Upper GI Diseases

Question 1

What catagories (+ examples) of pathology can cause Dysphagia?

Answer 1

1. 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
2. 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

Question 2

What are some common complications of Dysphagia?

Answer 2

1. Choking
2. Pulmonary aspiration –> subsequent aspiration pneumonia
3. Malnutrition - either due to ↓ consumption or vomiting of consumed food

Question 3

Is Barrett’s oesophagus?:

1. Neoplasia
2. Premalignant
3. Dysplasia
4. Malignant
5. Metaplasia

Answer 3

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)

Question 4

Define Barrett’s Oesophagus?

Answer 4

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

Question 5

What course of progression does Barrett’s follow?

Answer 5

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

Question 6

What are some risk factors for Barrett’s?

Answer 6

1. GORD - 5-10% of GORD pts develop Barrett’s
2. Men > women
3. Caucasian

Question 7

What 2 things are protective of the progression from Barrett’s to Oesophageal cancer?

Answer 7

1. NSAIDs
2. Helicobacter Pylori

Question 8

Patient presents with dysphagia, anorexia, vomiting, weight loss + Hx of GORD, smoking + alcohol excess.

What are they at risk of?

Answer 8

Oesophageal Cancer

Question 9

Patient presents with dysphagia, odynophagia (painful swallowing) + Hx of heartburn.

No weight loss + appears systemically well.

What are they at risk of?

Answer 9

Oesophagitis

Question 10

Patient presents with dysphagia, systemically unwell and Hx of steroid inhalers + HIV.

What are they at risk of?

Answer 10

Oesophageal Candidiasis

Question 11

Barrett’s Oesophagus is classified based on length of affected segment. What are the classifications?

Answer 11

• Short segment = < 3cm
• Long segment = > 3cm

Question 12

What investigations might you do in a patient you suspect of having Barrett’s Oesophagus?

Answer 12

1. 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)
2. Endoscopic ultrasound:
   
   • If high-grade dysplasia / cancer found on surveillance endoscopy –> endoscopic ultrasound needed to evaluate resectability
3. Surveillance endoscopies:
   
   • Involves repeat endoscopies - duration of gap depends on grade of dysplasia, length of affected oesophagus etc.
4. FBC:
   
   • ↑ WCC - indicates inflammatory cause
   • ↓ Hb - anaemia, could be due to lack of nutrition (deficiencies) or bleeding
5. CXR:
   
   • Can identify other oesophageal pathology e.g. mediastinal masses causing dysphagia
6. ECG:
   
   • To eliminate cardiac arrhythmias as cause of chest pain
7. U+Es:
   
   • Confirm good renal function in case contrast CT is needed
8. LFTs:
   
   • Deranged LFTs could imply liver metastases if cancer is a concern

Question 13

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?

Answer 13

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

Question 14

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?

Answer 14

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

Question 15

Progressive dysphagia of solids but not liquids is suggestive of what kind of oesophageal issue?

Answer 15

Mechanical obstruction or stricture

• Dysphagia of liquids is suggestive of neurological, muscular or achalasia

Question 16

What is an OGD?

Answer 16

Oesophago-gastro-duodenoscopy

Question 17

What are the guidelines on referring patients suspected of Oesophageal cancer?

Answer 17

Offer URGENT direct access upper gastrointestinal endoscopy (to be performed within 2 weeks) to assess for oesophageal cancer in people:

1. With dysphagia OR
2. 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

Question 18

When gaining consent from a patient for a procedure, what points need to be covered?

Answer 18

1. 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.
2. 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.
3. Advise on alternatives if pt is not happy
4. 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
5. Assess capacity
6. Direct to NHS choices website for more info + offer for a superior to come have a more detailed chat about the procedure

Question 19

The majority of Oesophageal cancers are what 2 types?

Answer 19

Squamous cell carcinoma (SCC) or adenocarcinoma (ACA)

Question 20

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?

Answer 20

Features:

1. Epigastric pain - made better (duodenal) or worse (gastric) by eating, relieved by antacids, can occur at night
2. Nausea
3. 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

Question 21

Which organism is associated with peptic ulcer disease?

Answer 21

Helicobacter pylori

Question 22

What does ‘triple therapy’ for H.pylori eradication in peptic ulcers?

Answer 22

7-day course of:

1. PPI (e.g. omeprazole, lansoprazole or esomeprazole)
   
   • H2-receptor antagonist if PPI not tolerated
2. Clarithryomycin
3. Amoxicillin or metronidazole

Question 23

What are the 3 methods for testing for H.pylori infection?

Answer 23

1. Urea breath test
2. Stool antigen test
3. Blood test for antibodies (less commonly used)

Question 24

What are some risk factors for developing peptic ulcer disease? (6)

Answer 24

1. NSAIDs
2. Smoking
3. Alcohol excess
4. FHx of peptic ulcers
5. Physical stress e.g. major trauma or surgery or ICU admission ‘stress ulcer’
6. Hypersecretory syndromes e.g. Zollinger-Ellison syndrome

Question 25

What is Zollinger-Ellison Syndrome?

Answer 25

**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

Question 26

What are the 3 main complications of peptic ulcers?

Answer 26

1. 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 2. **Perforation** * **​​**More common in the duodenum * Causes peritonitis and pneumoperitoneum 3. Gastric outlet **obstruction** * **​​**Epigastric pain * Postprandial vomiting (after meals) * Normally due to pancreatic cancer or primary gastric cancer

Question 27

Which 2 scoring systems can be used in cases of upper GI bleeding?

Answer 27

1. **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 2. **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

Question 28

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

Answer 28

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)

Question 29

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

Answer 29

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)

Question 30

Who should be screened for Barrett's Oesophagus?

Answer 30

1. Pts with **chronic / severe GORD** (duration \>5yrs or at least twice weekly symptoms or symptoms interfering with QoL) 2. **AND** **at least 3** of: 1. Age \> 50yrs 2. Male 3. Caucasian 4. Obese 5. Smoking 3. **OR** - **FHx** of Barrett's oesophagus or oesophageal adenocarcinoma

Question 31

Define Peptic Ulcer

Answer 31

* 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)

Question 32

How do you treat a peptic ulcer?

Answer 32

Active bleeding ulcer: 1. 1st line = Endoscopy +/- blood transfusion + PPI 2. 2nd line = surgery / interventional radiology H.Pylori positive: 1. 1st line = H.pylori eradication 'triple therapy' 2. 2nd line = Alternative eradication regimen H.Pylori negative 1. 1st line = Full dose PPI for 4-8 weeks (if not on NSAIDs) 2. 2nd line = H2-receptor antagonist 3. Repeat endoscopy in 6-8 weeks to monitor ulcer