Upper GI Flashcards
What are the three main presentations that have upper GI causes?
- Dyspepsia- eg heartburn
- Dysphagia- difficulty swallowing
- Haematemesis- vomiting blood
What are the main GI conditions that cause dyspepsia?
- GORD
- Barrett’s oesophagus
- Peptic ulcer disease
What are the main GI conditions causing dysphagia?
- Oesophageal stricture
- Oesophageal web
- Oesophageal cancer
What are the main GI conditions that cause haematemesis?
- Perforated peptic ulcer disease
- Oesophageal tear
- > Mallory Weiss tear
- > Boerhaave’s perforation
SBA 1
45 year old female
2 month history of upper abdominal pain, 2-3 hours after meals
Blood tests (see picture attached)
Microcytic anaemia
Which of these is the most likely diagnosis?
A.GORD
B.Duodenal ulcer
C.Gastric ulcer
D.Biliary colic
E.Cholecystitis
B. Duodenal Ulcer
**SBA 2
61 year old male
3 month history of burning, localised, upper abdominal pain after meals
Weight loss
Long history of headaches
Which of these is the most important investigation to arrange? (and what is the most likely differential diagnosis?)
A. H. Pylori breath test
B. Full Blood Count
C. OGD Endoscopy
D. Trial of Proton pump inhibitor (PPI)
E. Abdominal X-ray
A.OGD Endoscopy
Important to rule out oesophageal/gastric cancer esp b/c over 55y and weight loss
Most likely diagnosis=
gastric ulcer
Headaches: either mets of gastric cancer
or NSAIDS for headache contributed to ulcer
SBA 3
40 year old lady
Heartburn and problems swallowing
Worse at night
Funny taste in mouth and when coughs
No change in weight + no systemic symptoms
Which of these should be the next step?
A.OGD endoscopy
B.Barium Swallow
C.Manometry
D.Serum gastrin levels
E. Trial of Proton pump inhibitor (PPI)
E. Trial of Proton pump inhibitor (PPI)
SBA 4
59 year old man
Severe retrosternal burning pain
Upper GI endoscopy= metaplastic epithelial changes
Which of these is the most likely diagnosis?
A.Gastric ulcer
B.Gastric carcinoma
C.Oesophageal carcinoma
D.GORD
E.Barrett’s oesophagus
E.Barrett’s oesophagus
Dyspepsia
Definition
Aetiology
Dyspepsia
Definition
Collection of (6) symptoms:
- Epigastric burning/pain- retrosternal (heartburn)
- Upper abdominal discomfort/indigestion
- Belching
- Nausea
- Early satiety/post prandial fullness
- Bloating
Aetiology
- Peptic ulcer disease
- Gastric cancer
Oesophageal cancer
GORD
Hiatus hernia
Barrett’s oesophagus
Biliary/pancreatic pathology
Non-ulcer dyspepsia
Peptic Ulcer disease
Definition
Types of ulcer
Aetiology
(Risk factors
Epidemiology)
Symptoms
Signs
Investigations + results
Management
Complications
Peptic Ulcer disease
Definition
Break in lining of stomach/upper GI tract
Types of ulcer
Gastric- pain on eating, avoid eating=weight loss
Duodenal- pain 2-3 hours after eating, wake up at night with pain , overeat=weight gain
Aetiology
Increased stomach acid- increased irritation- leads to break in stomach lining + inflammation
If erodes blood vesels= bleed
Some foods act like pepsin- break down stomach- eg pineapple
Risk factors
[in order of most common]
- H Pylori infection
- NSAIDs [less gastric prostagladins, impaired repair of mucosa]
- Smoking
- Alcohol
- Bisphosphonates
- Burns
- Head trauma
- Zollinger-Ellison syndrome
Epidemiology
Duodenal ulcers more common
Symptoms
- Dypepsia (heartburn + indigestion)
- Recurrent sharp burning/gnawing epigastric pain- related to eating
- Nausea and Vomiting
- Early satiety
- Sometimes- anorexia + weight loss
- Tiredness- anaemia
Signs
- Epigastric tenderness
- Pointing sign- can point to exactly where pain is
- Conjunctival pallor- anaemia
Investigations + results
Under 55 and no red flag symptoms:
- H Pylori- carbon urea breath test/stool antigen
- {FBC, serum gastrin [Zollinger ellison], faecal occult blood}
Over 55/red flag symptoms/PPI trial failed:
- Upper GI endoscopy
- Biopsy- histology + urease testing
- Repeat endoscopy in 6-8 weeks
Management
Conservative:
- Risk factor modification- diet, smoking, NSAIDs/bisphonates
Medical:
- PPI or histamine-h2 antagonist
- If H Pylori positive- triple therapy
[Treat anaemia if necessary]
Complications and management
Perforation
- Erect CXR- Ix
- NBM
- IV antibiotics
- Surgery
- Bleed [+ anaemia (due to blood loss)]
- Endoscopy +/- therapy=adrenaline
- IV PPI
- blood transfusion if needed
What is an additional symptom specific to duodenal ulcers?
