Upper GI Flashcards
Difference between gastritis and PUD?
Gastritis = histological presence of gastric mucousal inflammation
Ulcer: break in the mucousal lining of the stomch or duodenum with depth to the submucosa >5mm
Main causes of PUD?
H.Pylori as increased inflammatory response and mucousal permeability
NSAIDs = decrease gastric mucousal blood flow = loss of protective barrier
Zollinger-ellsion syndrome
Bisphosphonates, infections e.g. CMV, ICU stay >48hours, Crohns and idiopathic
What is Zollinger-Ellison syndrome?
Gastric acid hypersecretion by gastrin-secreting neuro-endocrine tumour.
PC: abdo pain, diarrhoea and multiple recurrent duodenal ulcers
HPC = MEN
Ix = Inreased fasting serum gastrin level >1000pg/ml
PC for PUD/Gastritis?
Abdo pain = POINTING SIGN
Related to eating
Nocturnal
N+V
Early satiety
Weight loss
Diarrhoea (think Zollinger)
Main tests for PUD/Gastritis?
H.Pylori (1st line) via urea breathe test or stool antigen
OGD (gold standard)
FBC = low Hb = anaemia, bleeding ulcer
IF Dyspepsia +>60 or weight loss +>55 = OGD 1st line
What is the treatment for H.Pylori?
Triple therapy
PPI = omeprazole
Clarithromycin
Amoxicillin (or metronadizole
Discontinue NSAIDS
How to manage acute bleeding in PUD/Gastritis?
OGD: adrenaline. clips and thermocoagulation
Use Blatchford score for patient needs
Rockall score for severity of GI bleeding
Difference where the ulcer is in PUD?
Gastric = 5-6th decade peak, NSAIDS>H.Pyloir, pain shortly after eating
Dueodenal = 4-5th decade peak, H.Pylori?NSAIDS, pain a few hours after eating and may radiate to the back
RFs for PUD?
Poor diet, NSAIDS< smoking, increasing age, high alcohol
Pathology of GORD?
Relaxation of LOS so reflux of grastric contents into the oesophagus
RFs for GORD?
OBESITY, HIATUS HERNIA, alcohol, smoking, Fhx, ol age, NSAIDS< acidic food e.g. coffee, mints, citrus
CCB can cause LOS relaxation
PC For GORD?
Heartburn (after meals and worse lying down or bending over) Acid regurgitation (bitter taste and after eating/waterbrash)
Other = dysphagia, bloating early satiety, laryngitis, halitosis and dyspepsia
Ix for GORD?
PPI trial for 8 weeks is 1st line
If persistent then DDx so OGD, oesophageal manometry and barium swallow
GORD management?
PPI trial for 8 weeks
Lifestyle changes: weight loss, bed elevation, avoid late ight eating, avoid chocolate, caffeine alcohol and acidic spicy foods
Adjuntc: H2 antagonists
Persistent GORD = fundoplication surgery
What are the complications of GORD?
Ulcer, bleeding, perforation, BArrets -> adenocarcinoma
Histology of Barrets?
Squamous epithelium -> columnar epithlium + intestinal metaplasia + goblet cells
RFs for Barrets?
Same as GORD GORD obesity smoing FHx Age
PC for Barrets?
Same as GORD with heartburn and regurgitation
Dysphagia (may indicate malignancy)
CHest pain
Ix for Barrets?
OGD + Biopsy = diagnostic
(show salmon colour mucosa and columnar lined epitheliun)
Barium oesophogram (if dysphagic)
Barrets management?
PPI + surveillance
Endoscopic ablation or resection
Fundoplication as anti-reflux surgery
Oesophagectomy
WHat is a hiatal hernia and types?
protrusion of the stomach through an enlarged oesophageal hiatus on the diaphragm
1 = sliding (most common 90%) 2 = para-oesophagela hernia/rolling 3 = mixed: sliding + rolling 4= giant hernai +stomach + 1 more structure)
RFs for hiatal hernia>
OBESITY, previous gastro-oesophageal proceudres
Elevated intra-abdomincal pressure
PMH of other hernias
PC of hiatus hernia?
GORD like: Heartburn, regurgitation, chest pain, dysphagia, odynophagia, haematemesis, SOB
Bowel sounds in chest and oropharyngitis
Ix for hiatal hernia?
CXR: retrocardiac air bubble = OSCE buzz
Upper GI series = barium swall / criterion test
OGD for dysplasia
CT/MRI for other patholgies
Management of hiatus hernia?
