Upper GI Conditions Flashcards
What type of muscle is the Oesophagus made of?
- Upper 3-4cm = skeletal muscle
- The remainder = smooth muscle
What type of epithelium is present in the Oesophagus?
Non-keratinised stratified squamous epithelium
What should you enquire about when a pt. presents with Dysphagia?
- Type of food (solid vs liquid)
- Pattern (progressive, intermittent)
- Associated features (weight loss, regurgitation, cough)
• Location:
o ?Oropharyngeal
o ?Oesophageal
What are the common causes of Oesophageal Dysphagia?
- Benign stricture
- Malignant stricture (ie. oesophageal cancer)
- Motility disorders (ie. achalasia, presbyoesophagus)
- Eosinophilic oesophagitis
- Extrinsic compression (ie. Lung cancer)
When is Endoscopy used in Oesophageal Disease?
- Investigation of Dysphagia
- Reflux symptoms with alarm features
When is Barium Swallow (Contrast Radiography) used in Oesophageal Disease?
- 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
When are pH studies used in Oesophageal Disease?
- Investigation of Refractory Heartburn or Reflux (GORD)
refractory to meds -> to check if the meds are acc working!
When is Manometry used in Oesophageal Disease?
- 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)
What symptoms are associated with Reflux?
- Heartburn = retrosternal pain/discomfort
- Waterbrash = acidic taste in the back of the mouth
- Cough
What are the common symptoms of Diffuse Oesophageal Spasm?
Severe, intermittent chest pain +/- dysphagia -> precipitated BY FOOD
(nb. confused with Angina/MI)
How is Diffuse Oesophageal Spasm diagnosed?
- Barium swallow
- > corkscrew appearance
- Manometry
- > abnormal contractions
What is the treatment for Diffuse Oesophageal Spasm?
Smooth muscle relaxants
ie. nitrates, CCBs
What are the Achalasia?
- Progressive dysphagia for solids AND liquids (!!!) (from the beginning)
- Dysphagia
- Regurgitation + chest infection
- Weight loss
How is Achalasia diagnosed?
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
What causes Achalasia?
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..
What is the Treatment of Achalasia?
- Heller’s Myotomy = 1st line!!
- Endoscopic balloon dilatation
- Nitrates, CCBs
- > (pts unfit for more invasive treatments)
What are the complications of GORD?
- Oesophagitis + ulceration
- Benign Oesophageal Stricture
(-> nb. difficulty swallowing solids THEN liquids) - Barrett’s Oesophagus
- Oesophageal Adenocarcinoma
What are the common symptoms of GORD?
- Heartburn
- > (retrosternal discomfort)
- Waterbrash
- > (acidic taste in the back of the mouth)
- Cough
- Sleep disturbance
What are the risk factors for GORD?
- Pregnancy
- Obesity
- Drugs lowering LOS pressure
- Smoking
- Alcoholism
- Hypomotility (ie. systemic sclerosis)
- Hiatus Hernias
Which drugs lower LOS pressure? (increase reflux symptoms and risk of GORD)
- Nicotine (smoking)
- Alcohol
- Dietary Xanthines (ie. caffeine)
- Anti-muscarinics
- CCBs
- Nitrates
- Tricyclics
What is the difference in the LOS in Achalasia vs. GORD?
- 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…)
How is GORD diagnosed?
- Clinical Diagnosis
- (Endo only used in certain cases…)
- (24hr oesophageal pH monitoring +/- manometry may help diagnosis when Endo is normal)
When should you refer a patient for UGIE/EGD?
- Everyone with Dysphagia
- ≥55 and ALARMs or persistent symptoms (ie. dyspepsia, heartburn, reflux, etc)
- Acute GI bleed
What is the aetiology of GORD?
- Increased transient relaxations of the LOS
- > (most common!)
- Hypotensive LOS
- Delayed gastric emptying
- Delayed Oesophageal emptying
- Hiatus Hernia
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)
Which drugs should you avoid in GORD?
