Upper GI Flashcards
PUD, Zollinger-Ellison, gastric cancer, hiatus, GORD, oesophageal
What is the definition of peptic ulcer disease?
Break in the epithelial lining of the gastrum or duodenum
What are the symptoms of PUD?
Recurrent epigastric pain
(pointing sign- can point to exact site of pain)
Related to eating
Nocturnal- varies am-pm
Early satiety
Nausea and vomiting
Potential anorexia and weight loss (if>55 = 2WW urgent OGD)
Diarrhoea (ZE syndrome)
What are the signs of PUD?
Epigastric tenderness Pointing sign (able to locate specific pain) Anaemic signs (if bleeding)
Are duodenal or gastric ulcers more common?
Duodenal ulcers
What are the key characteristics of duodenal ulcers?
Pain 2-3 hrs after eating
Antacids relieve pain
Weight gain due to overeating
What are the key characteristics of gastric ulcers?
Pain shortly after eating
Antacids don’t relieve pain
Weight loss due to undereating
What are the risk factors for PUD?
- H pylori- induces a severe inflammatory response and increased mucosal permeability.
- NSAIDS
Bisphosphonates Smoking Head trauma (Cushing ulcer) Zollinger Ellison syndrome CMV (in HIV pts) Crohn’s disease
What is the mechanism of NSAID induced PUD?
NSAIDs inhibit COX1
Decreased prostaglandin production decreases mucosal protection
Decreased thromboxane reduces gastric mucosal blood flow
What type of bacteria is Helicobacter pylori?
Gram negative rod flagellate
What investigations can be done for a H pylori-induced ulcer?
13C urea breath test (stop PPI before test)
Stool antigen test
Serology- Antibodies ( less accurate)
What is the treatment for H pylori-induced ulcers?
TRIPLE THERAPY
- PPI
- Clarithromycin
- Amoxicillin OR metronidazole
What are the complications of a H pylori-induced ulcer?
Perforation
Gastric carcinoma
Lymphoma
Define Zollinger-Ellison syndrome
A syndrome of gastric acid hypersecretion caused by a gastrin secreting pancreatic neuro-endocrine tumour (gastrinoma)
When should you consider Zollinger-Ellison syndrome?
Multiple peptic ulcers refractory to treatment
FHx of MEN
What specific investigations should you do on a Pt with Zollinger-Ellison syndrome?
Fasting serum gastrin (very high)
Serum calcium (parathyroid tests)
Gastric acid secretory tests
What is the management for Zollinger-Ellison syndrome?
PPI
Surgical resection
What is the prognosis for Zollinger-Ellison syndrome?
Good, as long as the tumour has not metastasised
How does Cushing’s ulcer occur?
Head trauma
Raised ICP
Increased vagal stimulation
Increased gastric acid secretion
How does Curling’s ulcer occur?
Severe burn injuries
Reduced plasma volume
Ischaemia and necrosis of gastric mucosa
What is the treatment for H pylori negative ulcers?
Stop making it worse: diet, smoking, NSAIDs, bisphosphonates
MEDICAL (4-6 weeks)
1st line: PPI
2nd line: H2 antagonist (ranitidine)
How would you manage a haemorrhagic (acutely bleeding) ulcer?
Visualise bleed (OGD) Adrenaline Clips Thermocoagulation IV PPI \+/- transfusion
How would you manage a perforated ulcer?
NBM
IV ABx
Surgery
What is the most common gastric cancer?
Adenocarcinoma
What are the symptoms of gastric cancer?
Epigastric pain
Nausea + vomiting
Anorexia, weight loss (FLAWS)
What are the risk factors of gastric cancer?
Smoking H pylori (inflammation) Diet - high salt, low fruit + veg, n-nitroso compounds (cured meats) Chronic gastritis EBV Pernicious anaemia
What are the signs of gastric cancer O/E?
Lymphadenopathy = signs of metastatic abdominal malignancy:
- Palpable Virchow’s (left supraclavicular) node (aka Troisier’s sign)
- Sister Mary Joseph nodule – Periumbilical mass
- Irish node – Left axillary
[NB: these are non-specific for abdominal cancer, not just gastric]
There may be a palpable epigastric mass
Define GORD
Symptoms or complications resulting from the reflux of gastric contents into the oesophagus or beyond, into the oral cavity or lung
What may a Pt with GORD present with?