Severe abdominal pain
Radiating to back
Has
H Pylori
What type of bacteria is it?
How common is it?
Where is it most common?
How many people who have it will develop an ulcer?
What does it cause?
What investigations are done?
What is the management?
H Pylori
What type of bacteria is it?
Gram negative flagellate
How common is it?
Prevalent in 50% of population
Where is it most common?
Developing countries
How many people who have it will develop an ulcer?
10%
What does it cause?
Inflammation of stomach and duodenum
What investigations are done?
Carbon urea breath test
Stool antigen test
What is the management?
Triple therapy- PPI + two antibiotics:
PPI
Clarithromycin
Amoxicillin/Metronidazole
What is Zollinger Ellison syndrome?
Cause?
[What condition is it associated with?]
Pathophysiology?
How many people with duodenal ulcers have it?
When to consider?
Investigations?
Management?
Prognosis?
Increased risk of ulcers
Neuroendocrine tumour secreting excess gastrin
In duodenal wall or pancreas
Cause?
Sporadic
or
Associated with MEN- 25% of cases
Pathophysiology?
Hypergastrinaemia
Hypertrophy of gastric mucosa + increased stimulation of acid secreting cells-> increased gastric acid
Ulcers and mucosal damage
Malabsorption- GI mucosal damage
Inactive pancreatic enzymes
How many people with duodenal ulcers have it?
0.1 – 1%
When to consider?
Multiple ulcers refractory to treatment
FH/other symptoms of MEN
Investigations?
Fasting serum gastrin
Serum calcium- other MEN symptoms, parathyroid
Gastric acid secretion levels
Stimulation tests
Imaging
Management?
PPI
Surgical resection if needed
Prognosis?
Good if not metastasised
- Don’t really need to know-
What is Curling’s Ulcer?
What is Cushing’s Ulcer?
What is Curling’s Ulcer?
Ulcer after severe burns
Reduced plasma volume -> ischaemia + necrosis of gasric mucosa
What is Cushing’s Ulcer?
Head trauma related ulcer- raised ICP stimulates vagus nerve- increased gastric acid
Gastric cancer
Epidemiology/which type is most common?
Symptoms
Signs
Risk factors
Investigations
Gastric cancer
Epidemiology/which type is most common?
Adenocarcinoma
Symptoms
Dyspepsia
Epigastric pain
FLAWS
Anorexia
Weight loss
Melaena
Haematemesis
Nausea/vomiting
Signs
Virchow’s node/Troisier’s sign- palpable lymph node in left supraclavicular fossa
Sister Mary Joseph’s node- metastatic node in umbilicus
Palpable epigastric mass
Risk factors
Peptic ulcer disease/chronic gastritis
H pylori
Smoking
Investigations
Endoscopy, biopsy + histology
GORD
What does it stand for?
Pathophysiology
Symptoms- oesophageal and extra oesophageal
Signs
Risk factors
Investigations
Management
Complications
GORD
What does it stand for?