Lower LOS pressure:
- Nitrates
- Anti-Muscarinics/Anti-Cholinergics
- CCBs
Damage Mucosa:
- NSAIDs
- K+ salts
- Bisphosphonates
What is the metaplastic change in Barrett’s Oesophagus?
Non-keratinising stratified squamous epithelium to columnar epithelium (found in stomach)
What causes Barrett’s Oesophagus?
Chronic GORD
What is the treatment of Barrett’s Oesophagus?
- EMR (Endoscopic Mucosal Resection)
- RFA (Radio-Frequency Ablation)
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
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
What is the Investigation of choice for diagnosis of Oesophageal cancer?
- Flexible Endoscopy (oesophagoscopy) + Biopsy
What is the Investigation of choice for staging of Oesophageal cancer?
- EUS
- CT chest + abdomen
What is the radical treatment of Oesophageal cancer?
- Surgical oesophagectomy +/- adjuvant or neoadjuvant chemo
only for localised disease T1/T2
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)
How is Eosinophilic Oesophagitis diagnosed?
- via Endoscopy and Biopsy
- ≥15 eosinophils per high-power microscopy field on oesophageal biopsy
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)
What is the treatment of Eosinophilic Oesophagitis?
- Topical/swallowed corticosteroids
- Dietary elimination
- Endoscopic dilatation (in severe strictures)
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)
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
What is the investigation of choice for diagnosis of Gastric cancer?
- UGIE/EGD + Biopsy
What is the investigation of choice for staging of Gastric cancer?
- CT Chest/Abdo
- Staging Laparoscopy (in pts w locally-advanced tumours)
What is the radical treatment of Gastric cancer?
Proximal:
- Total Gastrectomy -> usually open surgery
Distal:
- Partial (Subtotal) Gastrectomy -> usually laparoscopic (“keyhole”) surgery
What is the definition of Dyspepsia?
- Pain or discomfort in the upper abdomen
- for 4 weeks
How common is Dyspepsia?
Occurs in roughly 25-40% of ppl
Frequent GP consultations
What are organic causes of Dyspepsia?
Upper GI
- GORD
- Peptic Ulcer
- Gastritis
- Gastric cancer
Other systemic disease
- Gallstones
- Pancreatic disease
What are functional causes of Dyspepsia?
- Non-Ulcer Dyspepsia -> H. Pylori (most common!!)
- Smoking and Alcohol
- IBS
- Psychological (ie. anxiety, depression)
Which drugs precipitate Dyspepsia?
- NSAIDs
- Corticosteroids
- CCBs
- Nitrates
- Theophylline
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)
Should you do any investigations for Dyspepsia?
- Bloods: FBC, ferritin, LFTs, U+Es, Ca2+, glucose, coeliac serology (tTG-IgA)
- UGIE: if ALARMS symptoms present
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)
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
What type of bacterium is H. Pylori?
- Gram-negative
- Spiral-shaped
- Micro-aerophilic
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
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%)
What are the characteristics of Antral-predominant H. Pylori infection?
- Increased Acid production
- Low risk of Gastric cancer
- DU disease
What are the characteristics of Corpus-predominant H. Pylori infection?
- Decreased Gastric acid (increased pH)
- Gastric atrophy
- Gastric cancer
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*
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)
What causes Gastritis?
- Autoimmune (parietal cells)
- Bacterial (H. Pylori)
- Chemical (bile/NSAIDs)
What is more common, DU or PU?
DU!!
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
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)
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
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
What is the most common cause of Gastric Outlet Obstruction?
Peptic Ulcer Disease
90% of cases
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
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
What is the treatment of Gastric Outlet Obstruction?
- Medical: H. Pylori eradication therapy, PPIs
- Endoscopic balloon dilatation
- Surgery
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
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
What is the management of Gastric cancer?
- Histological diagnosis: Endoscopy + biopsy
- Staging: CT Chest/Abdo
What is the radical treatment of Gastric cancer?
- Surgery + adjuvant or neoadjuvant chemo
