Upper GI tract Flashcards
Define hiatus hernia with regard to anatomical type (sliding and paraoesophageal).
Sliding - Cardia and some of the fundus slide superiorly into the thorax.
Paraoesophageal - a pouch of the peritoneum, often containing the fundus of the stomach extends through the oesophageal hiatus (also contains vagus nerve) anterior to the oesophagus.
Bochdalek and Morgagni are congenital hernias due to diaphragmatic malformation.
List the anatomical and physiological factors predisposing to gastrooesophageal disease.
Anatomical: Trauma, obesity, pregnancy, diaphragm malformations, poor posture, sphincter dysfunction.
Physiological: Spicy food, NSAIDs, H Pylori, alcohol/smoking, Zollinger-Ellison syndrome.
Name three typical symptoms of gastro-oesophageal reflux disease (GORD).
The 3 cardinal symptoms of reflux disease are: Retrosternal burning pain,
Waterbrash/acid regurgitation,
Dysphagia/odynophagia.
Other symptoms include night cough (assoc w/ aspiration), nausea, laryngitis and tooth decay. The pain may be mistaken for angina if it has a spasmodic character to it..
Describe the investigations used to confirm a diagnosis of GORD.
Endoscopy used to establish some of the causes: malignancy, Barretts oesophagus, oesophagitis, hiatus hernia.
Barium meal/swallow can diagnose anatomical problems.
Younger patients may be placed on therapy and if the problem subsides, they are diagnosed.
A 24 hour pH test may also be used. If pH drops below 4 for over 6% of the monitored duration, then diagnosis made.
What is the definition of dysphagia?
Difficulty or discomfort swallowing.
List the common causes and discuss the main investigations for dysphagia.
Intraluminal: Inflammation, malignancy, foreign body, infection.
Intramural: Achalasia, oesophageal spasm, oesophageal web, strictures.
Extramural: Hiatus hernia, malignancy, pharyngeal pouch.
Neuromuscular: Parkinson’s, MG, MS, stroke.
List the symptoms suggestive of an oesophageal malignancy.
Progressive dysphagia (first with solids, then liquids).
Weight loss and anorexia (due o increased metabolic demands and dysphagia).
Pain with food impaction.
Lymphadenopathy.
Less common: Early satiety and haematemesis.
Describe the pathology and natural history of a malignant lesion of the oesophagus.
Adenocarcinomas - Arise in the lower third of the oesophagus, may be preceded by Barretts oesophagus (metaplasia) caused by chronic acid reflux. They metastasise early to lymph nodes
Squamous cell carcinomas - Arise in the middle section of the oesophagus at the level of the carina (may cause fistulation) or less commonly at the level of the cricoid cartilage (Plumer-Vinson syndrome).
Tumours may narrow the lumen or cause a polypoid mass. In both forms, the tumour grows both proximally and distally in the submucosal lymphatics – meaning the surgeon has to remove the tumour with wide margins.
Risk factors include: Strictures, achalasia, obesity, smoking, alcohol, a diet low in fruit and fish, breast cancer radiotherapy and coeliac disease.
List the main causes of peptic ulcer disease.
H.Pylori, Zollinger-Ellison syndrome, NSAIDs, steroids, SSRIs, excess coffee/acid intake, smoking.
Describe the relationship between H.Pylori, smoking and NSAIDs and peptic ulcer disease, and the mechanisms by which they cause peptic ulceration.
90% of DU and 70% of GU due to H.Pylori.
H.Pylori may cause gastritis in the antrum by causing a local inflammatory response.
CagA protein inserted into cells causing changes in cell morphology, apoptosis and replication.
VacA causes vacuole formation and suppresses immune function.
This leads to decreased somatostatin release from D cells, decreasing inhibition of gastrin release from G cells. This results in increased acid production by parietal cells.
Smoking decreases mucosal healing.
NSAIDs inhibit COX enzymes, importntly, COX-1 in the stomach, inhibiting prostaglandin synthesis, which decrease acid production and increase bicarbonate and mucus secretion.
Prostaglandins may also increase blood flow to the stomach, increasing healing.
List the symptoms of peptic ulcer disease and discuss differences between gastric and duodenal ulcer.
Peptic ulceration causes a localised burning epigastric pain which may radiate to the back. The pain may be worse (GU) or better (DU) upon eating and is most likely worse/only at night. Weight loss/anorexia may accompany this pain. Bleeding/perforation may occur which may be noticed in vomit/faeces, although vomiting is not always present. Perforation into adjacent structures such as the transverse colon may cause fistulation.
The natural history of the disease may take 2 paths.
1 Relapse and remittance over a number of years due to atrophic gastritis and decreased acid secretion.
2 Acutely via anaemia, haematemesis or acute perforation.
DUs tend to occur in a younger demographic, in patients between 45-55 years old, with GUs occurring in 55-65 year olds. DUs are 2-3 times more common than GUs.
Discuss the investigation of peptic ulcer disease and the role of endoscopy.
Endoscopy is capable of visualising ulceration and should be given to patients displaying ALARMS<55 symptoms (Anaemia, loss of weight, anorexia, rapid onset, melaena/haematemesis, swallowing problems, age<55).
All ulcers should be biopsied to rule out cancer.