Heartburn = burning sensation in the chest after meals
Worst on lying down/bending over
Acid regurgitation
waterbrash
Mainly post-prandial (=after eating)
Dysphagia (think achalasia) Bloating early satiety (rule out cancer) Laryngitis/hoarseness (corosion from acid regurg) Halitosis (= bad breathe) Dyspepsia (= difficulty digesting) Coughing/wheezing Non-cardiac chest pain Enamel erosion
What are the risk factors for GORD?
Increased intra-abdominal pressure:
- Obesity
- Pregnancy
Lower oesophageal sphincter hypotension: Alcohol Smoking FHx Old Age Hiatus hernia
Gastric acid hypersecretion:
Acidic food: coffee, mints, citrus
Drugs (NSAIDs, anti-muscarinics, CCBs, nitrates, smoking)
Zollinger Ellison syndrome
What are the types of hiatus hernias?
Congenital vs acquired
Acquired can be: traumatic vs non-traumatic
NT can be: sliding vs para-oesophageal
What are the risk factors for hiatus hernias?
Similar to GORD Muscle weakening w/ age Pregnancy Obesity Abdominal ascites
What investigations would you do on a Pt with a hiatus hernia?
Barium swallow
Chext x-ray
Endoscopy
What is the management for a Pt with a hiatus hernia?
Risk factor modification
PPIs
Nissen fundoplication
What is the investigation for a Pt with GORD?
NA
GORD is a clinical diagnosis
What is the management for a Pt with GORD?
Conservative:
- Avoid precipitants/lose weight
- Sleep with more pillows
- Stop smoking
Medical:
-PPI/H2 antagonist
Surgical:
- Nissen fundoplication (if HH is the cause)
- Endoluminal gastroplication
What if the GORD symptoms persist/get worse after a trial of PPIs?
Endoscopy
What may be seen upon endoscopy of a Pt with GORD?
Oesophagitis
Barrett’s
What are the complications of GORD?
Ulcer, Bleeding, Perforation
Metaplasia –> Barret’s oesophagus –> Dysplasia –> adenocarcinoma
What is Barrett’s oesophagus?
The change in the normal squamous epithelium of the oesophagus to specialised intestinal metaplasia due to chronic oesophagitis
What is the histological change in Barrett’s oesophagus?
Squamous epithelia > columnar-lined epithelium
(± intestinal metaplasia) + goblet cells
Barret’s is a HISTOLOGICAL diagnosis
What is the risk of oesophageal cancer for a Pt with Barrett’s?
11 times
What is the management for high grade dysplasia Barrett’s?
Radiofrequency ablation
PPIs
What is the management for nodule dysplasia Barrett’s?
Endoscopic mucosal resection
PPIs
Dysplasia associated with macroscopically visible lesions, such as ulcers, nodules or polyps, carry a high risk of synchronous or metachronous adenocarcinoma
What are the symptoms of oesophageal cancer?
Progressive dysphagia from solids to liquids
Burning chest pain
Red flag symptoms (weight loss, anaemia)
What are the two types of oesophageal cancer?
Adenocarcinoma (80%) Squamous cell (15%)
Where are oesophageal adenocarcinomas located and what are the associated risk factors?
Lower 1/3 = distal oesophagus, LOS
RF:
Chronic GORD –> Barret’s, Obesity, Diet
= RF of GORD as well (H. Pylori etc..)
Where are oesophageal squamous cell carcinomas located and what are the associated risk factors?
Upper 2/3 of oesophagus
Smoking, alcohol
What are the investigations for a Pt with oesophageal cancers?
OGD endoscopy and biopsy- FIRST LINE + DIAGNOSTIC
Others:
- CT chest/abdo – monitor progress of tumor(s)
- MRI – ID distant mets
- FDG – PET scan - mets & monitoring
How can dysphagia be categorised?
High or low dysphagia
Functional or structural
What are the causes of functional high dysphagia?
Stroke Parkinsons Myaesthenia gravis MS MND
What are the causes of structural high dysphagia?
Cancer
Pharyngeal pouch
What are the causes of functional low dysphagia?
Achalasia
Oesophageal spasm
Limited cutaneous scleroderma (CREST syndrome)
Chagas disease
What are the causes of structural low dysphagia?
