Upper GI Flashcards
What is GORD
Gastro-oesophageal reflux disease (GORD) is where acid from the stomach refluxes through the lower oesophageal sphincter and irritates the lining of the oesophagus
What type of lining does the oesophagus have
squamous epithelium
What type of lining does the stomach have
columnar epithelium
What is the presentation of dyspepsia
Heartburn Acid regurgitation Retrosternal or epigastric pain Bloating Nocturnal cough Hoarse voice
What can endoscopy be used to assess?
peptic ulcers
oesophageal or gastric malignancy
evidence of GI bleed
What are the key red flags for dyspepsia
Dysphagia (difficulty swallowing) at any age gets a two week wait referral Aged over 55 (this is generally the cut off for urgent versus routine referrals) Weight loss Upper abdominal pain / reflux Treatment resistant dyspepsia Nausea and vomiting Low haemoglobin Raised platelet count
What lifestyle advice is given to patients with dyspepsia
Reduce tea, coffee and alcohol Weight loss Avoid smoking Smaller, lighter meals Avoid heavy meals before bed time Stay upright after meals rather than lying flat
What are examples of acid neutralising medicines
Gaviscon
Rennie
What is the management of GORD
- Lifestyle advice
- Acid neutralising medications
- PPIs
- Ranitidine
- Surgery: laparoscopic fundoplication
What is ranitidine
This is an alternative to PPIs
H2 receptor antagonist (antihistamine)
Reduces stomach acid
What is laparoscopic fundoplication
tying the fundus of the stomach around the lower oesophagus to narrow the lower oesophageal sphincter.
What is helicobacter pylori?
- gram negative aerobic bacteria
- Buries into gastric mucosa to avoid the exposing the epithelial tissue to the acid
- Produces ammonia
- Causes gastric ulcers and increases risk of stomach cancer
What does producing ammonia in the stomach mean
neutralises the acid
directly damages the epithelial cells of the stomach
How do we investigate for helicobacter pylori
Urea breath test using radio-labelled carbon 13
Stool antigen test
Rapid urease test
What is a rapid urease test
CLO test (Campylobacter-like organism test)
- Performed during endoscopy
- Small biopsy of stomach mucosa
- add urea to sample, if H pylori present, urease enzymes will convert urea to ammonia
- Ammonia makes pH more alkali
How do we eradicate H. pylori
triple therapy:
- proton pump inhibitor (e.g. omeprazole)
- 2 antibiotics (e.g. amoxicillin and clarithromycin) for 7 days.
What is Barretts Oesophagus?
- Constant reflex of acid causes metaplasia of the squamous epithelium in the oesophagus to columnar
- Considered pre-malignant
Why is Barretts Oesophagus considered pre-malignant
3-5% lifetime risk of developing into adenocarcinoma
From columnar epithelium to high grade dysplasia
Monitored with endoscopy
What is the treatment of Barretts Oesophagus
- PPI
- regular aspirin can reduce rate of cancer - not in guidelines yet
- Ablation treatment
What is ablation treatment
- Photodynamic therapy, laser therapy or cryotherapy destroys the epithelium so that it is replaced with normal cells during endoscopy
- Only recommended if an element of dysplasia is present
What is a peptic ulcer
ulceration of the mucosa of the stomach (gastric ulcer) or the duodenum (duodenal ulcer). Duodenal ulcers are more common.
What are the causes of a stomach ulcers
Breakdown of the protective layer of the stomach and duodenum
Increase in stomach acid
Medications (e.g. steroids or NSAIDs)
Helicobacter pylori
What can increase acid production
Stress Alcohol Caffeine Smoking Spicy foods
What is the presentation of peptic ulcers
Epigastric discomfort or pain
Nausea and vomiting
Dyspepsia
Bleeding causing haematemesis, “coffee ground” vomiting and melaena
Iron deficiency anaemia (due to constant bleeding)
What type of ulcer causes more pain on eating
gastric ulcers
What type of ulcer improves pain on eating
duodenal
What investigations should be carried out for ? peptic ulcers
- Endoscopy
- rapid urease test (CLO test)
- Biopsy to rule out malignancy
What is the management of peptic ulcer disease
- High dose PPIs
What are the complications of peptic ulcers
- Bleeding
- Perforation
- Scarring and stricture: can lead to pyloric stenosis
What are the symptoms of pyloric stenosis
- upper abdominal pain
- distention
- nausea and vomiting, particularly after eating.
