Week Ten - Case Two Flashcards
according to the NICE guidelines, how should you organise an urgent direct access upper GI endoscopy
1.3
Referral guidance for endoscopy links to NICE guidelines on suspected cancer: recognition and referral for patients with dysphagia or those over the age of 55 with weight loss and either upper abdominal pain, reflux or dyspepsia
what is GORD
describes the symptomatic passing of gastric contents back up into the oesophagus.
what is the pathophysiology of GORD
the pathology is complex and can involve the abnormal transient relaxation of the LOS, impaired oesophageal clearance and delayed gastric emptying that increase gastric pressure
what is GORD also associated with
also associated with hiatus hernia where a weakness in the curial diaphragm allows the proximal stomach to pass upwards into the chest
what are the risk factors for GORD
Smoking and alcohol
Obesity
Stress
Hiatus hernia
Pregnancy
Trigger foods
Medications that reduce the lower oesophageal sphincter tone (such as NSAIDS and beta-blockers)
for patients where cancer is not suspected, what is organised?
a routine upper GI endoscopy can be organised for patents who do not respond to acid suppression therapy such as proton pump inhibitors
what can objectively assess the degree of reflux as well as the motility of the oesophagus for those who are being considered for surgery
oesophageal manometry and ambulatory 24 hour oesophageal pH monitoring
what are the surgical options used to treat GORD
Nissen fundoplication
this is usually performed laparoscopically and involves wrapping the funds of the stomach around the lower oesophagus to reinforce the lower oesophageal sphincter
what are the potential complications resulting from untreated GORD
benign stricture
Barrett’s oesophagus
oesophagi’s
chronic cough
recurrent chest infections
what are the indications for surgery in GORD treatment
failure of medical therapy, desire to discontinue medical therapy or the presence of a hiatus hernia
what kind of lining does the oesophagus have
a squamous epithelial lining that makes it more sensitive to the effects of stomach acid
the stomach has a columnar epithelial lining that is more protected against stomach acid
what are the causes and triggers of GORD
Greasy and spicy foods
Coffee and tea
Alcohol
Non-steroidal anti-inflammatory drugs
Stress
Smoking
Obesity
Hiatus hernia
what is dyspepsia
non-specific term used to describe indigestion
what symptoms does dyspepsia cover
Heartburn
Acid regurgitation
Retrosternal or epigastric pain
Bloating
Nocturnal cough
Hoarse voice
what are the red flags
Dysphagia (difficulty swallowing) at any age gets an immediate two week wait referral
Aged over 55 (this is generally the cut-off for urgent versus routine referrals)
Weight loss
Upper abdominal pain
Reflux
Treatment-resistant dyspepsia
Nausea and vomiting
Upper abdominal mass on palpation
Low haemoglobin (anaemia)
Raised platelet count
what is the most critical red flag
dysphagia is a critical red flag, any patient presenting with the feeling that food is getting stuck on the way down needs an urgent two week wait referral for an endoscopy
what is an OGD
involves inserting a camera through the mouth down to the oesophagus, stomach and duodenum
what can OGD be used to assess for
Gastritis
Peptic ulcers
Upper gastrointestinal bleeding
Oesophageal varices (in liver cirrhosis)
Barretts oesophagus
Oesophageal stricture
Malignancy of the oesophagus or stomach
patients with what symptoms, need admission and urgent endoscopy?
patients with evidence of upper GI bleeding - melaena or coffee ground vomiting
what does hiatus hernia refer to
a herniation hernia is when the stomach goes up through the diaphragm
where should the diaphragm opening be
at the LOS level and fixed in place. a narrow opening helps to maintain the sphincter and stops acid and stomach contents from refluxing into the oesophagus
when the opening of the diaphragm is wider, the stomach can enter through the diaphragm and the contents of the stomach can reflux into the oesophagus
what are the four types of hiatus hernia
Type 1: Sliding
Type 2: Rolling
Type 3: Combination of sliding and rolling
Type 4: Large opening with additional abdominal organs entering the thorax
what is a sliding hiatus hernia
A sliding hiatus hernia is where the stomach slides up through the diaphragm, with the gastro-oesophageal junction passing up into the thorax.
what is a rolling hiatus hernia
A rolling hiatus hernia is where a separate portion of the stomach (i.e., the fundus), folds around and enters through the diaphragm opening, alongside the oesophagus.
what is type 4 hiatus hernia
Type 4 hiatus hernia refers to a large hernia that allows other intra-abdominal organs to pass through the diaphragm opening (e.g., bowel, pancreas or omentum).
what is the management of GORD
Lifestyle changes
Reviewing medications (e.g., stop NSAIDs)
Antacids (e.g., Gaviscon, Pepto-Bismol and Rennie) – short term only
Proton pump inhibitors (e.g., omeprazole and lansoprazole)
Histamine H2-receptor antagonists (e.g., famotidine)
Surgery
what is the usual medical stragety when someone presents for the first time
The usual medical strategy when someone presents for the first time is to exclude red flags, address potential triggers, offer a 1 month trial of a proton pump inhibitor and consider H. pylori testing.
what is the surgery for reflux called
Surgery for reflux is called laparoscopic fundoplication. This involves tying the fundus of the stomach around the lower oesophagus to narrow the lower oesophageal sphincter.
what is Zollinger-Ellison syndrome
is a rare conditon where a duodenal or pancreatic tumour secretes excessive quantities of gastrin.
what Is gastrin
it is a hormone that stimulates acid secretion in the stomach.
what are gastrin secreting tumours associated with
multiple endocrine neoplasia type 1 (MEN1), an autosomal dominant genetic condition, which can also cause hormone-secreting tumours of the parathyroid and pituitary glands
