Upper GI Presentations Flashcards
What is a Mallory-Weiss tear?
A longitdinal tear in the mucosa around the gastro-oesophageal junction
What generally causes a Mallory-Weiss tear to bleed?
Increased abdominal pressure, usually due to vomiting
What is the typical presentation of a Mallory-Weiss tear?
Small amounts of haematemesis after several episodes of vomiting (most commonly due to alcohol)
What is the management for a Mallory-Weiss tear?
Usually conservative, as the bleeding will generally resolve
What is a hiatus hernia?
When the proximal stomach herniates through the diaphragmatic hiatus
What two kings of hiatus hernia can you get?
Sliding hernia (80%) = Gastroesophageal junction slides up into the chest Rolling hernia (20%) = Gastroesophageal junction remains in abdomen, portion of stomach herniates into the chest
What BMI is associated with hiatus hernias?
Over 30 (obesity)
What is the best diagnostic test for a hiatus hernia?
Barium swallow
What is the treatment for a hiatus hernia?
H2 antagonists, alginates, antacids, proton pump inhibitors and pro kinetic drugs = relieve reflux symptoms
Surgery = symptoms are intractable or complications develop
What are the risk factors for GORD?
Hiatus hernia Smoking Alcohol Pregnancy Systemic sclerosis Drugs (e.g. nitrates, anticholinergics) Obesity Age
What happens to the lower oesophageal sphincter tone in GORD?
It is decreased
What condition can result from long term GORD?
Barrett’s Oesophagus
Which change occurs in the epithelium in Barrett’s Oesophagus?
Metaplastic change from squamous to columnar epithelium
How do nitrates affect the symptoms of GORD?
Usually aggravate symptoms
Which value is likely to be raised in an Upper GI beed?
Serum urea
Due to metabolism of amino acids from protein rich blood contents
Why is there a change in lower oesophageal tone in GORD?
Usually due to increased intra-abdominal pressure
What are the symptoms of GORD?
Heartburn (particularly when lying down, stooping, straining or after meals) Belching Acid or bile regurgitation Waterbrash (mouth fills with water) Odynophagia Nocturnal asthma Chronic cough Laryngitis Sinusitis
What are the potential complications of GORD?
Oesophagitis Ulcers Benign strictures Iron deficiency Metaplastic change (Barrett's Oesophagus)
How is damage to the oesophagus by GORD graded?
Grade 1 = erosions less than 5mm
Grade 2 = erosions more than 5mm
Grade 3 = less than 75% of lower oesophagus involved
Grade 4 = more than 75% of lower oesophagus involved
Which medications can be used to treat GORD?
Antacids
H2 receptor antagonists
Proton Pump Inhibitors
How do antacids help in GORD?
Relieve reflux by coating the lower oesophageal lining
Only relieve symptoms, do not prevent complications
How do H2 receptor antagonists help in GORD?
Cause acid suppression
Symptoms can worsen on stopping medication
How do PPIs help in GORD?
Effective at both reducing acid secretion and preventing acid related damage
Timing is important for these drugs
When might surgery be considered for GORD, and what are the aims of surgery?
Ongoing symptoms despite medication, or poor tolerance to medication
Keyhole laparoscopic surgery to physically repair the damaged sphincter
In which type of hiatus hernia is acid reflux more common?
Sliding hiatus hernia
What are the symptoms of achalasia?
Dysphagia
Regurgitation
Substernal cramps
Weight loss
What caused achalasia?
Lower oesophageal sphincter fails to relax
Food cannot easily enter the stomach and so oesophagus fills with food
usually accompanied by poor oesophageal motility
How is achalasia diagnosed?
Barium swallow = shows dilated tapering oesophagus
How is achalasia treated?
Endoscopic balloon dilatation
Heller’s cardiomyotomy
Botox injections for a non-invasive treatment
What are the two types of oesophageal cancer?
Adenocarcinoma (reflux->Barret’s)
Squamous Cell Carcinoma (smoking and alcohol)
What types of gastric cancer can occur?
Adenocarcinoma (H.pylori, environmental)
Lymphoma
GISTs (cancers of muscle layer)
How might oesophageal cancer present?
Dysphagia Odynophagia Upper GI haemorrhage Anaemia Weight loss
How might gastric cancer present?
Subtle, non specific symptoms Dyspepsia Upper GI haemorrhage Anaemia Weight loss Abdominal mass Anorexia/early satiety Vomiting
How is oesophago-gastric caner diagnosed?
Upper GI endoscopy
also colonoscopy if presenting symptom is anaemia
How do you stage oesophageal cancer?
CT thorax/abdomen
CT/PET, EUS, Laparoscopy
Search hard for metastatic disease
What are the palliative options for oesophageal cancer and pros/cons?
Stenting - BEST
Radiotherapy - can shrink tumour and aid swallowing without need for stent
Chemotherapy - almost no benefit
What are the potentially curative options for oesophageal cancer?
Surgery with or without NAC
Radical chemoradiotherapy
How do you stage gastric cancer?
CT thorax/abdomen
Laparoscopy
Search hard for metastatic disease
What are the palliative options for gastric cancer and pros/cons?
