Upper GI Diseases Flashcards
What catagories (+ examples) of pathology can cause Dysphagia?
-
Neuromuscular: - mainly affects 1st and/or 2nd phase of swallowing
- Muscular - e.g. muscular dystrophy, myasthenia gravis, weakened muscles / impaired coordination (elderly)
- Neurological - e.g. stroke, Parkinson’s, multiple sclerosis
-
Narrowing of Oesophagus: - mainly affects the 3rd phase of swallowing
- Cancers e.g. oropharyngeal cancer, oesophageal cancer, mediastinal masses
- GORD - scars from stomach acid cause stricture
- Schatzki rings - thickenings of mucosa or muscle
- A-ring = above squamocolumnar junction (oesophagus/stomach junction)
- B-ring = found at the squamocolumnar junction
What are some common complications of Dysphagia?
- Choking
- Pulmonary aspiration –> subsequent aspiration pneumonia
- Malnutrition - either due to ↓ consumption or vomiting of consumed food
Is Barrett’s oesophagus?:
- Neoplasia
- Premalignant
- Dysplasia
- Malignant
- Metaplasia
2 + 5 (premalignant + metaplasia)
- Barrett’s ↑ risk of oesophageal cancer by ~ 50 times (risk of cancer is still relatively low i.e. 3 per 1000 - this is higher is dysplasia is present)
-
Metaplasia = cellular adaptation to a stimulus which causes change from one mature cell type to another
- E.g. Barrett’s - stratified squamous epithelium (oesophageal) –> simple columnar epithelium (stomach)
- Dysplasia = replacement a mature cell type with a less mature cell type + loss of cell uniformity and tissue organisation (varying severities)
Define Barrett’s Oesophagus?
Define:
- Pre-malignant condition which involves, asymptomatic replacement of normal squamous epithelium of the oesophagus by metaplastic columnar epithelium, clearly visible endoscopically >1cm above gastro-oesophageal junction and confirmed histo-pathologically from biopsies
What course of progression does Barrett’s follow?
Oesophagitis –> metaplasia –> dysplasia –> adenocarcinoma (most likely form of cancer)
- Progression from Barrett’s (metaplasia) to adenocarcinoma occurs in 1-2% of cases over 25-30 years of having Barrett’s
What are some risk factors for Barrett’s?
- GORD - 5-10% of GORD pts develop Barrett’s
- Men > women
- Caucasian
What 2 things are protective of the progression from Barrett’s to Oesophageal cancer?
- NSAIDs
- Helicobacter Pylori
Patient presents with dysphagia, anorexia, vomiting, weight loss + Hx of GORD, smoking + alcohol excess.
What are they at risk of?
Oesophageal Cancer
Patient presents with dysphagia, odynophagia (painful swallowing) + Hx of heartburn.
No weight loss + appears systemically well.
What are they at risk of?
Oesophagitis
Patient presents with dysphagia, systemically unwell and Hx of steroid inhalers + HIV.
What are they at risk of?
Oesophageal Candidiasis
Barrett’s Oesophagus is classified based on length of affected segment. What are the classifications?
- Short segment = < 3cm
- Long segment = > 3cm
What investigations might you do in a patient you suspect of having Barrett’s Oesophagus?
-
Endoscopy (specifically OGD) + histological biopsy
- Histological confirmation of endoscopically visible columnarisation/metaplasia of oesophagus = gold standard diagnosis
- Histological confirmation is via prescence of goblet cells in oesophageal epithelium biopsy - this is termed intestinal metaplasia (turning into intestine like)
-
Endoscopic ultrasound:
- If high-grade dysplasia / cancer found on surveillance endoscopy –> endoscopic ultrasound needed to evaluate resectability
-
Surveillance endoscopies:
- Involves repeat endoscopies - duration of gap depends on grade of dysplasia, length of affected oesophagus etc.
-
FBC:
- ↑ WCC - indicates inflammatory cause
- ↓ Hb - anaemia, could be due to lack of nutrition (deficiencies) or bleeding
-
CXR:
- Can identify other oesophageal pathology e.g. mediastinal masses causing dysphagia
-
ECG:
- To eliminate cardiac arrhythmias as cause of chest pain
-
U+Es:
- Confirm good renal function in case contrast CT is needed
-
LFTs:
- Deranged LFTs could imply liver metastases if cancer is a concern
Patient presents with dysphagia of both solids + liquids, heartburn, feels like they are coughing food and sometimes describe it as going down the wrong pipe.
