are the 2 main risk factors in ulcer development
- NSAIDs
2. H. pylori
What are the risk factors for ulcer development
- NSAIDs
- H. pylori
- smoking
- Zollinger Ellison syndrome
Name 3 NSAIDs
- ibuprofen
- Naproxen
- Aspirin
What is the prevalence of Helicobacter Pylori
Prevalent in 50% of the population
10% of these may develop an ulcer
What are the investigations for H pylori
- Breath test
2. stool antigen test
What is the management for H Pylori
triple therapy:
- PPI
- Clarithromyocin
- amoxicillin or metronidazole
What is Zollinger-Ellison syndrome
Neuroendocrine tumour in pancreas
produces gastrin
which leads to increased gastric acid secretion
consequently 90% patients will develop gastric and duodenal ulcers
What is a gastrinoma
A neuroendocrine tumour in pancreas seen in Zollinger-Ellison Syndrome
What gene is a risk factor of a gastrinoma (seen in Zollinger Ellison syndrome)
MEN1
What are the investigations for Zollinger-Ellison syndrome
- Fasting serum gastrin
- serum calcium
- gastric acid secretory tests, stimulation tests, imaging
What is the treatment of Zollinger-Ellison Syndrome
- PPI
2. Surgical resection if needed
What are Cushing ulcers
Harvey Cushing (neurosurgeon) found patients suffering from head trauma developed peptic ulcers
How to Cushing ulcer’s come about
Raised ICP (due to brain trauma) stimulates the vagus nerve - leads to increased gastric secretion
What are curling ulcers
Ulcer following severe burns
How to Curling ulcers come about
These are ulcers following burns
The reduced plasma volume leads to ischaemia and necrosis of gastric mucosa
Peptic ulcer: if patient is under 55 with no red flag symptoms, what investigations are done
- Breath test/stool antigen
2. FBC, stool occult, serum gastrin
Peptic ulcer: if patient is above 55, red flag symptoms are present or treatment has failed, what are the investigations
- OGD endoscopy
- Histology + biopsy urease testing
- repeat endoscopy after 6-8 weeks
What are red flag symptoms
- weight loss
- bleeding
- anemia
- vomiting
- early satiety
- dysphagia
What is the management for a peptic ulcer (where H pylori is not responsible)
PPI (omeprazole) or H2 antagonist (ranitidine)
Peptic ulcers: what are the complications
- bleeding
2. perforation
Peptic ulcer: management for bleeding
- endoscopy +/- therapy e.g. adrenaline
- IV PPI
- +/- blood transfusion
Peptic ulcer: management for perforation
- Nil by mouth
- IV antibiotics
- surgery
what is the most common type of gastric cancer
adenocarcinoma
What are symptoms of gastric cancer
- Epigastric pain
- Nausea, vomiting +/- blood
- Weight loss - anorexia
What are the risk factors for gastric cancer
- Smoking
- H Pylori
- Chronic gastritis - and therefore peptic ulcer disease
What are the clinical signs of gastric cancers
- palpable epigastric mass
- Virchow’s node/Troisier’s sign
- Sister Mary Joseph node - metastatic nodule on umbilicus
What are the investigations for gastric cancer
- endoscopy
2. biopsy + histology
A 61 year old man presents to his GP with a 3 month history of upper abdominal pain following meals. On questioning, he describes this pain as burning and is able to point to the pain on his abdomen. He reports having noticed his clothes have been looser recently, and has a long standing history of headaches. Which of these is the most important investigation to arrange?
H. Pylori breath test Full Blood Count OGD Endoscopy Trial of Proton pump inhibitor (PPI) Abdominal X-ray
OGD Endoscopy
What is Gastro-oesophageal Reflux Disease (GORD)
Reflux of stomach contents into the oesophagus
What are the symptoms of GORD
- Heartburn
- Regurgitation
- Dysphagia
- Coughing and/or wheezing
- Hoarseness, sore throat
- Non-cardiac pain
- enamel erosion
- enamel erosion or other dental manifestations
What are the risk factors for GORD
- Increased intra-abdominal pressure:
- obesity
- pregnancy - Lower oesophageal sphincter hypotension
- Drugs: anti-muscarinics, CCB, nitrates, smoking
- Treatment of achalasia (back up of food due to failure of the lower oesophageal sphincter to open)
- hiatus hernia - Gastric hyper-secretion
- Diet
- Smoking
- Zollinger Ellison’s syndrome
What is a hiatus hernia
portion of the stomach prolapses through the diaphragmatic oesophageal hiatus
What are the complications of a hiatus hernia
predisposing patient to reflux or worsening existing reflux
What are the risk factors for a hiatus hernia
- raised intra-abdominal pressure
2. defect in the wall
What are the symptoms of a hiatus hernia
Most are asymptomatic and are discovered incidentally
otherwise patient is likely to present with symptoms of GORD
What are the investigations for a hiatus hernia
- Barium swallow
- Chest X ray
- Endoscopy
What is management of a hiatus hernia
- conservative - risk factors modification
- pharmacological (PPI)
- Surgery - Nissen fundoplication
What are the investigations for GORD
- Clinical diagnosis
- trial of PPI
- OGD endoscopy
- biopsy (if endoscopy shows presence of oesophagitis or Barrett’s)
- consider other tests
In GORD, what investigations do you do if endoscopy is unrevealing
- ambulatory pH monitoring
- oesophageal manometry
- Barium swallow
- oesophageal capsule endoscopy
A 40 year old lady presents to her GP with heartburn and problems swallowing. She reports that the heartburn worsens at night, and is often accompanied by a ‘funny taste’ in her mouth and cough. She reports no change in weight or systemic symptoms. Which of these should be the next step?