Cancer
Stricture
Plummer-Vinson syndrome
Foreign body
What are the symptoms of achalasia?
Dysphagia- solids AND liquids
Posturing to aid swallowing
Retrosternal Pressure/Pain
Regurgitation
- Different to GORD taste (not sour = not gastric contents)
Weight loss
- Gradual/Mild
- If rapid = think malignancy
NO PAIN ON SWALLOWING- IF PAIN THINK CANCER
What is the cause of achalasia?
Absence of oesophageal peristalsis
Failure of LOS relaxation
Due to loss of ganglion cells in myenteric plexus
In what situation should you assume dysphagia is due to oesophageal cancer?
New onset dysphagia
Age >55
Carcinoma until proven otherwise
What are the potential investigations for dysphagia?
Barium swallow
Endoscopy
Videofluoroscopy
Manometry
When would you consider the use of a barium swallow?
Pharyngeal pouch- avoid perf on endoscopy
Achalasia
Hiatus hernia
When would you consider the use of endoscopy?
First line, most specific and sensitive
When would you consider the use of videfluoroscopy?
Used by SALT as a treatment
Can help modify a Pt’s swallowing technique
When would you consider the use of manometry?
Useful for achalasia/oesophageal spasm
Often used only when other investigations are unremarkable
What is a Mallory-Weiss tear?
Tear/laceration in the mucosal layer of the oesophagus near the GOJ as a result of increased abdominal pressure
What is the cause of a Mallory-Weiss tear?
ANYTHING TO INCREASE INTRABDOMINAL PRESSURE (with low/unchanged intra-thoracic pressure)
Vomiting
- Alcoholism
- food poisoning
- gastroenteritis
- hyperemesis gravidarum
- bulimia
Coughing
- Whooping cough, COPD, Lung Ca
Straining
- Constipation
Hiccups
- Oesophageal ca?
Trauma
Acute abdominal blunt trauma
How do you diagnose a Mallory-Weiss tear?
Endoscopy
What is Boerhaave syndrome?
Full tear of the oesophageal wall, complication of a Mallory-Weiss tear
Spontaneous or due to force (as discussed previously)
What investigations would you do on a Pt with Boerhaave syndrome?
Check for pneumomediastinum:
CXR
CT Chest
What are you looking for in a CXR/CT of a Pt with Boerhaave syndrome?
Pneumomediastinum
Can also see pleural effusion, pneumothorax, wide mediastinum, subcutaneous emphysema
What is the management for a Pt with Boerhaave syndrome?
Analgesic, antiemetic, fluid rescusitation
Surgical management
What is Mackler’s triad for Boerhaave syndrome?
Chest pain
Vomiting
Subcutaneous emphysema
What are oesophageal varices?
Dilated submucosal veins in lower third of oesophagus
What is the cause of oesophageal varices?
Portal hypertension
Due to cirrhosis
What is the presentation of oesophageal varices?
Extreme haematemesis
May be unconscious/in shock
Malaena
What investigations would you do on a Pt with oesophageal varices?
FBC- macrocytic anaemia, dec platelets
LFT- inc GGT, inc bilirubin, dec albumin
U+E- inc urea
(signs of alcoholism/cirrhosis)
What is the management of a Pt with oesophageal varices
ABCDE
Fluid resus
Terlipressin- reduce portal hypertension
Endoscopy- band ligation is first line
What is the presentation of a ruptured peptic ulcer?
Background of PUD
(Long term NSAID use/H pylori infx)
Coffee ground emesis
Malaena
What investigations would you do for a Pt with a ruptured peptic ulcer?
BP- low
FBC/LFTs- normal (rule out varices)
Endoscopy
What is the management for a Pt with a ruptured peptic ulcer?
Endoscopy w/ IM adrenaline at site of ulcer
PPI
Triple therapy if H pylori infx
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, which shows microcytic anaemia and normal LFTs. Which of these is the likely diagnosis?
A. GORD B. Duodenal ulcer C. Gastric ulcer D. Biliary colic E. Cholecystitis
B. Duodenal ulcer
Normal LFts rules out biliary colic. Microcytic anaemia indicates blood loss, and having a few hours’ interval between the pain indicates a duodenal ulcer.
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?