What is an upper GI bleed
Bleeding from the oesophagus, stomach or duodenum
What are the key causes of Upper GI bleed
Oesophageal varices
Mallory-Weiss tear, which is a tear of the oesophageal mucous membrane
Ulcers of the stomach or duodenum
Cancers of the stomach or duodenum
What is the presentation of an Upper GI bleed
- Haematemesis (vomiting blood)
- Malaena
- Haemodynamic instability
- Epigastric pain and dyspepsia in peptic ulcers
- Jaundice for ascites in liver disease with oesophageal varices
What is haematemesis
“Coffee ground” vomit. This is caused by vomiting digested blood that looks like coffee grounds.
What is malaena
tar like, black, greasy and offensive stools caused by digested blood
What is the Glasgow Blatchard Score?
- scoring system in suspected upper GI bleed on their initial presentation
- Establishes risk of Upper GI bleed
Why does urea rise in upper GI bleed
blood in the GI tract gets broken down by the acid and digestive enzymes. One of the breakdown products is urea and this urea is then absorbed in the intestines.
What is the management of an Upper GI bleed?
A - ABCDE
B – Bloods
A – Access (ideally 2 large bore cannula)
T – Transfuse
E – Endoscopy (arrange urgent endoscopy within 24 hours)
D – Drugs (stop anticoagulants and NSAIDs)
NB. it is NOT recommended to give PPI prior to endoscopy
What is the Rockalls Score?
Used in patients that have had an endoscopy to calculate their risk of rebleeding and overall mortality
What bloods must you send off in an acute Upper GI bleed
Haemoglobin (FBC) Urea (U&Es) Coagulation (INR, FBC for platelets) Liver disease (LFTs) Crossmatch 2 units of blood
What is the difference between group and save and a cross-match?
“Group and save” is where the lab simply checks the patients blood group and keeps a sample of their blood saved incase they need to match blood to it. “Crossmatch” is where the lab actually finds blood, tests that it is compatible and keeps it ready in the fridge to be used if necessary.
In a massive heamorrhage, what should be transfused
blood, platelets and clotting factors (fresh frozen plasma)
When should platelets be given in an Upper GI bleed
Active bleeding and thrombocytopenia (platelets < 50)
If a patient is on warfarin and is actively bleeding what should be given
Prothrombin complex concentrate
What additional steps should be taken if oesophageal varices are suspected
- Terlipressin
- Prophylactic broad spectrum antibiotics
- oesophagogastroduodenoscopy (OGD) to provide interventions that stop the bleeding
Features of achlasia
- Difficulty swallowing solids and fluids
- retrosternal chest pain
- regurgitation (usually bland)
- gradual weight loss
what do you see in barium swallowin achlasia
birds peak
what is the management of a barium swallow
- intra-sphincteric injection of botulinum toxin
- Heller cardiomyotomy
- pneumatic (balloon) dilation
- Nifidipine bridges until definitive surgery/not fit for surgery
Investigations for achlasia
- manometry: excessive LOS tone which doesn’t relax on swallowing
- barium swallow shows grossly expanded oesophagus, fluid level, ‘bird’s beak’ appearance
- CXR: wide mediastinum, fluid level
Which ulcer is relieved on eating
duodenal ulcer
What is Zollinger-Ellison syndrome
rare cause of ulcers characterised by excessive levels of gastrin, usually from a gastrin secreting tumour
