Upper GI tract

Question 1

What’s the anatomical location of a pharyngeal pouch?

Answer 1

Posteromedial diverticulum through Killians dehiscence.

Above oesophageal sphincter (c5-c6)

Question 2

What’s the treament for bleeding oesophageal varices?

Answer 2

Terlipressin,
Endoscopy with endoscopic variceal band ligation.
Sengstaken- blakemore tube
Transjugular intrahepatic portosystem shunt

Question 3

What’s the preventative management of variceal haemorrhage?

Answer 3

Propanaolol

Endoscopic band ligation

Question 4

Referral guidelines for urgent upper GI cancer?

Answer 4

1) all dysphasia
2) all upper abdominal masses
3) pt >55 with weight loss and upper abdominal mass or reflux or dyspepsia.

Question 5

Referral guidelines for non-urgent upper GI cancer?

Answer 5

1) patients with haematemesis
2) pts >55 with treatment resistant dyspepsia, upper abdo pain and low Hb levels, raised platelet count, nausea or vomiting with another Reg flag symptom.

Question 6

What drugs must be stopped before a urea breath test for H. Pylori?

Answer 6

Antibiotics - 4 weeks before

Anti secretory - 2 weeks before (eg PPI)

Question 7

Difference in presentation between oesophageal cancer and achalasia?

Answer 7

Cancer dysphagia to solids then progresses to liquids

Achalasia - both solid and liquids cause dysphagia

Question 8

What is the blatchford score?

Answer 8

For first assessment of upper GI bleed.

Considers : urea (raised in blood meal), Hb (low with bleed), blood pressure (shock), other markers: pulse, melena, syncope, hepatic disease, cardiac disease.

Question 9

Treatment for upper GI bleed

Answer 9

1) resuscitation (including platelets, FFP..)
2) urgent endoscopy
If variceal - terlipressin and abx ASAP. Oesophagela do Banding
Gastric do injections of n-butyl-2-cyanoacrylate
Consider TIPS

      If non-variceal -  haemostatis with adrenaline, thermal coagulation, fibrin glue or endoclips.

Question 10

What’s the Rockall score?

Answer 10

Predicts bleeding and mortality

Initial score : age, shock, comorbiditis,

Final score: final dx and evidence of haemorrhage, active bleeding, visible vessel, adherent clot,

Surgery needed if intial score >3 or final >6

Question 11

Whats the management for Barrett’s oesophagus?

Answer 11

High dose PPI and endoscopic surveillance

If dysplasia found need - endoscopic resection or radiofrequency ablation

Question 12

How does gord lead to oesophageal Ca?

Answer 12

Gord - Barrett’s (squamous epithelium becomes columnar) - dysplasia - cancer (adenocarcinoma)

Question 13

What are the investigations for achalasia?

Answer 13

1) manometry - high LOS tone
2) barium swallow - birds beak, expanded oesophagus, fluid level
3) CXR - wide mediastinum, fluid level

Question 14

What is oral hairy leukoplakia a sign of?

Answer 14

White patches on the side of the tongue. Seen in EBV, almost always in HIV patients.

Question 15

What is strophic glossittis?

Answer 15

Smooth sore tongue, with loss of papillae.

Sign of iron, b12 or folate deficiency

Question 16

What is geographic tongue?

Answer 16

Discrete areas of depapilation on the dorsum of tongue. Unknown causes.

Question 17

Trouble with salivation and CN VIII palsy indicated what?

Answer 17

?Parotid malignancy

Question 18

Whats the first line test in suspected oesophageal cancer?

Answer 18

Upper GI endoscopy

Then CT CAP for staging

Question 19

What’s the treatment for oesophageal cancer?

Answer 19

Ivor-Lewis oesophagectomy, with stomach moved up into chest and anastomosed with the oesophagus.
Other ways include Mc Keown total oesphagectomy w/ cervical anastomosis.

Challenges are anastomotic leak. Especially causing mediastinitis.

Question 20

What are the causes of oesophagitis?

Answer 20

Infection - HSV/Candida, GORD, drugs - slow release potassium, bisphosphonates

Question 21

How often do people with Barrett’s oesophagus undergo surveillance?

Answer 21

ODG with multiple biopsy every 2/3-5 years.

And are treated with PPIs prophylactically.

Question 22

What is achalasia?

Answer 22

Oesophageal Aperistalisis and failure of LOS to relax. Due to a decrease in ganglionic cells and vagus nerve inervation.

Sx: dysphagia to solids AND liquids, +- regurgitation.

Question 23

What’s the work up for achalasia?

Answer 23

Barium swallow (birds beak) dilated oesophagus and tapered LOS.

Manometry confirms the Dx. PH studies.
ODG to exclude oesophageal cancer,

Question 24

Treatment for achalasia?

Answer 24

1) surgical - Balloon dilation or surgical division of the LOS (Hellers cardiomyotomy).
2) medical Rx - nitrates or nifedipine, or injection of Botox to relax the LOS

Complications - gord, rupture 2%,
2) line used in frail and elderly people

Progression of achalasia to squamous cell cancer.

Question 25

What are the types of hiatus hernia?

Answer 25

Sliding (95%)
Rolling ( paraoesophageal) - more of a risk of gastric volvulus, bleeding and respiratory complications. Treat surgically.

Question 26

What’s the difference between mallory Weiss and boerhaave syndrome?

Answer 26

Both severe vomiting.
MW - mucosal lacerations at gastroesophageal junction causes haematemesis.

BS - oesophageal rupture

Question 27

What is Plummer Vinson syndrome?

Answer 27

Triad : dysphagia (oesophageal webs), glossitis and iron D anaemia.

Question 28

Immediate management of upper GI bleed?

Answer 28

Bloods
X Match
CXR - air under diaphragm
ECG - ischemia ?hypovolemia

Not ODG - until done previous tests

Question 29

When not to give terlipressin in GI bleed

??

Answer 29

PVD - causes vasoconstriction and can cause Critial limb ischemia

Only give if you know that it is variceal
Important to give Abx