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Upper GI Conditions Flashcards

1
Q

What type of muscle is the Oesophagus made of?

A
  • Upper 3-4cm = skeletal muscle

- The remainder = smooth muscle

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2
Q

What type of epithelium is present in the Oesophagus?

A

Non-keratinised stratified squamous epithelium

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3
Q

What should you enquire about when a pt. presents with Dysphagia?

A
  • Type of food (solid vs liquid)
  • Pattern (progressive, intermittent)
  • Associated features (weight loss, regurgitation, cough)

• Location:
o ?Oropharyngeal
o ?Oesophageal

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4
Q

What are the common causes of Oesophageal Dysphagia?

A
  • Benign stricture
  • Malignant stricture (ie. oesophageal cancer)
  • Motility disorders (ie. achalasia, presbyoesophagus)
  • Eosinophilic oesophagitis
  • Extrinsic compression (ie. Lung cancer)
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5
Q

When is Endoscopy used in Oesophageal Disease?

A
  • Investigation of Dysphagia

- Reflux symptoms with alarm features

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6
Q

When is Barium Swallow (Contrast Radiography) used in Oesophageal Disease?

A
  • Investigation of Dysphagia in certain cases (less-invasive than endoscopy)
  • Used in “high” dysphagia prior to endoscopy to exclude a pharyngeal pouch or post-cricoid web
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7
Q

When are pH studies used in Oesophageal Disease?

A
  • Investigation of Refractory Heartburn or Reflux (GORD)

refractory to meds -> to check if the meds are acc working!

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8
Q

When is Manometry used in Oesophageal Disease?

A
  • Investigation of Dysphagia / suspected motility disorder, refractory GORD

(to check if the LOS is opening and closing properly to prevent food/acid going back up)

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9
Q

What symptoms are associated with Reflux?

A
  • Heartburn = retrosternal pain/discomfort
  • Waterbrash = acidic taste in the back of the mouth
  • Cough
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10
Q

What are the common symptoms of Diffuse Oesophageal Spasm?

A

Severe, intermittent chest pain +/- dysphagia -> precipitated BY FOOD

(nb. confused with Angina/MI)

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11
Q

How is Diffuse Oesophageal Spasm diagnosed?

A
  • Barium swallow
  • > corkscrew appearance
  • Manometry
  • > abnormal contractions
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12
Q

What is the treatment for Diffuse Oesophageal Spasm?

A

Smooth muscle relaxants

ie. nitrates, CCBs

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13
Q

What are the Achalasia?

A
  • Progressive dysphagia for solids AND liquids (!!!) (from the beginning)
  • Dysphagia
  • Regurgitation + chest infection
  • Weight loss
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14
Q

How is Achalasia diagnosed?

A

Combo of…

  • Barium swallow
  • > Rat’s tail appearance!
  • Manometry
  • > high pressure in LOS at rest (>45mmHg), failure of LOS to relax after swallowing, absence of useful peristaltic contractions in the lower oesophagus
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15
Q

What causes Achalasia?

A

Degeneration of inhibitory neurones in the Myenteric Plexus of the distal oesophagus and LOS

  • > lack of peristaltic contractions and failure of LOS to relax
  • > high resting LOS pressure on Manometry, dysphagia, regurgitation of solids AND liquids, etc..
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16
Q

What is the Treatment of Achalasia?

A
  • Heller’s Myotomy = 1st line!!
  • Endoscopic balloon dilatation
  • Nitrates, CCBs
  • > (pts unfit for more invasive treatments)
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17
Q

What are the complications of GORD?

A
  • Oesophagitis + ulceration
  • Benign Oesophageal Stricture
    (-> nb. difficulty swallowing solids THEN liquids)
  • Barrett’s Oesophagus
  • Oesophageal Adenocarcinoma
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18
Q

What are the common symptoms of GORD?

A
  • Heartburn
  • > (retrosternal discomfort)
  • Waterbrash
  • > (acidic taste in the back of the mouth)
  • Cough
  • Sleep disturbance
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19
Q

What are the risk factors for GORD?