Gastrointestinal Reflux Disease
Pathophysiology
Lower oesophageal sphincter doesn’t fully contract- allowing stomach contents back up
Symptoms- oesophageal and extra oesophageal
Oesophageal:
- Reflux/regurgitation
- Dyspesia
- Epigastric/retrosternal burning- Heartburn
Extra oesophageal:
- Coughing/wheeze- esp noctural/lying down
- Hoarse voice/sore throat- irritated vocal cords
- Chest pain- non cardiac
- Dental erosion
Signs
Risk factors
Anything that causes increased intra abdominal pressure:
Increased IAP:
Obesity
Pregnancy
Lower oesophageal sphincter relaxation/hypotension:
Treatment of achalasia
Hiatus hernia
Drugs- smooth muscle relaxers- antimuscarinic, ccb, nitrates
Smoking
Gastric hypersecretion
Diet
Smoking
Zollinger- Ellison syndrome
Investigations
Clinical diagnosis- if no red flag symptoms
Trial of PPI inhibitor- [if symptoms resolve=GORD]
If don’t resolve- look for other causes:
Endoscopy- upper GI
Biopsy
Consider other tests- barium swallow, manometry, capsule endoscopy ambulatory pH monitoring etc
Management
Medical: PPI or H2 antagonist
Conservative:
- Diet and weight loss
- Sleep with head elevated
- Stop smoking
- Stop taking drugs that may contribute
Surgical:
- Endoluminal gastroplication
- Nissen fundoplication- if due to hiatus hernia
- Future- Linx system- magnets
Complications
- Barrett’s oesophaguus
- Oesophageal carcinoma
What is a hiatus hernia?
Risk factors?
Symptoms?
Types?
Investigations?
Management?
Complications?
What is a hiatus hernia?
Herniation of part of the stomach through diaphragmatic oesophageal hiatus
Predisposes to/worsens reflux- wide hiatus
Risk factors?
Anything that causes herniation/increased intrabdominal pressure-
Obesity
Pregnancy
Ascites
Age- less muscle, less elasticity
Defect in containing wall
Symptoms?
Asymptomatic or signs of GORD
Types?
Sliding
Paraoesophageal
Investigations?
Barium swallow
Chest X ray
Endoscopy
Management?
Conservative: risk factor modification
Medical: PPI
Surgery- Nissen fundoplication
[Also toupet procedure variant, belsey fundoplication, hill repair]
Complications?
Can become strangulated
Barrett’s oesophagus
Definition
Pathophysiology
What is seen on endoscopy?
What does it predispose you to?
Investigations
Management
Barrett’s oesophagus
Definition
Metaplasia due to chronic oesophagitis
Pathophysiology
GORD- exposure to excess acid
Squamous cell epithelium-> columnar epithelium
What is seen on endoscopy?
Tongues of gastric mucosa
What does it predispose you to?
Oesophageal adenocarcinoma - by 11x
Investigations
Endoscopy + biopsy + histology
Regular surveillance
Management
PPI
If high grade dysplasia: radiofrequency ablation
If nodule: endoscopic mucosal resection
Oesophageal cancer
Types
Symptoms
Investigations
Oesophageal cancer
Types
Adenocarcinoma-more common-lower third
Squamous cell carcinoma- middle third
Risk factors
Adenocarcinoma- Barrett’s
Squamous cell carcinoma- Smoking, alcohol
Symptoms
Progressive dysphagia- solids first, then liquids
FLAWS
Burning chest pain
Investigations
Upper GI endoscopy, biopsy, histology
Staging: CT
What are the differential diagnoses of dyspesia?
Peptic ulcer disease
GORD
Gastric cancer
Oesophageal cancer
Biliary/pancreatic
Functional/non-ulcer dyspesia- negative endoscopy
How do you investigate dypepsia if <55 years old and no red flags?