Radiotherapy - generally reserved for bleeding
Chemotherapy - almost no benefit
What are the potentially curative options for gastric cancer?
Surgery with or without NAC
What is the prognosis for oesophageal cancer?
Dismal
11% 5 year survival, most die within 1 year
What are the adverse prognostic factors for oesophageal cancer?
Oesophageal obstruction
Tumour longer than 5cm
Metastatic disease
What is the prognosis for gastric cancer?
15% 5 year survival
What are the adverse prognostic factors for gastric cancer?
Metastatic disease Short history Advanced age Proximal lesion Locally advanced lesion Superficial gross appearance
What is the definition of dyspepsia?
Epigastric pain or burning
Postprandial fullness
Early satiety
What are the organic causes of dyspepsia?
Peptic ulcer disease
Drugs (NSAIDs, COX2 inhibitors)
Gastric cancer
What are the function causes of dypepsia?
Idiopathic
No evidence of causative structural disease
Accounted with other functional gut disorders (IBS etc)
What might be found on examination of uncomplicated dyspepsia?
Epigastric tenderness only
What might be found on examination of complicated dyspepsia?
Cachexia
Mass
Evidence gastric outflow obstruction
Peritonism
What is the management of dyspepsia in the absence of alarm symptoms?
Check H.pylori status
Eradicate if infected
If negative, treat with acid inhibition as needed
What are the causes and risk factors for peptic ulceration?
H. Pylori NSAIDs Steroids Aspirin Zollinger Ellison Syndrome Stress
What is the common presentation of peptic ulcer disease?
Epigastric pain
Usually occurring at night or before meals
Relieved by drinking a glass of milk
How are peptic ulcers diagnosed?
Endoscopy
What is the treatment for H.Pylori +ve peptic ulcers?
PPI
Amoxicillin or metronidazole and clarythromycin for 1 week
What is the treatment for H.Pyori -ve peptic ulcers?
H2 receptor antagonist
PPI
What is H.Pylori and how is it spread?
Gram negative microaerophilic flagellated bacillus
Oral-Oral/faecal oral spread
Usually acquired in infancy, with complications arising after in life
What are the consequences of H.Pylori infection?
Majority = No pathology
20-40% = Peptic ulcer disease
1% =Gastric cancers
How are H.Pylori and duodenal ulcers connected?
Increase in gastrin release leads to increased acid secretion
This increases duodenal acid load, causing gastric metaplasia, H.Pylori colonisation and ulceration
How is H.Pylori infection diagnosed?
Gastric biopsy
Urease breath test
Faecal antigen test
Serology (less accurate in older patients)
What are the complications of peptic ulcer disease?
Anaemia
Bleeding
Perforation
Gastric outlet/duodenal obstruction
What is the follow up for duodenal ulcers?
None needed if uncomplicated
Only follow up with ongoing symptoms
What is the follow up for gastric ulcers?
Endoscopy at 6/8 weeks
Ensure healing and no malignancy
What is the most likely cause of haematemesis in a jaundiced patient?
Oesophageal varices (due to portal hypertension)
What is the most likely cause of haematemesis in a young patient with a sore knee?
Peptic ulcer
due to NSAIDs
What is the most likely cause of haematemesis in a patient with a two month history of increasing dysphagia?
Oesophageal cancer
Which factors indicate a severe upper GI bleed?
Low BP
Tachycardia
Postural hypotension
What is the initial management of an upper GI bleed?
Resuscitation: Airway protection Oxygen IV access Fluids HDU Senior review
What drugs should you consider giving someone with an upper GI bleed?
IV terlipressin = Management of portal hypertension
IV septrin = Prophylactic antibiotics
What fluids should be given to someone with an upper GI bleed?
Cross matched blood
may give gelofusine or O -ve in the meantime if urgent
How do you treat an upper GI bleed due to oesophageal varices?
Endoscopic banding
If endoscopy fails to treat bleeding oesophageal varices, what would be done next?
C Sengstaken Blakemore Tube
How does eating affect gastric pain caused by peptic ulcers?
Duodenal = Pain relieved by eating Gastric = Pain worsened by eating
What is the more likely cause of dysphagia to solids and liquids from the start?
Motility disorder
Achalasia, CNS or pharyngeal causes
What is the more likely cause of worsening dysphagia (e.g. solids then liquids)?
Stricture - benign or malignant
What is the more likely cause of dysphagia where there is difficulty in making the swallowing movement?
Bulbar palsy, especially if the patient coughs on swallowing
What are the more likely causes of dysphagia if there is accompanying odynophagia?
Cancer
Oesophageal ulcer - benign or malignant
Candida
Spasm
What is the more likely cause of intermittent dysphagia?
Oesophageal spasm
What is the more likely cause of constant and worsening dysphagia?
Malignant stricture
What is the more likely cause of dysphagia where the neck bulges or gurgles on drinking?
Pharyngeal pouch
What are the alarm symptoms associated with dyspepsia and peptic ulcer disease?
Anaemia Loss of weight Anorexia Recent onset or progressive symptoms Melaena/haematemesis Swallowing difficulty