A. H. pylori breath test B. Full blood count C. OGD endoscopy D. Trial of proton pump inhibitor (PPI) E. Abdo XR
C. OGD endoscopy
The diagnosis is likely to be an ulcer due to the burning pain and pointing sign. However there is a risk of this being cancer due to the weight loss and age >55. Therefore this case should be referred for an endoscopy asap. The headache can be indicative of 2 things:
A. a SOL metastasis
B. a headache which is treated with a long term use of NSAIDs, leading to a potential ulcer
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?
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)
This is a classic presentation of GORD, for which a PPI trial is both diagnostic and therapeutic.
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?
A. Gastric ulcer B. Gastric carcinoma C. Oesophageal carcinoma D. GORD E. Barrett’s oesophagus
E. Barrett’s oesophagus
The latter 3 are more likely than the first 2, however the histological description is characteristic of Barrett’s oesophagus.
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
A. Achalasia
Bird-beak is characteristic of 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
B. Oesophageal cancer
A pharyngeal pouch or benign stricture would not cause weight loss. A solid dyphagia and progressive dysphagia means a stroke is unlikely. Although PV syndrome may explain the IDA, it doesn’t explain the malaena or the worsening progression.
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
This is unlikely to be a variceal rupture, as they present with sudden vomiting of fresh blood, whereas this case had a period of normal blood followed by bleeding afterwards. The is not in shock, hence further ruling out a varix or Boerhaave syndrome. A ruptured ulcer would present with abdominal pain and coffee ground blood.
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
This patient presents with Mackler’s triad: chest pain, emesis, and subcutaneous emphysema. The CXR also shows air in the mediastinum, and the food poisoning indicates a history of abdominal straining.
3 uses of endoscopy
- Visualise – investigative
- Take biopsies – diagnostic
- Treat
(adrenaline injections, banding, removal of polyps)
Define gastritis
The histological presence of gastric mucosal inflammation.
Can result in ulcers
Define gastric ulcer
A break in the mucosal lining of the stomach or duodenum with depth to the submucosa. (>5mm)
Signs and symptoms of Zollinger-Ellison Syndrome
Abdominal pain, diarrhoea
Multiple recurrent duodenal ulcers
Zollinger-Ellison Syndrome is associated with what genetic syndrome?
MEN1
Hereditary tumour syndrome characterised by the development of multiple endocrine tumours
ZE syndrome triad
Zollinger-Ellison Syndrome refers to a triad of
(i) severe peptic ulcer disease
(ii) gastric acid hypersecretion and
(iii) gastrinoma
ZE syndrome characteristic finding
a fasting gastrin level of>1000 pg/ml.
Which patients may commonly present with ZE syndrome?
Young males
FHx MEN1
Investigations for PUD- explain each Ix
H Pylori testing = FIRST LINE
Urea breathe test (carbon 13)
Stool antigen test
Serology- Antibodies ( less accurate)
OGD = GOLD STANDARD DIAGNOSTIC
Visualise lesion
Biopsy = H Pylori (?malignant)
Treat if bleeding ( clips, adrenaline )
FBC
Low Hb = anemia, bleeding ulcer.
When would OGD be first line investigation for PUD?
If dyspepsia + >60yo
If weight loss + >55yo
RULE OUT GASTRIC CANCER
What lifestyle changes would you advise for patients with PUD/GORD?
Weight loss smoking cessation Head of bed elevation Avoid late night eating Avoid: chocolate, caffeine, alcohol, acidic/spicy foods discontinue NSAIDs/bisphosphonates
Compare peptic/duodenal ulcers:
- age of onset
- aetiology
- pain
GASTRIC
- peak 50s-60s
- NSAIDs > H.pylori
- Pain shortly after eating
DUODENAL
- peak 40s-50s
- H.pylori > NSAIDs
- Pain a few hours after eating, may radiate to back
Which structural weakness is associated with GORD?
lower Oesophageal sphincter
How do you investigate/manage GORD?
PPI TRIAL (8 weeks) = FIRST LINE “investigation”
If persistent symptoms or other ddx in mind:
OGD
- Normal or signs of erosion, ulcers, strictures or Barrets
Oesophageal manometry
- May suggest achalasia if LOS seems relaxed.
Barium Swallow
- Visualise GI tract in detail
What surgical intervention could be done to manage refractory GORD?