A
  • Pregnancy
  • Obesity
  • Drugs lowering LOS pressure
  • Smoking
  • Alcoholism
  • Hypomotility (ie. systemic sclerosis)
  • Hiatus Hernias
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20
Q

Which drugs lower LOS pressure? (increase reflux symptoms and risk of GORD)

A
  • Nicotine (smoking)
  • Alcohol
  • Dietary Xanthines (ie. caffeine)
  • Anti-muscarinics
  • CCBs
  • Nitrates
  • Tricyclics
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21
Q

What is the difference in the LOS in Achalasia vs. GORD?

A
  • The LOS doesn’t open in Achalasia -> high resting pressure
  • The LOS doesn’t shut properly in GORD -> bc of low-resting pressure (ie. due to drugs, alcohol, smoking, etc…)
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22
Q

How is GORD diagnosed?

A
  • Clinical Diagnosis
  • (Endo only used in certain cases…)
  • (24hr oesophageal pH monitoring +/- manometry may help diagnosis when Endo is normal)
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23
Q

When should you refer a patient for UGIE/EGD?

A
  • Everyone with Dysphagia
  • ≥55 and ALARMs or persistent symptoms (ie. dyspepsia, heartburn, reflux, etc)
  • Acute GI bleed
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24
Q

What is the aetiology of GORD?

