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Y4 Gastroenterology and Hepatology > 3. Upper GI Disease > Flashcards

3. Upper GI Disease Flashcards

1
Q

Diff btw oropharyngeal and oesophageal dysphagia

A

Oropharyngeal ⇒ can’t bring food from the mouth to the oesophagus ( ENT rather than gastro), diff initiating swallowing - may have choking or aspiration

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2
Q

Eg. of oropharyngeal dysphagia

A
  • Skeletal muscular disorders in context of stroke ⇒ dysphagia may be one of the early Sx, may take weeks to get better
  • Neuromuscular - MND, bulbar pulsy
  • Throat tumour or pharyngeal tumour would block the back of mouth ( mech obst.)
  • Sjogren’s ( decreased saliva) is associated with primary BILIARY sclerosis or rheumatic diseases
  • Alzheimer’s and depression
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3
Q

Eg. of oesophageal dysphagia

A
  • mech obstr due to narrowing of oesophagus eg. strictures
  • Motility disorders
  • Autonomic neuropathy due to diabetes
  • Alcohol and GOR can also disorganize oeso motility
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4
Q

What CN are involved if weak tongue or cheek muscles cannot move food around in the mouth for chewing?

A

V, VII

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5
Q

What CN are possibly involved if pts are not able to start swallowing reflex that allows foods to move safely through pharynx? And what can cause this?

A

IX, X, XI, XII
Stroke, nervous system disorder

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6
Q

What could progressive dysphagia suggest

A

Tumour getting worse?

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7
Q

What does intermittent dysphagia suggest?

A

Dysmotility syndrome or oesophagitis

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8
Q

If dysphagia to solids then liquids, is it likely to be obstructive or dysmotility

A

Obstructive, dysmotility more likely to be both

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9
Q

What could cause odynophagia

A

Severe oesophagitis associated with inflammation
Red flag as may suggest malignancy

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10
Q

Can benign UGI diseases cause weight loss

A

Yes if severe eg. severe strictures

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11
Q

What does hoarse voice with dysphagia suggest

A

Tumour pressing on recurrent laryngeal nerve (branch of vagus nerve)

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12
Q

What do chest pains associated with dysmotility suggest

A
  • Oesophageal spasm ( may be caused by acid reflux)
  • Referred pain ⇒ similar nerves from heart and oesophagus
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13
Q

What are the likely causes of dyspjagia in an elderly patient?

A

Elderly patient ⇒ neurological causes if intermittent/ long standing, or sinister causes like oesophageal ca if new, progressive with regurgitation and weight loss

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14
Q

What are the likely causes of dysphagia in an younger patients?

A

Oesinophillic oesophagitis ( with food bolus obstruction), or dysmotility

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15
Q

What are the likely causes of dysphagia in middle aged patients?

A

Dysmotility eg. achalasia secondary to acid reflux

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16
Q

Is dysphagia for liquids netter than for solids for achlasia

A

No, equal

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17
Q

Regurg of prev day’s food, bad breath

A

Pharyngeal pouch

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18
Q

Should endoscopy be done for pharyngeal pouch

A

No, risk of camera going into pouch and causing perforation during endoscopy

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19
Q

What could Inflammation, bleeding, hyperplastic process on endoscopy suggest

A

Stricture

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20
Q

Causes of struictures

A
  • Benign :Acid reflux oesophagitis, Barrettt’s, extrinsic comppresion ( mediastinal tumour), post-radio, anastomotic from area of previous oesophagectomy, corrosive (alkali ingestion)
  • Malignant stricture
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21
Q

What sphincter is involved in Achalasia and what happens to it

A

Increased tone of LOS, inability to relax and high resting pressure, when oesophagus contracts, goes through stage of hypertrophy and dilatation ( baggy oeso)

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22
Q

Test for achalasia

A

Oesophageal function test (manometry) can check for decreases motility of oesophagus- LOS is tight and fails to open completely

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23
Q

What is treatment for benign strictures

A
  • Dilatation
    • Endoscopic Balloon or push dilators to stretch oeso
  • PPIs ( long term therapy)
  • Recurrent strictures → put stent to open oesophagus
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24
Q

62 yo man, 3mo history of progressive dysphagia for solids- frequent choking and feeling of food stuck in middle of chest
Eventually also liquid dysphagia

longstanding smoker and drinker
lost 6 kg of weight but bmi 31
long standing gord, rennies for years
regurg even liquid and pain every time food gests into gullet

What are other more severe Sx possibly.

