Upper GI

Question 1

Draw anatomy & blood supply of stomach

Answer 1

Lesser curvature: L gastric (from celiac artery), R . gastric (common hepatic)
Greater curvature: L gastro-epiploic (from splenic artery), R gastro-epiploic from gastroduidenal

Question 2

Differential diagnosis of dyspepsia

Answer 2

Functional dyspepsia (most common, idiopathic) 
GORD 
Gastritis 
PUD 
Hiatus hernia 
Gastric cancer

Question 3

Red flags of dyspepsia

Answer 3

ALARMS
Anaemia . 
Loss of weight 
Age >55
Recent onset 
Melena or haematemesis 
Swallowing difficulties - dysphagia or odynophagia

Question 4

What are the investigations for PUD?

Answer 4

Labs: FBC, iron studies, LFTs, lipase, UECs, CMP
Testing: H.pylori - serology, urease breath test, stool Ag
Endoscopy (indicated when red flags or not getting better with medical)
USS to exclude biliary disease
CT to investigate pancreatic cancer

Question 5

Treatment for PUD

Answer 5

non-pharmacological:

• reassure no significant underlying cause
• Diet: small meals and low fat (increase gastric emptying)
• Avoid smoking, alcohol and NSAIDs
• Screen & treat H.pylori
• PPI
• H2 receptor antagonist

Elective surgery for ulcers is rarely performed - only for complications (perforation, haemorrhage, gastric outlet or suspicion of malignancy)

Question 6

What is gastritis, the etiology and treatment

Answer 6

Inflammation of mucosa (confirmed by biopsy) with not ulceration
Acute: H.pylori, stress ulcers, chemical (NSAIDS, Alcohol)
Chronic: H.pylori, NSAIDs/Aspiring, Crohns

Treat avoiding trigger and treat H.pylori

Question 7

What is peptic ulcer disease and its etiology?

Answer 7

Defect in gastric or duodenal wall penetrating muscularis mucosal layer due to imbalance between normal defence mechanisms and damaging forces.

• H.pylori (Mostly duodenal)
• NSAIDS (mostly Gastric)
• Physiological stress

Question 8

What are the virulence factors of H.pylori?

Answer 8

Protease - breaks down mucous barrier
Urease - converts urea to NH3 (alkaline) which neutralises gastric acid
Flagella - motile in mucous

Question 9

How to diagnose H.pylori?

Answer 9

• Urea breath test - most accurate non-invasive test
• H.pylori serology (IgG)
• Stool H.pylori antigen test
• Biopsy with histologic identification (gold standard)

Question 10

How to treat H.pylori

Answer 10

Esomeprazole 20mg + Clarithromycin 500mg + amoxicillin 1g

Test eradication with urea breath test .

Question 11

What are the three most common sides of peptic ulcers?

Answer 11

1. Duodenal bulb in first part of duodenum
2. Antrum lesser curvature
3. Pyloric sphincter (angular incisura)

Question 12

Management of peptic ulcer bleed

Answer 12

Resuscitation (ABCDE) 
DRS - call general surgeons & gastro
A - ETT to protect airway  
B - O2 15L 
C - 2 large bore cannulas, send blood tests, IVF bolus, start blood products, activate MTP, IDC 

Ix: VBG, FBC, UEC (increased urea:creatinint), LFTs, coag studies, G&H, crossmatch

IV pantoprazole
Endoscopy - diagnose and stop bleeding (risk of rebleeding)
Surgical - open surgery for severe haemorrhagic shock or if endoscopy fails. Stop bleed and oversew ulcer.

In gastric ulcer bleed do erect CXR for pneumoperitoneum.
CT amdbomen with contrast gold standard for GI perforation

Question 13

Investigations and Management for gastric outlet obstruction

Answer 13

(Fibrosis of pylorus)
Blood gas - hypochloraemic metabolic alkalosis (loss of Cl- & H+ from vomiting)
UEC: hypokalaemia, hyponatremia

NGT: decompression of stomach
Correct electrolytes & acid bast disturbance (K+, IVFs
IV omeprazole
Surgical: pyloric dilation surgery, resection ob obstruction with gastrojejunostomy

Question 14

Complications of Hiatus Hernia

Answer 14

1. Strangulation
2. Gastric volvulus (twisting on own mesentary)
3. bleeding & anaemia
4. Palpitations (irritation of pericardium)