Upper GI tract Flashcards
Dysphagia
difficulty swallowing
different types, solids vs fluids, intermittent vs progressive, precise vs vague
Can be either in the cricopharyngeal sphincter or distal
odynophagia
Painful swallowing
Regurgitation
Expulsion of undigested food from the oesophagus
reflux
passive return of gastroduodenal contents to the mouth.
Very acidic, can cause decay of teeth
What is an example of hypermotility?
Achalasia
Why does achalasia occur?
Loss of ganglion cells in Aurebach’s myenteric plexus, decreased activity of inhibitory NCNA neurons
What can achalasia be caused secondary to?
Immune dysfunction/diseases causing oesophageal motor abnormalities
Chagas’ Disease - parasitic usually endemic to south america
Protozoa Infection
oesinophilic oesophagitis- young children
How does the oesophagus appear in achalasia?
Bird’s beak - dilation of oesophagus
Why does the oesophagus dilate in achalasia?
Muscles contracted, food cannot pass through, stuck in oesophagus
What condition is much higher in risk with achalasia?
Oesophageal Cancer (28 times)
sp squamous cell
Disease course of achalasia
Insidious onset - symptoms for years
What is the treatment for achalasia?
Pneumatic Dilatation - stretching of oesophagus and sometimes tearing muscle fibres
Radiologically or endoscopically
Can also have botox to the oesophagus
What is the efficacy of this pneumatic dilatation like?
Most patients respond initially but relapsing is common
What are the two surgical techniques for achalasia?
Heller’s Myotomy - slight incision on oesophagus and stomach to loosen pressure. Longitudinal incision.
Dor Fundoplication - wrapping fundus of stomach around oesophagus to prevent reflux
Risks of surgery for achalasia
Oesophageal and gastric perforation
division of vagus nerve
splenic injury
What is an example of hypomotility?
starting with S
Scleroderma - autoimmune disease
What is the resting pressure of the Lower OS in scleroderma compared to normal?
Decreased
What condition can develop as a result of scleroderma?
GORD
What syndrome is often associated with scleroderma?
CREST Syndrome
C - calcinosis, calcium deposits
R - raynaud’s, blood flow issues
E - esophageal dysmotility, dysphagia
S - sclerodactyly, thickening of finger skin
T - telangiectasia, red spots due ot wide blood vessels
systemic sclerosis
How would you treat scleroderma?
Exclude obstructions // Improve peristalsis with prokinetics (cisapride)
What is an example of disordered coordination?
Corkscrew Oesophagus
What is incoordinate contraction of the oesophagus known as?
Diffuse oesophageal Spasm
What muscle do you see hypertrophy of in corkscrew oesophagus?
Circular muscle
What symptoms do you see in corkscrew oesophagus?
Dysphagia and chest pain
How can you treat corkscrew oesophagus?
Forceful pneumatic dilation of cardia
Which areas of the oesophagus are more prone to oesophageal perforations?
Areas of anatomical contraction (cricopharyngeal, aortic/bronchial, diaphragmatic)
What is the most common aetiology of oesophageal perforation?
Iatrogenic (usually from OGD - Oesophagogastroduodenoscopy)
more common in derverticula or cancer
Which is the most common site of oesophageal perforation?
Killian’s Triangle (near cricopharyngeal)
What are other conditions that cause oesophageal perforation?
Boerhaave’s Syndrome, Foreign Body, Trauma
What is happens in Boerhaave’s Syndrome, and what is pressure like?
Spontaneous oesophageal perforation due to ^ oesophageal pressure + -ve intrathoracic pressure. Usually as a result of forced vomiting
Results in leak of contrast with CT/barium swallow, usually into the left chest
Common in alcoholics
What foreign objects are particularly harmful when causing oesophageal perforation?
Disk batteries - cause electrical burns
magnets
sharp objects
dishwasher tablets
acid/alkali - cause burning or stricture of the oesophagus
Trauma causing oesophageal perforation presentation
dysphagia
blood in saliva
haematemesis
surgical emphysema
What are the most common presentations of oesophageal perforations?
Pain, Fever, Dysphagia, Emphysema
Gas in the mediastinum
What is the primary management for oesophageal perforation?
Surgical emergency
Nil by mouth, IV fluids
ITU
Bloods (type)
Tertiary referral
What is a conservative management of oesophageal perforations?
Cover the oesophagus with a metal stent, allows eating
Temporary
What is a operative management of oesophageal perforations?
Primary repair is optimal
oesophagectomy, oesophagus joined to the stomach
What is the stomach’s main protective mechanism against reflux?