A

Possible oeso cancer
Fistulation between the oesophagus and the trachea or bronchial tree leads to coughing after swallowing, pneumonia and pleural effusion. cachexia, cervical lymphadenopathy or other evidence of metastatic spread is common.

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25
Q

Squamous vs adenocarcinoma oeso cancer- different pop?

A

Adeno- GORD, overweight, younger, typically lower 3rd oeso
Squamous- Alcohol, smoking, most common worldwide

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26
Q

how to establish Dx of oeso cancer

A

Endoscopy and biopsy

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27
Q

oesophager CA T staging

A
  • T4 - beyond to nearby tissues
  • T1- usually mucosa or submucosa
  • T2- muscularis
  • T3- border of lesion
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28
Q

What imaging modality to stage tumour for oeso ca

A

Endoscopic US- allows to see through the wall and take biopsies of LNs, determin depth of penetration into oesophageal wall and LN involvement

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29
Q

How to look at mets and LN and what can be done to show met spread and invasion (if tumour is malignant)

A

CT scan best way to look at mets and LN, CT PET can show if tumour is malignant or not

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30
Q

Palliative care for malignant strictures

A

Stenting (SEM) ,

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31
Q

40 YO F , 9 mo history of intermittent dysphagia for liquids and solids
Weight gone down, normal UGE

A

Typical dysmotility, severe as weight has gone down
DO BARIUM SWALLOW- Dx of achlasia

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32
Q

Treatment for achalasia

A
  • Pneumatic dilatiation using air filled balloon to disrupt sphincter
    • Risk of perforation
  • Surrgical myotomy
    • done laprascopially to weaken LOS
      • Most common in young people
      • may need PPI after
  • Botox injection at LOS in older people → much safer but need to repeat because last for only 1-1.5 yr
    • Most common in older people
  • POEM
    • Open oesophagus and cut muscle
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33
Q

17Yo man, asthmatic, 3wks hx of dysphagia and bolus obstr.

A

Eosinophillic oesophagitis - FBO common presentation, pmhx of atopy of food allergies

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34
Q

How to make confirmation dx of Eosinophillic Oesophagitis

A
  • esophageal biopsy - 3 in middle and 3 in lower oeso
    • > 15 eosinophils per HPF
    • May have white spots ( eosinophillic abscesses,) tram line (linear ulcerations)
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35
Q

Tx of Eosinophillic Oesophagitis

A

An empiric 8-week trial of high-dose PPI can be used in the first instance. Around one-third of patients will respond to this, known as PPI-responsive oesophageal eosinophilia.

In patients who do not respond, 8–12 weeks of therapy with topical glucocorticoids can be used, such as fluticasone and budesonide. Treatment with topical steroids (orodispersible budesonide )

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36
Q

Can liquids be swallowed when there are stirctures

A

Yes, until it becomes severe

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37
Q

What drugs can cause benign strictures

A

Bisphosphonates, can cause intermittent dysphagia and oesophageal ulceration

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38
Q

Ix algorithm for dyspepsia

A

If alarm features eg. unintentional weight loss, anaemia, persistent vomiting, hematemesis and/or melaena, dysphagia, palpable abdominal mass - do urgent endoscopy OR above 55 despite alarm features, then endoscopy

If not, just H pylori test if persistent Sx eg. urea breath test or stool antigen
If positive, triple therapy, if not, treat Sx

39
Q

Main causes of UGIB

A

Peptic ulcer - NSAIDs or peptic ulcer
Varices ( liver disease or portal vein thrombosis)
Retching can cause Mallory-Weiss tear
Ca
Gastric erosions/ Gastritis due to NSAIDs and Alcohol
Oesophagitis may also cause UGIB