Conservative: risk factor management
- Stop smoking
- Stop taking drugs that worsen - eg NSAIDs
- Diet
Pharmacological: Trial PPI
or test for H Pylori [breath test/stool antigen] and give triple therapy
What investigations do you do for dyspepsia in >55 year old/ someone with red flag symptoms/ someone who’s had a failed PPI trial?
Upper GI endoscopy
Biopsy and histology
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?
A.Achalasia
B.Benign stricture
C.Plummer-Vinson syndrome
D.Oesophageal spasm
E.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:
A.Stroke
B.Oesophageal cancer
C.Pharyngeal pouch
D.Plummer-Vinson syndrome
E.Benign stricture
Oesophageal cancer
Table classifying causes of dysphagia
High vs low dysphagia
Functional vs structural dysphagia
Achalasia
Definition
Dysphagia due to:
Inability of lower oesophageal sphincter to relax
Oesophageal dysmotility- aperistalsis
Aetiology
Inability of lower oesophageal sphincter to relax
Oesophageal dysmotility- aperistalsis
Like reverse of GORD
Pathophysiology
Absence of ganglion cells in myenteric [Auerbach] plexus
Symptoms
Dysphagia- both solids AND liquids, intermittent
Regurgitation
Dyspepsia
Weight loss
Investigations
Barium swallow- bird’s beak
If nothing seen: Manometry
[What diseases are related/differentials?]
Achalasia
Definition
Dysphagia due to:
Inability of lower oesophageal sphincter to relax
Oesophageal dysmotility- aperistalsis
Aetiology
Inability of lower oesophageal sphincter to relax
Oesophageal dysmotility- aperistalsis
Like reverse of GORD
Pathophysiology
Absence of ganglion cells in myenteric [Auerbach] plexus
Symptoms
Dysphagia- both solids AND liquids, intermittent
Regurgitation
Dyspepsia
Weight loss
Investigations
Barium swallow- bird’s beak
If nothing seen: Manometry
[What diseases are related/differentials?
Hirschprung’s disease- megacolon of the intestine- congenital
Chagas’s disease- pseudo-achalsia
Carcinoma]
Table investigating dysphagia
What features distinguish oesophageal cancer from achalasia?
Age
Onset
Type of dyphasia
Course of symptoms
Red flag symptoms
Investigations
Oesophageal cancer - progresses from solids to liquids
Achalasia- always solids and liquids
What are the neurological causes of dysphagia?
What symptoms point towards a neurological cause?
What underlying conditions does cranial nerve pathology point to?
Stroke
Parkinson’s
MS
What symptoms point towards a neurological cause?
- Coughing- immediately after eating
- Choking
- Slow eating
- Early dysphagia for LIQUIDS
- [Functional dysphagia]
What underlying conditions does cranial nerve pathology point to?
- MND- pseudobulbar palsy
What other rarer causes of dysphagia are there?
- Plummer Vinson- oesophageal web with iron deficiency anaemia
- Pharyngeal pouch
- CREST syndrome [corkscrew oesophagus on barium swallow]
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?
A.Ruptured oesophageal varices
B.Mallory-Weiss tear
C.Ruptured peptic ulcer
D.Boerhaave syndrome
E.Oesophagitis
B.Mallory-Weiss tear
NB: ruptured varices WOULD NOT start with normal vomiting of blood- would be sudden vomiting of fresh blood, and unlikely to be normotensive
Ruptured peptic ulcer= coffee ground vomit
Boerhaave= sudden onset severe retrosternal pain + haemodynamc compromise
Oesophagitis- no bleeding
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?