Closing of Lower OS as a result of increased pressure caused by parasympathetic nervous system
What are the other protective mechanisms against reflux?
Oesophageal Peristalsis Reflex (volume clearance)
Saliva (pH clearance)
Epithelium (barrier)
Disruptions that lead to increase in risk of GORD
Decreased sphincter pressure
Decreased saliva production
What type of hernia causes GORD?
Sliding Hiatus Hernia
What is the difference between a sliding hernia and a rolling hernia?
Rolling hernias - stomach is next to the oesophagus and. moves up in the chest
Sliding hernia - stomach and oesophagus move up and down. stomach moves up into the oesophagus
What is the other name for rolling hiatus hernias?
Paraoesophageal Hiatus Hernia
What investigations would you do for GORD?
OGD,
Manometry,
24H pH recording
What medical treatments would you do for GORD?
Lifestyle Change (weight loss, smoking)
PPIs
What surgical treatments would you do for GORD?
Dilatation peptic strictures,
Laparoscopic Nissen’s Fundoplication (wrap fundus over oesophagus)
Functions of the stomach
- Breakdown of food
- Holds food, releasing it at a steady state tot he duodenum
- kills parasites and certain bacteria
What are the five regions of the stomach?
Cardia (at junction), - mucus
Fundus (top), - mucus, HCL, pepsinogen
Body, - mucus, HCL, pepsinogen
Antrum, - gastrin
Pyloric Region - mucus
What are 4 types of gastritis?
Erosive&Haemorrhagic
Nonerosive Chronic
Atrophic
Reactive
What is a cause for each type of gastritis?
E&H (acute ulcer)
NC (H. Pylori)
Atrophic (autoantibodies)
Reactive (alcohol, steroids)
What can stimulate gastric secretion?
Neural - ACh // Endocrine - Gastrin // Paracrine - Histamine
What can inhibit gastric secretion?
Endocrine - Secretin // Paracrine - Somatostatin // Paracrine & Autocrine - Prostaglandins, TGF-Alpha
What is an ulcer?
A damage to epithelium
What are four elements of mucosal protection against ulcers?
Mucus film, HCO3- secretion, Epithelial barrier, Mucosal blood perfusion
What are the three mechanisms of repairing epithelial damage in ulcers?
Migration of epithelial cells // Cell growth (by TGF) // Acute wound healing (regeneration of ECM)
What is the primary medical treatment for ulcers?
PPI or H2 Blocker,
Triple Treatment (amoxicillin, clarithromycin, pantoprazole)
What are the surgical indications for ulcers?
If medical treatment doesn’t work
Continual need of NSAIDs,
Complications (haemorrhage, obstruction, perforation)
Oesophagus origins and musculature
Made of both skeletal and smooth muscle. Becomes smooth as it decreases
Origin C4-C5
Ends at T10, oesophageal hiatus
Blood supply of the oesophagus
Thoracic oesophagus supplied by the aorta, superior aspect also supplied by the inferior thyroid artery
Venous drainage via azygous vein - systemic circulation
Abdominal oesophagus supplied by the left gastric artery and the phrenic artery
venous drainage via portal vein
Lower Oesophageal Sphincter
Surrounded by diaphragm
Supported by the Phrenoesophageal ligament, anchors oesophagus to the diaphragm
What is the angle at which the oesophagus enters the diaphragm at called?
Angle of His
Allows valve like action, to prevent reflux
What are the four phases of swallowing?
Stage 0: Oral (preparing bolus, sphincters constricted)
- chewing, saliva breakdown
Stage 1: Pharyngeal (Upper OS opens, pharyngeal muscles push bolus down, Lower OS opens via vasovagal reflex)
Stage 2: Upper Oesophageal (Upper OS closes, Superior circular muscle rings contract, inferior rings dilate; sequential contraction of longitudinal muscle)
Stage 3: Lower Oesophageal (lower sphincter closes as soon as food passes through)
What reflex opens the Lower Oesophageal Sphincter?
Vasovagal Reflex - Receptive Relaxation Reflex
How can you measure the pressure of the oesophagus?
Manometry
determines oesophageal motility
What neurons maintain the Lower OS pressure?
Inhibitory NCNA (non-cholinergic, non-adrenergic) Neurons in myenteric plexus
What is a stricture?
A restriction in movement
What are the causes of absent strictures?
Hyper/Hypomotility , Disordered Coordination , GORD
What do you test for in ulcer treatment?
Serum gastrin (Zollinger-Ellison Syndrome)