A
  • Increased transient relaxations of the LOS
  • > (most common!)
  • Hypotensive LOS
  • Delayed gastric emptying
  • Delayed Oesophageal emptying
  • Hiatus Hernia
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25
What is the treatment of GORD?
- Lifestyle measures: weight loss, smoking cessation, small regular meals, remove precipitating drugs/foods - Drugs: PPIs, Alginates (Gaviscon) -> empiric w/o investigation! - (Anti-reflux surgery (Fundoplicayion) in hella refractory cases)
26
Which drugs should you avoid in GORD?
Lower LOS pressure: - Nitrates - Anti-Muscarinics/Anti-Cholinergics - CCBs Damage Mucosa: - NSAIDs - K+ salts - Bisphosphonates
27
What is the metaplastic change in Barrett's Oesophagus?
Non-keratinising stratified squamous epithelium to columnar epithelium (found in stomach)
28
What causes Barrett's Oesophagus?
Chronic GORD
29
What is the treatment of Barrett's Oesophagus?
- EMR (Endoscopic Mucosal Resection) | - RFA (Radio-Frequency Ablation)
30
What are the Clinical Features of Oesophageal Cancer?
- Progressive Dysphagia (90%) - Anorexia and Weight loss (75%) - Odynophagia - Retrosternal chest pain - Cough - Pneumonia - Hoarse Voice (vocal cord paralysis) - Haematemesis
31
What are the Risk Factors for Oesophageal Cancer?
Squamous cell carcinoma - Achalasia - Caustic strictures - nitrosamine exposure, hot drinks - Plummer-Vinson syndrome Adenocarcinoma - Barrett's Oesophagus - Obesity - Male sex - Middle age - Caucasian
32
What is the Investigation of choice for diagnosis of Oesophageal cancer?
- Flexible Endoscopy (oesophagoscopy) + Biopsy
33
What is the Investigation of choice for staging of Oesophageal cancer?
- EUS | - CT chest + abdomen
34
What is the radical treatment of Oesophageal cancer?
- Surgical oesophagectomy +/- adjuvant or neoadjuvant chemo | only for localised disease T1/T2
35
What is the palliative treatment of Oesophageal cancer?
*Palliation of Dysphagia -> top priority* - Endoscopic stenting - Endoscopic laser - Palliative Chemo/RT (most ppl at presentation have incurable disease)
36
How is Eosinophilic Oesophagitis diagnosed?
- via Endoscopy and Biopsy | - ≥15 eosinophils per high-power microscopy field on oesophageal biopsy
37
What is the typical clinical presentation of Eosinophilic Oesophagitis?
- Children and Young adults - Males - Dysphagia - Food stuck in throat (food bolus obstruction) (due to strictures)
38
What is the treatment of Eosinophilic Oesophagitis?
- Topical/swallowed corticosteroids - Dietary elimination - Endoscopic dilatation (in severe strictures)
39
What are the risk factors for Gastric Cancer?
- H. Pylori infection (!!!) - Pernicious Anaemia - Atrophic Gastritis - Adenomatous Polyps - Smoking - Diet (high nitrate, high salt, pickling, low Vitamin C)
40
What is the clinical presentation of Gastric cancer?
* Often non-specific -> ALARMS symptoms should prompt investigation with UGIE! * - Dyspepsia (pain in the upper epigastrium, esp. after eating) - Weight loss - Vomiting - Dysphagia - Anaemia
41
What is the investigation of choice for diagnosis of Gastric cancer?
- UGIE/EGD + Biopsy
42
What is the investigation of choice for staging of Gastric cancer?
- CT Chest/Abdo | - Staging Laparoscopy (in pts w locally-advanced tumours)
43
What is the radical treatment of Gastric cancer?
Proximal: - Total Gastrectomy -> usually open surgery Distal: - Partial (Subtotal) Gastrectomy -> usually laparoscopic ("keyhole") surgery
44
What is the definition of Dyspepsia?
- Pain or discomfort in the upper abdomen | - for 4 weeks
45
How common is Dyspepsia?
Occurs in roughly 25-40% of ppl | Frequent GP consultations
46
What are organic causes of Dyspepsia?
Upper GI - GORD - Peptic Ulcer - Gastritis - Gastric cancer Other systemic disease - Gallstones - Pancreatic disease
47
What are functional causes of Dyspepsia?
- Non-Ulcer Dyspepsia -> H. Pylori (most common!!) - Smoking and Alcohol - IBS - Psychological (ie. anxiety, depression)
48
Which drugs precipitate Dyspepsia?
- NSAIDs - Corticosteroids - CCBs - Nitrates - Theophylline
49
What are the symptoms of Dyspepsia?
- Epigastric pain - often related to hunger, specific foods, time of day - Fullness after meals - Heartburn (retrosternal pain) - Tender Epigastrium - Beware: ALARMS symptoms!! (refer for Upper GI)
50
Should you do any investigations for Dyspepsia?
- Bloods: FBC, ferritin, LFTs, U+Es, Ca2+, glucose, coeliac serology (tTG-IgA) - UGIE: if ALARMS symptoms present
51
What are the ALARMS symptoms?