UGI endoscopy Barium Swallow Manometry Serum gastrin levels Trial of Proton pump inhibitor (PPI)
Trial of Proton pump inhibitor (PPI)
What is the conservative management for GORD
- Diet: avoid precipitants and loose weight
- Sleep: head of bed elevation
- Stop smoking
What is the pharmacological management for GORD
- PPI (omeprazole 20mg daily)
2. H2 antagonist (ranitidine )
What is the surgical management for GORD
- Nissen fundoplication
What is the complications of GORD
GORD leads to Barrett’s which leads to adenocarcinoma
What is Barrett’s oesophagus
Metaplasia of the oesophagus due to chronic oesophagitis
What are the histological changes in Barrett’s oesophagus
Metaplasia
Squamous epithelium changes to columnar epithelium
What are the complications of Barrett’s oesophagus
11 x increased risk of oesophageal cancer
What is the initial management for Barrett’s oesophagus
Regular surveillance: endoscopy and biopsy
Barrett’s oesophagus: management for high grade dysplasia
- Radio-frequency ablation
2. PPI
Barrett’s oesophagus: management for a nodule
- endoscopic mucosal resection
2. PPI
What are the 2 types of oesophageal cancer
- Adenocarcinoma
2. Squamous cell
What are the symptoms of oesophageal cancer
- Progressive dysphagia from solids to liquids
- Burning chest pain
- Red flag symptoms - particularly weight loss, anaemia
oesophageal cancer: what is the location and risk factor for adenocarcinoma
- Lower third
2. Barrett’s
oesophageal cancer: what is the location and risk factor squamous cell carcinoma
- middle third
2. smoking + alcohol
What are the investigation s for oesophageal cancer
- OGD endoscopy and biopsy to diagnose/grade
2. CT to stage cancer
A 59 year old man presents with severe retrosternal burning pain. Upper GI endoscopy shows ‘metaplastic changes within the epithelium’. Which of these is the most likely diagnosis?
Gastric ulcer Gastric carcinoma Oesophageal carcinoma GORD Barrett’s oesophagus
Barrett’s oesophagus
What us dyspepsia
indigestion
What are the differential diagnosis of dyspepsia
- PUD
- Gastric cancer
- GORD
- Oesophageal cancer
- biliary pancreatic pathology
A patient comes in to the clinical with dyspepsia, what treatment algorithm do you use
<55 y/o, no red flag symptoms:
- Life style changes and drug review
- Trial of PPI/triple therapy
> 55 y/o and/or red flags
- UGI endoscopy
- Biopsy and histology
What is dysphagia
difficulty swallowing
What is high dysphagia
Associated with neuromuscular disase
[Think higher functions]
What is low dysphagia
Dysphagia due to obstruction or achalasia
Dysphagia: what is a functional abnormality
the muscles or the nerves supplying them are not functioning properly
Dysphagia: what is a structural abnormality
something in the way
What does intermittent dysphagia suggest
motility issue/neurological
What does progressive dysphagia suggests:
structural blockage
What does dysphagia with both solids and liquid suggest
functional abnormality (high dysphagia: Stroke, Parkinson’s; low dysphagia: achalasia)
What does dysphagia which progresses to from solid to liquid suggest
structural abnormality (cancer)
What are the symptoms of achalasia
- Dysphagia (solids and liquids)
- Regurgitation
- Dyspepsia
- weight loss
What is the aetiology of achalasia
- absence of oesophageal peristalsis
2. failure of lower oesophageal sphincter (LOS) to relax
Lower oesophageal sphincter is hypertensive in 50% of patients, what does this mean
Smooth muscle contracted too much
leading to failure of lower oesophageal sphincter to open and absence of oesophageal peristalsis
New-onset dysphagia in patients over 55 is what until proven otherwise
oesophageal cancer
How is dysphagia investigated
- barium swallow
- endoscopy
- Videofluroscopy
- Manometry
Dysphagia: why is a barium swallow conducted
For:
high dysphagia: avoid perforation on endoscopy
Low dysphagia: suspect achalasia
What is the first line investigation for low dysphagia (obstruction - cancer )
Endoscopy
In achalasia, what is the sign on a barium swallow
Bird’s beak
What is the pathophysiology of achalasia
Absence of ganglion cells in myenteric plexus
A-peristalsis
failure of LOS to relax
What are the investigations for achalasia
Barium swallow + manometry
A 28 year old lady presents with a 2-year history of mild dysphagia to both solids and liquids. She has no weight loss, but symptoms of heartburn and nocturnal cough. PPIs and bronchodilators haven’t helped. She is systemically well, and her examination is unremarkable. A “bird’s beak” appearance is noted on barium swallow. What is the most likely diagnosis?