What are they likely to have?
Achalasia
- Achalasia = failure of oseophageal peristalsis + failure of relaxation of lower oesophageal sphincter (LOS) i.e. LOS contracted + dilated oesophagus
- Aetiology: degenerative loss of ganglia from Auerbach’s plexus
Patient presents with a long history of dysphagia which has been remained the same (non-progressive), burning chest pain, coughing, not systemtically unwell.
What are they likely to have?
Peptic Stricture (also called Oesophageal Stricture)
- Account for the majority of benign oesophageal strictures
- Caused by exposure to stomach acid
- Endstage results of chronic GORD oesophagitis
Progressive dysphagia of solids but not liquids is suggestive of what kind of oesophageal issue?
Mechanical obstruction or stricture
- Dysphagia of liquids is suggestive of neurological, muscular or achalasia
What is an OGD?
Oesophago-gastro-duodenoscopy
What are the guidelines on referring patients suspected of Oesophageal cancer?
Offer URGENT direct access upper gastrointestinal endoscopy (to be performed within 2 weeks) to assess for oesophageal cancer in people:
- With dysphagia OR
- aged ≥ 55 with weight loss + any of the following:
- Upper abdominal pain
- Reflux
- Dyspepsia (indigestion)
Other situations to consider non-urgent direct access upper gastrointestinal endoscopy:
- Haematemesis
-
≥ 55 with:
- Treatment‑resistant dyspepsia
- Upper abdo pain + ↓ Hb levels
- ↑ platelet count with any of the following:
- nausea
- vomiting
- weight loss
- reflux
- dyspepsia
- upper abdo pain
- nausea or vomiting with any of the following:
- weight loss
- reflux
- dyspepsia
- upper abdo pain
When gaining consent from a patient for a procedure, what points need to be covered?
- Explain purpose of the procedure:
- What does /might it involve?
- E.g. endoscopy - involves putting a tube with a camera on it down your throat so we can have a look at the tube (oesophagus) leading to your stomach for any abnormalities. If we find something abnormal, a biopsy (that’s a small sample) might be taken for the lab to examine.
- Advise on risks of the procedure:
- E.g. endoscopy - it does involve some risks, some of which are common, such as some post-op pain or bleeding, and some are rarer and can be more serious, such a perforation. Generally, the benefits largely outweigh the risks associated and this will help provide both us and you with a better idea of what’s going on.
- Advise on alternatives if pt is not happy
- Advise about pre-procedure things to do and not to do:
- What to bring? - might want a friend/family due to anaesthesia
- Medication - take most of your medication as normal, but any anti-coagulants need to stop beforehand
- Assess capacity
- Direct to NHS choices website for more info + offer for a superior to come have a more detailed chat about the procedure
The majority of Oesophageal cancers are what 2 types?
Squamous cell carcinoma (SCC) or adenocarcinoma (ACA)
What are the 3 most common features of un-perforated peptic ulcers?
Which is more common duodenal or gastric ulcers?
How does pain often differentiate duodenal vs gastric ulcers?
Features:
- Epigastric pain - made better (duodenal) or worse (gastric) by eating, relieved by antacids, can occur at night
- Nausea
- Hx of NSAID or alcohol use
Commonality: duodenal > gastric
Pain:
- Duodenal = relieved by eating, pain on empty stomach
- Gastric = worse when eating
Other symptoms of peptic ulcers:
- Dyspepsia (indigestion)
- Heartburn
- Vomiting
- Loss of appetite
- Weight loss
NB Peptic ulcer = just class of ulcer, gastric and duodenal are more specific
Which organism is associated with peptic ulcer disease?
Helicobacter pylori
What does ‘triple therapy’ for H.pylori eradication in peptic ulcers?
7-day course of:
-
PPI (e.g. omeprazole, lansoprazole or esomeprazole)
- H2-receptor antagonist if PPI not tolerated
- Clarithryomycin
- Amoxicillin or metronidazole
What are the 3 methods for testing for H.pylori infection?