- Anorexia - Loss of Weight - Anaemia (iron-deficiency) - Recent onset or persistent despite treatment >55yrs - Malaena/Haematemesis (GI bleeding) or Mass - Swallowing problems (Dysphagia)
52
What is the management of Dyspepsia? (summarised)
- Dysphagia, >55 and ALARMs or persistent symptoms (ie. in this case dyspepsia) -> UGIE - If just Dyspepsia: Lifestyle measures, Gaviscon, antacids - If no improvement with meds: test for H. Pylori - If +ve: H. Pylori eradication treatment -> if no improvement then Urea breath test -> if shown to be eradicated then treat as H. Pylori -ve (and give PPIs) - If -ve: PPIs (Omeprazole) or H2-Receptor Antagonists (Ranitidine) -> if no improvement then refer for UGIE
53
What type of bacterium is H. Pylori?
- Gram-negative - Spiral-shaped - Micro-aerophilic
54
What is the pathogenesis of H. Pylori infection?
- H. Pylori releases urease | - Increases pH -> allows H. Pylori to attach itself to the epithelium and penetrate into the gastric mucosa
55
What are the Clinical outcomes of H. Pylori infection?
- Asymptomatic or Chronic Gastritis (>80%) - Chronic Atrophic Gastritis / Intestinal Metaplasia (15-20%) - GU or DU (15-20%) - Gastric Cancer / MALT Lymphoma (<1%)
56
What are the characteristics of Antral-predominant H. Pylori infection?
- Increased Acid production - Low risk of Gastric cancer - DU disease
57
What are the characteristics of Corpus-predominant H. Pylori infection?
- Decreased Gastric acid (increased pH) - Gastric atrophy - Gastric cancer
58
How is the diagnosis of H. Pylori infection made?
- Urea (13C) Breath Test - Stool Helicobacter Antigen Test (SAT) - (Nb. Refer for UGIE if dysphagia, ≥55 with ALARMs or persistent symptoms, or acute GI bleed) * should NOT be performed within 2 weeks of treatment with a PPI or within 4 weeks of antibacterial treatment due to false-negatives*
59
What is the Treatment for H. Pylori?
- Remove precipitating drugs (NSAIDs!!) - Eradication treatment (triple therapy) for 7 days: PPI + Clarithromycin + Amoxycillin (or Metronidazole if Penicillin allergy) (CA(M)P)
60
What causes Gastritis?
- Autoimmune (parietal cells) - Bacterial (H. Pylori) - Chemical (bile/NSAIDs)
61
What is more common, DU or PU?
DU!!
62
What are the possible causes of PU/DU?
- H. Pylori infection (= majority !!) - NSAIDs - Smoking - Rarely: Zollinger-Ellison syndrome (inc. gastrin production), Hyperparathyroidism, Crohn's disease
63
What are the symptoms of PU/DU?
- Epigastric pain (relieved by antacids) -> may be the only sign! - Nocturnal/hunger pain - Back pain (posterior DU) - Nausea (+ occasionally vomiting) - Weight loss + anorexia - Haematemesis and/or Melaena, or Anaemia (Bleeding GU/DU)
64
What is the treatment for Gastritis/PU/DU?
- H.Pylori-causing ulcers = Eradication Therapy - Acid-reducing drugs: PPIs (omprazole), H2-Receptor Antagonists (ranitidine) - Removal of precipitating drugs (ie. NSAIDs, anti-platelets) - Surgery, if complicated disease
65
What are the complications of Gastritis/PU/DU?
- Acute bleeding -> malaena, haematemesis - Chronic bleeding -> iron-deficiency anaemia - Perforation - Fibrotic stricture (narrowing) - Gastric Outlet Obstruction - oedema or stricture
66
What is the most common cause of Gastric Outlet Obstruction?
Peptic Ulcer Disease | 90% of cases
67
What are the clinical features of Gastric Outlet Obstruction?
- Vomiting -> Metabolic Alkalosis - Early satiety, abdominal distension, weight loss - Gastric splash (abdominal auscultation) - Dehydration - Bloods: Low Cl, Na+ and K+, Renal impairment
68
How is a diagnosis of Gastric Outlet Obstruction made?
- UGIE (after prolonged fast/aspiration of stomach contents) | - Nature of the vomiting: infrequent, projectile and large volume
69
What is the treatment of Gastric Outlet Obstruction?
- Medical: H. Pylori eradication therapy, PPIs - Endoscopic balloon dilatation - Surgery
70
What are the symptoms of Gastric cancer?
* Presents late in Western countries * * Dyspepsia * Early satiety * Nausea & vomiting * Weight loss * GI bleeding * Iron-deficiency Anaemia * Gastric Outlet Obstruction
71
What is the Aetiology of Gastric cancer?
- Long-term H. Pylori infection (main cause!!)/Gastritis - Obesity - Environmental risk factors: Smoking, Diet (high salt, high nitrates, low fruit + veg) - FH of Stomach cancer
72
What is the management of Gastric cancer?
- Histological diagnosis: Endoscopy + biopsy | - Staging: CT Chest/Abdo
73
What is the radical treatment of Gastric cancer?
- Surgery + adjuvant or neoadjuvant chemo

Alimentary System (11 decks)

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