40
Q

Can melaena be caused by LGIB

A

Yes, may be from right side of colon

41
Q

Should antithrombotic durgs be stopped during GIB

A

Yes, but aspirinn can be continued in UGIB

42
Q

Treatment for non-variceal UGIB

A

Can treat endoscopically using cautherization or clips, with adrenaline. Haemospray as rescue therapy
give PPI IV to reduce gastrin secretion and promote clot stability

43
Q

Tx for variceal blead

A

Band ligation, balloon tamponade if BL failed

44
Q

Risk factors that may exacerbate dyspepsia Sx

A

Obesity ( related to diet) , trigger foods like tomatoes, fatty or spciy foods, smoking and alchol. Stress, anxiety and depression may worsen Sx

45
Q

Drugs that can exacerbate dyspepsia -

A

Aspirin and NSAIDs

alpha-blockers, anticholinergics,benzodiazepines,beta-blockers, bisphosphonates, calcium-channel blockers, corticosteroids, nitrates,theophyllines,and tricyclic antidepressants.

46
Q

Tx for dyspepsia

A

Usually just use antacid
IF H pylori +ve
Full dose PPI for 1 mo if no H pylori
OR
If positive, then PPI and amox and clarithro or metro
If allergic to pen, then clarithro and metro

If Sx recure, switch to alternate therapy and cpnsider alternate acid supression therapy with histamine receptor antagonist eg. ranitidine

47
Q

For h pylori test, what should be ensured?

A

Pt has not taken PPI in past 2 weeks or abx in past 4 wks

48
Q

Is tone of LOS increased or decreased in GORD

A

Decreased

49
Q

Complications of GORD

A

Barrett’s - pre-malignant condition due to chronic GORD
Oesophagitis ( may have stricture)
Ca

50
Q

Barrett’s - what kind of cells

A

Columnar instead of squamous

51
Q

Risk factor for Barrett’s

A

Age, male, obseity and smoking

52
Q

Ix and Mx of Barrett’s

A

Endoscopy is gold standard, multiple bipsies should be taken
Mx only for Sx of reflux compl eg. stricture - endoscopic resection + RFA or oesophagectomy

53
Q

Ix for GORD

A

Usually treat empirically in young pts, but in older pts can do endoscopy to exclude other diseases

54
Q

tx for GORD

A

Give lifestyle advice (weight loss, avoidance of dietary items that worsen symptoms, having small mails often, elevation of the bed head in those who experience nocturnal symptoms, avoidance of late meals and cessation of smoking.)

Antacids, then empric full dose PPIs,if severe and progressive Sx despite anatacid.
if stilll poor response then consider pH monitoring and perform fundoplication if positive

55
Q

Pharyngeal pouch Ix and Tx

A

Barium swallow - will reveal incoordination of swallowing
Treatment is indicated in symptomatic patients, and can be via a surgical approach, such as cricopharyngeus myotomy (diverticulotomy), with or without resection of the pouch. or stapling

56
Q

Achalasia Sx

A

Dysphagia to solids and liquids, regurg to saliva and food may occur, may have chest pain due to oeso spasm, weight loss

57
Q

Causes of acute gastritis, Sx and usual treatment

A

NSAIDs + aspirin , alcohol, antacids and PPIs,
Sx include dyspepsia, anorexia, nausea or vomiting, and haematemesis or melaena
Tx include symptomatic therapy with antacids, and acid suppression using PPIs, prokinetics like domperidone or antiemetics like metoclopramide

58
Q

Where are peptic ulcers commonly located

A

Stomach or duodenum
BUT may also occur in lower oeso, jejunum after surgical anastomosisto stomach, or in ileum adjacent to Meckel’s diverticulum

59
Q

What other non GI cancer can cause dysphagia

A

Lung cancer or mediastinal adenopathy can cause external compression of oesophagus

Goitre compression can cause oropharyngeal dysphagia

60
Q

Ix for dysphagia -

A

If progressive and sever, or persistent, should do UGI endoscopy

61
Q

Two largest risk factors for PUD

A

H pylori and Aspirin + NSAIDs

62
Q

PUD sx

A

post prandial abd pain, localisation to epigastrium
Dyspesia, vomiting
Gastric outlet obst (persistent vomitting)
Perforation
Haemtemesis, coffee ground vomiting or malaena