Fundoplication surgery
Epidemiology of Barret’s
Linked to GORD incidence (same RF as GORD)
Increases with age
M > F
White people
RF for Barret’s
GORD*
Obesity
Smoking
FHx
How does Barret’s present?
Same as GORD- present exactly the same
Heartburn
Regurgitation
Dysphagia (?malignancy)
Chest pain
Which investigation is diagnostic + gold standard for Barret’s?
OGD + biopsy
- on endoscopy = salmon coloured mucosa. Z line migration (boundary between oesophageal and gastric epithelium migrated upwards)
- on histology = areas of columnar epithelium
Which investigation would you do in a patient with Barret’s who is also dysphagic?
Barium Oesophagogram
To visualize strictures
Also consider cancer
Management of Barret’s
PPI + Surveillance - high risk of adenocarcinoma
Endoscopic radiofrequency ablation / resection
Anti-reflux surgery
Fundoplication
Oesophagectomy (cancer)
Define hiatus hernia
the protrusion of the stomach through an enlarged oesophageal hiatus on the diaphragm
What is the most common type of hiatus hernia?
Type 1 – Sliding - stomach slides in and out of the chest cavity through the oesophageal hiatus
= 90% hiatus hernias
What are the 4 types of hiatus hernia?
Type 1 – Sliding * MOST COMMON (~90%)
Type 2 – Para-oesophageal hernia / Rolling hernia
Type 3 – Mixed: Sliding + Rolling
Type 4 – Giant hernia, stomach + 1 more structure
Hiatal hernias have a close association with which disease?
GORD- if stomach is herniating, LOS is not functioning correctly leading to reflux
RF for hiatus hernia
Obesity*
Previous gastro-oesophageal procedures
Elevated intra-abdominal pressure
PMH of other hernias
epidemiology for hiatus hernia
Western countries
M>F
Presentation of hiatus hernia
Basically the same as GORD:
Post-prandial heartburn + water brash/regurgitation
- worse on lying down
Other: Chest pain (angina pectoris ddx) Dysphagia Odynophagia Haematemesis - if complicated SOB – decreased lung expansion (no space)
Signs of hiatus hernia O/E
Bowel sounds in chest
Oropharyngitis - regurgitation causes inflammaiton at back of mouth
Investigations for hiatus hernia
CXR
Retrocardiac air bubble (could be normal)
Upper GI series- barium swallow
OGD
Check for dysplasia
CT/MRI
Suspecting other pathologies
How is hiatus hernia managed? (conservative, medical, surgical)
First line- LIFESTYLE CHANGES
- Same as GORD: lose weight, elevate bed rest, avoid large meals, avoid alcohol/acidic foods
Medical:
- PPI
Surgical:
- open/laproscopic fundlopication (Nissen)
- Gastric fundus is wrapped (plicated) around the LOJ
- strengthens LOS + increases size so cannot herniate
Prognosis hiatus hernia
Mostly asymptomatic
Managed as GORD
Surgery last resort – curative for a few years.
Complications of hiatus hernia
Surgical Emergencies:
- Obstruction (strangulation)
- Volvulus
- Upper GI Bleed
- Irreversible Ischaemia/Necrosis of the stomach
Investigation for gastric cancer
1st line + diagnostic = OGD + biopsy
Endoscopic US with FNA (other way of visualising and biopsy)
Bloods: cancer markers = CEA, CA 19-9
Staging:
CT abdo/pelvis
CXR
Name the layers of the oesophagus form lumen outwards
mucosa
submucosa
muscularis propria
adventitia
Explain what causes relaxation of the LOS
Post-ganglionic inhibitory nitrinergic neurons myenteric (Auerbach) plexus
release NO causing smooth muscle relaxation
Explain the pathophysiology of achalasia
Inflammatory destruction of inhibitory nitrinergic neurons in the oesophageal myenteric (Auerbach) plexus
results in loss of peristalsis and incomplete lower oesophageal sphincter relaxation
Explain the aetiology/RF for achalasia
Autoimmunity - Ab & T cells in myenteric plexus
Chagas disease (CAUSES PAINFUL ACHALASIA)
Genetics/FHx
Allgrove Syndrome
Define Allgrove syndrome
a multisystemdisorderwhich classically involves the triad of:
- oesophageal achalasia
- alacrim
- adrenal insufficiency
due to adrenocorticotropin hormone insensitivity
What causes chagas disease? (aka American Trypanosomiasis)
Trypanosoma cruzi
spread mostly by Triatominae, or “kissing bugs”- bite faces as they sleep
Epidemiology of chagas disease
Endemic in Latin American countries
Affects: 6-7m worldwide
Associated with: poverty, poor housing conditions
Signs and symptoms of Chaga’s disease
Dysphagia of LIQUIDS & Solids Odynophagia Hepatosplenomegaly Abdominal pain Jaundice
How may structural and functional dysphagia present differently?