- Urea breath test
- Stool antigen test
- Blood test for antibodies (less commonly used)
What are some risk factors for developing peptic ulcer disease? (6)
- NSAIDs
- Smoking
- Alcohol excess
- FHx of peptic ulcers
- Physical stress e.g. major trauma or surgery or ICU admission ‘stress ulcer’
- Hypersecretory syndromes e.g. Zollinger-Ellison syndrome
What is Zollinger-Ellison Syndrome?
Define:
- High levels of gastrin - often from gastrin secreting tumour of duodenum or pancreas
- ~30% occur as part of MEN type 1 (multiple endocrine neoplasia)
Features:
- Multiple gastroduodenal ulcers
- Diarrhoea
- Malabsorption
Diagnosis:
- Fasting gastrin levels (single best screen test) - will be high despite fasting
- Secretin stimulation test
- Secretin normally inhibits gastrin release from G-cells - but gastrinoma cell secrete gastrin in response to secretin
What are the 3 main complications of peptic ulcers?
- Internal bleeding
- Most commonly low volume bleeds - thus presents as iron-deficient anaemia
- Erosion of a significant vessel can cause: haematemesis ‘coffee-grounds’ or malaena - either of which can present with or without hypovolemic shock
-
Perforation
- More common in the duodenum
- Causes peritonitis and pneumoperitoneum
- Gastric outlet obstruction
- Epigastric pain
- Postprandial vomiting (after meals)
- Normally due to pancreatic cancer or primary gastric cancer
Which 2 scoring systems can be used in cases of upper GI bleeding?
-
Glasgow-Blatchford Bleeding Score (GBS)
- Risk stratification of patients with upper GI bleeding
- Doesn’t require OGD to calculate risk - thus can be used prior to sending for endoscopy
- GBS score > 0 suggests ‘High-risk’ –> likely to require medical intervention and thus can’t be managed as outpatient
-
Rockall score (RS)
- Risk stratification of patients with upper GI bleed + completed endoscopy
- Requires OGD to calculate risk - use after endoscopy
- Rockall score < 3 carries good prognosis
Which of the following medications are linked with the formation of peptic ulcers or GI bleeds?
- Potassium channel activators e.g. Nicorandil
- Corticosteroids
- Antiplatelets
- NSAIDs
- Anticoagulants
- SSRIs
ALL of them
- Nicorandil (K+ channel activator) = associated with risk of GI ulceration, including perianal ulceration
- Ulcers that result from nicorandil are refractory to treatment, including surgery (they respond only to withdrawal of nicorandil)
A proton-pump inhibitor should be given to prevent peptic ulcers in someone taking long-term aspirin or clopidogrel?
- No
- Yes
- Yes - only if high risk for developing peptic ulcer
Yes - only if high risk for developing peptic ulcer
Those patients at high risk are those:
- On high dose aspirin
- Older patients
- Hx of peptic ulcer or GI bleed
- With serious co-morbid conditions e.g CVD, hepatic or renal impairment, diabetes or hypertension)
- With H. Pylori infection + taking concomitant medications which also increase risk of ulcers or GI bleed (e.g. NSAIDs)
Who should be screened for Barrett’s Oesophagus?
- Pts with chronic / severe GORD (duration >5yrs or at least twice weekly symptoms or symptoms interfering with QoL)
-
AND at least 3 of:
- Age > 50yrs
- Male
- Caucasian
- Obese
- Smoking
- OR - FHx of Barrett’s oesophagus or oesophageal adenocarcinoma
Define Peptic Ulcer
- A break in stomach/duodenum mucosa down to submucosa that is > 5cm in diameter
- Ulcers smaller < 5cm = erosions
- Occur due to inbalance of:
- Factors promoting mucosal damage: gastric acid, pepsin, H.pylori and NSAIDs)
- Factors promoting gastroduodenal defense (prostaglandins, mucus, bicarbonate, mucosal blood flow)
How do you treat a peptic ulcer?
Active bleeding ulcer:
- 1st line = Endoscopy +/- blood transfusion + PPI
- 2nd line = surgery / interventional radiology
H.Pylori positive:
- 1st line = H.pylori eradication ‘triple therapy’
- 2nd line = Alternative eradication regimen
H.Pylori negative
- 1st line = Full dose PPI for 4-8 weeks (if not on NSAIDs)
- 2nd line = H2-receptor antagonist
- Repeat endoscopy in 6-8 weeks to monitor ulcer