Achalasia Benign stricture Plummer-Vinson syndrome Oesophageal spasm Stroke
Achalasia
A 76-year old retiree visits her GP with difficulty swallowing solids. She says this has been getting progressively worse over 1 month. There is no coughing, choking or heartburn. She reports food getting “stuck” 2-3 seconds after swallowing. She attributes her weight loss to not eating properly, and also thinks this has caused loose, brown-black stools. She feels tired. Bloods show a microcytic anaemia. Select the likely diagnosis:
Stroke Oesophageal cancer Pharyngeal pouch Plummer-Vinson syndrome Benign stricture
Oesophageal cancer
Although appropriate age for a stroke, the dysphagia is to solids and progressive, suggesting a obstructive course, not functional one. This is supported by absence of cough or choking. Pharyngeal pouch or benign stricture would not be accompanied by weight loss, tiredness and IDA.
Although Plummer Vinson may explain IDA, it wont account for melaena, it also would not typically be getting progressively worse.
Given systemic symptoms and age, plus other red flag symptoms proceed on suspicion of oesophageal cancer.
What is the best way to diagnose a pharyngeal punch
barium swallow
What is plummer vinson syndrome
combination of oesophageal wells (resulting in dysphagia) and iron deficiency anaemia
What are signs or severe iron deficiency anaemia
- Cheilosis (painful inflammation and cracking of the corners of the mouth)
- atrophic glossitis (soreness and redness of the tongue)
- Koilonychia (spoon-like nails)
What are 2 obscure causes of dysphagia
- limited cutaneous scleroderma
2. oesophageal spasm
What is a Mallory Weiss Tear
a tear in mucosal layer if the oesophagus
What can cause a Mallory Weiss Tear
Can occur after any event raising intragastric pressure, particularly vomiting
Following episode of severe vomiting due to alcohol, bulimia
How does a Mallory Weiss tear present
Blood streaked in vomit
remember: vomiting precedes bleeding
How is a Mallory-Weiss Tear diagnosed
endoscopy
What is the treatment for a Mallory-Weiss Tear
Resolves itself within 24-48 hrs
May need to be admitted if actively bleeding
What is Boerhaave syndrome
Full tear in the oesophageal wall
How do you diagnose Boerhaave syndrome
CXR/CT
will show pneumomediastinum
What is management for Boerhaave syndrome
Surgical management
What are the complications of Boerhaave syndrome
35% mortality
What is the clinical sign of pneumomediastinum on ascultation
Hamman’s sign: crunching sound on auscultation
What are oesophageal varices
extremely dilated sub-mucosal veins in lower third of oesophagus
What causes oesophageal varices
consequence of portal hypertension due to cirrhosis
What are the complications of oesophageal varices
Strong tendency to bleed - occurs in 10% of cirrhosis patients each year
What are the symptoms of oesophageal varices
- extreme haematemesis
- maybe unconscious or in shock (dropped bp)
- malaena
What are the investigations for oesophageal varices
- FBC (macrocytic anaemia, reduced platelets)
- LFTs (increased GGT and bilirubin and reduced albumin)
- U&Es (increased urea)
What is the management for an oesophageal varices
- ABCDE approach
- Fluids, regular monitoring
- Reduce portal HTN: Terlipressin
- Endoscopy: Band ligation is first line
What is the first line management of oesophageal varices
Endoscopy: band ligation
What drug is given to reduce portal HTN (in oesophageal varices)
Terlipressin
How does a ruptured peptic ulcer present
Coffee ground emesis
Malaena
What are the risk factors for a ruptured peptic ulcer
Background of PUD
- long term NSAID use
- H pylori infection
What are the investigations for a ruptured peptic ulcer
Observations: reduced blood pressure
FBC + LFTs are normal
What is the management of a ruptured peptic ulcer
- endoscopy: IM adrenaline at site of ulcer
- PPI e.g. Omprazole
- Triple therapy (if H pylori)
A 53-year old man staggers into A&E having vomited 6 times in 2 hours. He is intoxicated and jaundiced. His friend said his vomit was initially “normal”, but after the first couple of episodes had fresh blood in it. His blood pressure is 120/90 and HR 70 bpm. What is the most likely diagnosis?
Ruptured oesophageal varices Mallory-Weiss tear Ruptured peptic ulcer Boerhaave syndrome Oesophagitis
Mallory-Weiss tear
A 47 year old man is brought into A&E having vomited blood. His wife reports he developed food poisoning 2 days ago. Suddenly this morning he experienced extreme chest pain and began to vomit blood. His HR is 110 and BP 85/60. On auscultation of his chest you hear a crackling sound and his CXR shows pneumomediastinum. What is the most likely diagnosis?
Ruptured oesophageal varices Mallory-Weiss tear Ruptured peptic ulcer Boerhaave syndrome Myocardial Infarction
Boerhaave syndrome