A.Ruptured oesophageal varices
B.Mallory-Weiss tear
C.Ruptured peptic ulcer
D.Boerhaave syndrome
E.Myocardial Infarction
D- Boerhaave syndrome
Complete tear/perforation of oesophagus- pneumomediastinum
This is what causes crackling on auscultation
Due to vomiting from food poisoning
Mallory Weiss tear
Definition
Aetiology
Epidemiology
Symptoms/Signs
Investigations
Prognosis
Mallory Weiss tear
Definition
Tear in the mucosal layer of the epithelium
Longitidunal
Usually at gastro oesophageal junction
Aetiology
Due to severe vomiting or any other event causing a rise in intragastric pressure- eg TOE
Epidemiology
Young binge drinker, middle aged male
Symptoms/Signs
Blood streaked in vomit
Preceded by normal vomiting
Investigations
Endoscopy
Prognosis
Self resolves in 24-48 hr
Admit to hospital if actively bleeding
Boerhaave’s perforation
Definition
Aetiology
Epidemiology
Symptoms
Signs
Investigations
Boerhaave’s perforation
Definition
Tear in the full thickness of the oesophagus due to vomiting
Complication of Mallory Weiss tear
Aetiology
Severe vomiting
[Tears due to other pathology called oesophageal rupture, NOT boerhaave’s tears]
Trauma
Epidemiology
Male middle aged, alcoholic
Symptoms
Profuse vomiting of frank blood
Chest pain [retrosternal]
Signs
Haemodynamic collapse/shock:
Hypotension
Tachycardia
Crackling sound on ausculation
Pneumoperitoneum
Investigations
CXR - to look for pneumoperitoneum [not the same as perforated viscus]
CT
Management
Surgical
Complications
Subcutaenous emphysema
Pleural effusion
Pneumothorax
Widened mediastinum
Prognosis
35% mortality
Mackler’s triad includes chest pain, vomiting, and subcutaneous emphysema (air trapped in subcutaneous tissues), and while it is a classical presentation, it is only present in 14% of people
Oesophageal varices
Definition
Aetiology
Risk factors
Symptoms and signs
Investigations
Management
Oesophageal varices
Definition
Extremely dilated sub mucosal veins at point of anastomosis, in lower third of oesophagus
Can rupture and bleed- happens commonly
Aetiology
Portal hypertension
due to liver disease/cirrhosis
Risk factors
Alcohol
Chronic liver disease
Symptoms and signs
Extreme vomiting of frank blood
[blood is under high pressure]
Haemodynamic shock:
Tachycardia
Hypotension
Unconscious
Investigations
Endoscopy- also used for management
Signs of cirrhosis:
FBC- macrocytic anaemia, low platelets
LFT- high GGT, high bilirubin, high albumin
Clotting- low clotting factors- predict rebleeding risk
U+E- high urea
Management
ABCDE- IV fluid + monitoring
Immediate:
IV terlipressin
IV antibiotics
Endoscopy + band ligation- GOLD STANDARD
[second line endoscopy with sclerotherapy/balloon]
Sengstaken - Blakemore tube- balloon inflation compressing varices- if delay in endoscopy
If that doesn’t work- TIPS- transjugular intrahepatic portal vein shunt
Ruptured/bleeding peptic ulcer
[different to perforated peptic ulcer- full perforation of GI wall]
Presentation
Investigations
Management
Ruptured/bleeding peptic ulcer
[different to perforated peptic ulcer- full perforation of GI wall]
Presentation
Background/symptoms of peptic ulcer disease [some people with ulcer may be asymptomatic until bleeding happens]
Coffee ground vomit [haematemesis]
Melaena
Risk factors
H Pylori
Long term NSAIDS
[same as peptic ulcer disease]
Investigations
Hypotension- low blood pressure
FBC- normal
LFT- normal
[rule out hepatic cause- varices]
Management
Endoscopy + IM adrenaline at site of ulcer to vasoconstrict
Then treat ulcer:
PPI
If H pylori- triple therapy
What are the two main conditions that you can get both haematemesis and melaena with?
Ruptured/bleeding gastric ulcer
Gastric cancer
What is high vs low dysphagia?
High dysphagia- mouth, immediate swallowing
Low dysphagia- lower oesophageal sphincter
In practice - v difficult to patient to differentiate
What is the difference between structural and functional dysphagia?
Structural - physical blockage of passage of food
Functional- oesophageal dysmotility, muscle problems when swallowing