63
Q

Benign vs malignant ulcer

A

Shallow with no rolled edges vs craggy, quite deep

64
Q

Red flag Sx for PUD

A

Epigastric pain with weight loss

65
Q

Ix for PUD

A

Endoscopy with histologic biopsies to exclude cancer
+ H pylori testing- 1 wk triple therapy if +ve
+ 2 months high dose PPI for PUD

Requires follow up endoscopy for gastric ulcers to ensure healing and that they are not malignant

66
Q

What kind of oesophagealcancer arises from Barrett’s and where else can this type be found

A

Adenocarcinoma, can be found lower at GO jtn

67
Q

Tx for Oeso Ca

A

Oesophagectomy if resectable, if not then chemo +radio

68
Q

Common Sx of oesophagitis

A

Similar to GORD- Heartburn, regurgitation (provoked by bending, straining or lying down), water or acid brash

May have dysphagia or odynophagia

69
Q

Risk factors for oesophagitis

A

Smoking, obesity, alcohol, hiatus hernia

70
Q

What is dyspepsia

A

Discomfort in the epifastric area, usually after a meal

71
Q

What is heartburn

A

Burning restrostenal sensation, often due to acid reflux

72
Q

What is Schatzi ring

A

Fibrous rink at GOJ linked to acid reflux

73
Q

How may H pylori lead to duodenal ulceration?

A

may have hypergastrinaemia and increased acid productionby parietal cells.

Or may have gastric atrophy and hypochlorohydria, allowing proliferation of bacteria- predispose to cancer

74
Q

What should be prescrobed with long term NSAIDs

A

PPI

75
Q

Recent flu-like illness, worsening abd pain despite analgesia, nausea with dark stools (also on PR exam), non-specific tennderness, HR 92, BP 107/65

On aspirin + PPI , B blocker and statin, apixaban

Non-smoker, 0.5 bottle wine thrice a week

Likely bloods?

A

UGIB
Low Hb, High Urea and Creatinine normal

76
Q

Risk factors for bad outcome in acute UGIB

A

History of malignancy or cirrhosis, haematemesis, hypovolaemia, Hb <80

77
Q

Should anticoag be stopped in pts with UGIB

A

Stop apix ( esp if only one DVT and not recurrent), continue aspirin

78
Q

What does GBS predict

A

Risk stratifies pts at risk of UGIB
includes the need for endoscopic intervention

79
Q

Target for transfusion if have Sx

A

Hb>70

80
Q

Timing of endoscopy for UGIB

A

24 hrs if haemodynamically stable, no persistent hematemesis, and can discontinue anticoag temporarily, otherwise < 12hrs

81
Q

What to do if UGIB can’t be controlled endoscopically

A

Interventional radiology

82
Q

PPI post endoscopy

A

IV PPI continuous infusuion for 72 hrs

83
Q

Should H pylori tx be given for PUD

A

Yes if +ve for H pylori, if -ve and not on NSAID just treat emprically

84
Q

If alcohol history in pt with melena, suspect?

A

Variceal blead

85
Q

What does low lactate in pt with melena and jaundice suggest

A

Patient hypoxic

86
Q

What are platelet levels likely to be like in pt with splenomegaly and cirrhosis

A

Decreased levels as platelts will pool in spleen due to cirrhotic level

87
Q

Na and K levels in pt with severe cirrhosis

A

Hyponatremia and hypokalaemia

88
Q

How to manage pts with increased PT

A

Can give Vit K IV to stimulate pdtn of clottining factors

89
Q

Mx of variceal bleed, time limit

A

IV abx and consider IV terlipressin to reduce blood into varices
Then endoscopy and variceal ligation
Should be done < 12h if stable, earlier if not

90
Q

What drug should be given for long term Mx of variceal bleeds

A

Carvedilol

91
Q

Ix for pt with variceal bleed and liver cirrhosis

A

Assess Liver function, liver screen for Hep B and C, US or CT (flow in portal vein) for complications like HCC, and

92
Q

Another possible cause of ulcerative esophagitis and Tx

A

Alcohol, PPI

93
Q
A

Y4 Gastroenterology and Hepatology (4 decks)

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