Urea breath test is also used where patients ingest 13C urea and breath out 13C02. Over 96% sensitive and specific for identification of H.Pylori.
List the symptoms, signs of acute upper and lower gastrointestinal bleeding.
Cardinal symptoms: Malaena and haematemesis (appear due to a bleed proximal to the caecum).
Haematechezia in haemorrhage or shock may also occur.
In severe intravascular volume depletion postural hypotension may occur.The Rockall and Blatchford scores assess risk of rebleed and mortality on the following criteria: age, co-morbidity, shock, endoscopic Dx, ulcer, chronic liver disease.
Pain may be present.
Signs include pallor and sweating.
Outline conditions where such upper GI haemorrhage can occur
Chronic peptic ulcer (50%) – need to eradicate H. Pylori. If bleeding not controlled, surgical ligation. Adrenaline injection, thermal coagulation and PPI may be indicated.
Gastric Ca – oozing is difficult to control endoscopically, but not usually large bleeds
Oesophageal varices (10-20%) should be banded.
Mallory-Weiss tear (5-10%) – tear at GOJ after sudden IAP increase. Classically seen after
alcoholic “dry heaves”. Most bleeds are minor and discharge w/in 24hrs.
Bleeding after PCI – 2% of patients undergoing PCI, mortality rate 5-10%. PPI should be given
IV. Difficult to manage, as prevalence of concurrent anti-platelet treatment is high. High
Rockall scores would suggest risk:benefit ratio in favour of stopping anti-platelets.
Reflux oesophagitis (2-5%)
Haemorrhagic erosion and gastropathy (15-20%) (rebleed).
Outline the causes of lower GI bleeding.
Crohn’s ulcers, diverticula, colon cancer, anal fissures, haemorrhoids, ischaemic colitis, angiodysplasia, polyps.
Risk factors for gastric neoplasm
2:1 ratio men:women. H. Pylori Smoking Pernicious anaemia High salt diet Pickled foods Family history Blood group A
List the symptoms and signs that would suggest gastric cancer.
Nausea and vomiting (severe and frequent)
Epigastric pain (constant and severe, relieved by antacids)
Weight loss
Anaemia via occult blood loss
Palpable Virchow’s lymph node
Palpable epigastric mass
Other symptoms are due to metastasis: Jaundice, ascites, bone pain, epilepsy, SOB.
Describe the classification and morphology of gastric cancers.
Majority of gastric cancers are adenocarcinomas (90%) with most of them arising in the antrum.
Type 1 Intestinal- Tubular structures where H.Pylori infection is common.
May have multiple lumens.
Ulcerative or polypoid
Type 2 Diffuse- Signet ring shaped cells which cause linitus plastica and infiltration.
Tightening and thickening of mucosa causes a decrease in stomach capacity.
Describe the natural history of gastric cancers.
Gastric cancers may infiltrate through the peritoneum to cause malignant ascites.
Metastasis may occur to the ovary to give “Krukenberg” tumour, or to the umbilicus to give “Sister Mary Joseph’s nodule”.
Other tumours include GIST (GI stromal tumours) primary gastric lymphoma and gastric polyps.
List diagnostic methods used to investigate patients with suspected gastric neoplasia.
Gastroscopy and biopsy are used to make diagnosis.
CT used to stage cancer.
Specify a definition of the term “the acute abdomen”.
“An acute abdominal condition that causes the patient to be hospitalised within a few hours of the onset of pain.”.
Identify the cardinal symptoms of the acute abdomen.
Inflammation - Nausea, Pain
Obstruction - Pain, nausea and vomiting, absolute constipation.
Perforation - Bleeding, peritonitis, pain, hypotension.
Organic pathology - specific signs, referred pain.
List differential diagnoses for Acute RUQ pain
Cholecysitis, ascending cholangitis, acute hepatitis, pancreatitis, pleural rub.
List DDx for acute Epigastric pain.
GORD, peptic ulcer, MI.
List DDx for acute LIF pain.
Diverticulitis, bowel obstruction, gynaecological problems (ruptured/torted ovarian cysts, salpingitis).
List DDx for acute RIF pain.
Appendicitis, pyelonephritis, renal colick.
Identify and define the physical findings associated with the acute abdomen and relate these to the basic underlying pathology.
Patient may look ill, pale, sweaty, tachycardic with a weak pulse.
Guarding and rigidity suggest peritonitis.
High pitched tinkling sounds suggest fluid obstruction.
Distention suggests obstruction.
Fever may be present.
Select appropriate laboratory and ancillary studies to further define a cause for an acute abdomen.
FBC (Hb + WBC), CRP + ESR, lactate, U+Es, serum amylase, pregnancy test.
Erect CXR, Supine AXR, USS, CT, E/MRCP.
Laparoscopy.
Outline the appropriate initial management of a patient with an acute abdomen.
ABCDE: IV Fluids, Oxygen, Analgesia.
Insert catheter for fluid balance, NG tube for drain/feeding (patient should be kept NBM).
History and examination should be undertaken and the necessity of theatre assessed.
List the symptoms and signs of acute appendicitis.
Dull ache in umbilical region progressing to a sharper pain in the RIF.
Associated N/V
Rebound tenderness at McBurneys point
In perforation - pyrexia, tachycardia, tachypnoea.