structural = difficulty swallowing solids only (unless severely advanced obstruction)
functional = defect in peristalsis, difficulty swallowing solids AND LIQUIDS
Investigations for achalasia
FIRST LINE = OGD + BX (rule out ca)
Barium Swallow
- BEAK SIGN – Buzz buzz
- Loss of peristalsis
- Delayed Oesophageal Emptying
DIAGNOSTIC = High Resolution Manometry
Shows incomplete relaxation of LOS
CXR:
- absence of gastric gas bubble
- dilated oesophagus, air fluid level above LOS
What is the diagnostic test and criteria for achalasia?
High Resolution Manometry - measures intraluminal pressure of LOS
Shows:
- Incomplete relaxation of LOS with wet swallows
- oesophageal aperistalsis
What are the risk factors for MW tear?
Any conditions predisposing to vomiting, coughing,
retching, straining
Hiatal hernias - precipitating factor in 40-100%
–>Obesity and all of HH RFs
Significant alcohol use
PMH of recent endoscopy (iatrogenic)
Epidemiology MW tear
M>F (3:1) – alcoholism?
30-50yo
Presenting symptoms of MW tear
Haematemesis- significant vomiting of blood
Light headedness
Postural hypotension (due to loss of blood = ↓ BP)
Other: (not as important) Dysphagia Odynophagia Melaena, haematochezia Shock
What questions would you ask someone who presents with haematemesis?
How many times Has this happened before Quantify blood -Tea/table, cup fulls What colour? -Bright red, dark red, coffee ground Associated pain? -Where? Shoulder? Changes in your stool? -Dark, blood mixed in
Investigation of MW tear
Stabilise patient (A-E approach)
FBC- anaemia
LFT- may show co-existing liver disease (alcoholics)
Cross match / group blood- in all bleeding pts
CXR – normal (unless perforated!)
OGD = DIAGNOSTIC TEST
Management of MW tear
Stabilise: IV PPI (to decrease acidic secretions) Anti emetics (to stop vomiting)
FIRST LINE = ENDOSCOPY
- Adrenaline Injection - stops bleeding by vasoconstricting
- Band ligation - band around bleeding point
- Thermal/Mechanical Therapy
- Haemoclips
- Thermocoagulation therapy
SECOND LINE = Sengstaken-Blakemore tube
- Tube down to oesophagus – inflates and stops the bleeding
- Used commonly in Upper GI bleeds
LAST RESORT = SURGERY
When everything else fails / Boerhaave’s
what are the signs and symptoms of Boerhaave’s syndrome?
- retrosternal chest pain (ddx of MI), ± vomiting
- on auscultation: crackling sounds, decreased breath sounds (chest exam)
- surgical emphysema (crepitus around the neck from escaped air)
- subcutaneous emphysema
describe the sequence from GORD to adenocarcinoma
Chronic GORD –> metaplasia (Barrett’s oesophagus)(stratified squamous –> columnar)
metaplastic cells –> dysplastic –> malignant
(genetic alterations that activate proto-oncogenes and/or disable TSGs)
Barret’s is NOT a mandatory step though like adenoma-carcinoma sequence of CRC
symptoms of oesophageal cancer
Dysphagia (when 2/3rd of lumen obstructed)
Odynophagia (local invasion into mediastinum/trachea)
Reflux (adenocarcinoma)
FLAWS
Hoarseness- if recurrent laryngeal nerve invasion
Hiccups- if phrenic nerve invasion
prognosis oesophageal cancer
poor
present late- often only symptom is dysphagia, and this only occurs once the cancer has grown to obstruct 2/3rds of the lumen of the oesophagus