Lifestyle changes (1st line) = lose weight. elevate bd rest, avoid largem emas, avoid alcohol, acid foods
PPI
Correct defect = fundoplication (nissen = 360, Toupet = 270, Watson = 180
Complication of hiatus hernia?
Obstruction, volvulus, Upper GI bleed, irreversible necrosis or ischaemia of stomach
Gastric cancer type and RFS?
Most common = adneocarcinoma
Smoking, H.pylori, diet (salt, kow fruit and veg)
Familial, EBV infection and pernicious anaemia
PC for gastric cancer?
ABdo pain (epigastric and vague) FLAWS
Lymphaenopathy (Virchows) Sister mary joseph node = periumbilical Irish node (left axillary)
Gastric cancer Ix?
OGD and biopsy = 1st line
EUS + FNA CT/abdo pelvis for staging CXR PET Cancer = CEA or Ca19-9
What is the pathophysiology behind Achalasia?
Normally = inibitoary neurones release NO for LOS relaxation
Achalasia = loss of ganglion cells in myenetric pleux leads to series of inflammatory responses ending in destruction of post-ganglionic inhibitory neurones which contain NO so no NO or LOS relaxation
RFs for achalasia/
Autoimmunity Chagas disease Genes fro RH Allgrove syndrome Allgroves has triad of oesophageal achalasia, alacrime and adrenal insufficiency due to ACTH insensitivity
Features of Chagas disease?
AKA American trypanosomiasis by parasirt trypanosoma cruzi
Latin america
Associated with poverty and poor housing and apread by urine, faeces of kissingbugs?
PC of Chagas?
Dysphagi or liquids and solids and Odynophagia (also oesophageal cancer PC)
Hepatosplenomgealy
Abdo pain
Jaundice
Achalsia PC?
Dysphagia to liquids and solids Posturing to aid swallowing Restrosternal pressure/pain Regurgitation different to GORD Weight loss = gradual/mild
Achalasia Ix?
OGD + Biopsy = 1st line
Barium swallow = BEAK sign, loss of peristalsi and delayed emptying
High resolution manometry = diagnositc
CXR = absence of gastric bubble and dilated oesophagus
What is the pathophysiology of a Mallory-weiss tear?
Anything that increases intrabadominal pressure Vomiting (alcoholism) Coughing Straining Hiccups Trauma
RFs for Mallory-weiss tear?
ANy condition predisposing to vomiting, coughing, retchingm straining
Hiatal hernia
Significant alcohol use
PMH or recent endoscopy
PC of MW tear?
Haematemesis
Light headedness
Posturla hypotension
dysphagia, odynophagia, pain, haematochezia, shock, anaemia signs
OSCE haematemesis questions?
How many times, has it happened before, quantify bloods, what colour, associated pain and stool changes
IX for MW tear?
ABC 1st FBC (anaemia)and LFT for alocholic Cross match CXR - normal OGD is diagnostic ROCKALL score
Management for MW tear?
IV PPI
Anti-emetics
1st line endoscopy = adrenaline injection and band ligation. Maybe thermal, haemoclips or thermocoagulation
2nd line= Sengstaken-blakemore tube
Surgery = last cALL
What is a boerhaves perforsation?
Complication of MW tear and surgical emergency. Spontaneous due to force and RF = alcphl and obesity.
Retrosternal chest pain and crackling sounds on examination with decreased breath sounds
Pneumomediastiunnum on xray and needs surgery
what mediastinal structures can oesophageal cancer invade?
Trachea, bronchial tree, aorta, recurrent laryngeal nerve
Lungs, livers, lymph nodes
RFs for oesophageal cancer?
GORD and Barrets oesophagus
Smoking, alcohol and obesity
Diet low in fruit and veg
Fhx f upper Gi cancers
Types of oesophageal cancers?
Squamous cell = 15% and upper 2/3rds of oesophagus. RFs = smoking, alcohol and HPV
Adenocarcinoma = 80% and lower 1/4 and LOS. RF = chronic GORD amd barrets, obesity and diet.
Others = 5%
PC of oesophageal cancer?
Dysphagia Odynophagia Reflux Weight loss and FLAWS Hoarse voice from recurrent laryngeal nerve invasion Hiccups from phrenic nerve invasion
Oesophageal cancer Ix?
1st line = OGD and biopsy with biopsy as diagnostic
Metabolic profile and CT chest abdo, MRI for mets and PET scan
Oesophageal cancer management?
Early diagnosis = oesophagectomy
Intramuousal lesion = OGD removal
Late = CHemo +-radiotherapy + resection
