Case 17: Swallowing difficulties

Question 1

does the LOS contain muscle

Answer 1

no it is a physiological (functional) sphincter so does not have any specific sphincteric muscle

Question 2

which cells line the lower oesophagus

Answer 2

stratified squamous epithelium

Question 3

which cells line the stomach

Answer 3

columnar epithelium

Question 4

what do surface mucous cells do

Answer 4

secrete a protective coat of alkaline mucus
line gastric glands
prevents stomach from digesting itself

Question 5

what do tight junctions do in the stomach

Answer 5

they are between epithelial cells and they prevent gastric juice from penetrating the underlying tissue

Question 6

what do parietal cells do

Answer 6

what do parietal cells do
produce HCl and intrinsic factor (needed for B12 absorption)

Question 7

what do chief cells do

Answer 7

secrete pepsinogen
HCl cleaves pepsinogen into its active form- pepsin

Question 8

what do eneteroendocrine cells do

Answer 8

secrete various hormones into the interstitial fluid of the lamina propria
one of these hormones is gastrin

Question 9

what do stem cells in the stomach do

Answer 9

they are located where the gastric glands join the gastric pits
they quickly replace damaged epithelial mucosal cells

Question 10

how often is the surface epithelium of the stomach replaced

Answer 10

every 3-6 days

Question 11

differentials for dysphagia

Answer 11

gastrooesophageal reflux
hiatus hernia
oesophageal cancer
oesophageal candidiasis
achalasia
muscle tension dysphagia
diffuse oesophageal spasm
pharyngitis

Question 12

what does dysphagia to solids suggest

Answer 12

structural lesion

Question 13

what does dysphagia to liquids and solids suggest

Answer 13

liquids and solids suggest
myomotility/neurological disorder

Question 14

which type of oesophageal cancer is more common with alcohol and smoking

Answer 14

squamous cell carcinoma

Question 15

which type of oesophageal cancer is more associated with barrett’s

Answer 15

adenocarcinoma

Question 16

which type of oesophageal cancer is more common

Answer 16

squamous cell carcinoma

Question 17

what may predispose/trigger GORD

Answer 17

alcohol
smoking
coffee
mints
citrus
fats

Question 18

most common type of gastric cancer

Answer 18

adenocarcinoma

Question 19

what type of gastric cancer may present with dysphagia

Answer 19

tumour of the gastro-oesophageal junction

Question 20

is gastric cancer more common in men or women

Answer 20

twice as common in men

Question 21

what is barrets

Answer 21

metaplasia change of the distal oesophagus from stratified squamous to columnar epithelium

Question 22

is barrets malignant

Answer 22

no it is premalignant
increases risk of oesophageal cancer by 50 fold

Question 23

when would you consider referral for barrets rather than surveillance

Answer 23

if there is dysplasia

Question 24

when would those with barrets get endoscopes

Answer 24

every 3-5 years

Question 25

what type of cancer is related to virchows node

Answer 25

gastric

Question 26

when would you do 2 week endoscopy wait

Answer 26

dysphagia or 55 or over with weight loss and any of following- upper abdominal pain, reflux, dyspepsia

Question 27

what is first line investigation for dysphagia

Answer 27

ODG (oesophago-gastro duodenoscopy) with biopsy

Question 28

what abnormal bloods may be seen in oesophageal cancer

Answer 28

hypokalaemia due to the inability to swallow potassium rich saliva iron deficiency anaemia/ anaemia of chronic disease LFTs deranged in liver metastases CRP raised in malignancy bone profile (including ALP) may be raised in bone metastases

Question 29

what investigation would you do to identify a stricture

Answer 29

barium swallow

Question 30

why would you use a PET scan for oesophageal cancer

Answer 30

used for staging used before initiating therapy to identify primary tumour sight, locoregional disease and metastases

Question 31

pain with peptic ulcer disease is usually associated with what

Answer 31

hunger

Question 32

2 most common causes of peptic ulcer disease

Answer 32

NSAIDs H.pylori

Question 33

age and sex most commonly affected by peptic ulcer disease

Answer 33

50-70 men= women

Question 34

when does a mallory weiss tear typically occur

Answer 34

after a period of recurrent wrenching, vomiting, coughing or straining

Question 35

treatment for mallory weiss tear

Answer 35

usually self limiting so treatment is supportive

Question 36

do more men or women get malllory weiss tear

Answer 36

more men

Question 37

most common cause of mallory weiss tear in women of childbearing age

Answer 37

hyperemesis gravidarum

Question 38

causes of peptic ulcer disease in order of importance

Answer 38

h.pylori drugs- NSAIDs, bisphosphonates, corticosteroids, potassium supplements, SSRIss, recreational drugs smoking, alcohol consumption and stress zollinger-ellison syndrome

Question 39

how is h.pylori able to survive in the stomach

Answer 39

it migrates to less acidic regions it uses urease enzyme to convert urea to CO2 and ammonia this ammonia neutralises the stomach acid and protects h.pylori

Question 40

what cancers is h.pylori linked with

Answer 40

gastric malt lymphoma

Question 41

criteria for h.pylori testing work

Answer 41

must stop PPI within 14 days of treatment must not of had antibiotics in past 4 weeks retesting is only needed in those with associated peptic ulcer or persistent symptoms despite treatment

Question 42

what is the glasgow blatchford score

Answer 42

screening tool used to assess the likelihood that someone with an upper GI bleed with need to have medical intervention such as a blood transfusion/endoscopic intervention

Question 43

which medication would you give specific for variceal bleeding

Answer 43

terlipressin

Question 44

how does terlipressin work

Answer 44

it acts on the splanchnic circulation to reduce pressure in the portal vein which will help slow or stop bleeding varices

Question 45

two methods of endoscopic treatment for variceal bleeding

Answer 45

banding (cuts off blood supply) trans-jugular intrahepatic portosystemic shunt (TIPS)

Question 46

how does TIPS procedure work

Answer 46

radiologist inserts a stent to connect portal vein to hepatic vein this allows blood to be brought back from the bowel to the heart whilst bypassing the liver this reduces the pressure in the portal vein

Question 47

what are the endoscopic treatments for a peptic ulcer bleed

Answer 47

clips (mechanical) thermal coagulation (heat probe) fibrin and thrombin (haemostatic adjuncts) injection of vasoconstrictors (adrenaline)

Question 48

what does the rockhall score estimate

Answer 48

estimates the risk of rebleeding and overall mortality with upper GI bleeds

Question 49

what factors affect the rockhall score

Answer 49

age shock comorbidities diagnosis major stigmata of recent haemorrhage

Question 50

what drug must be given following peptic ulcer bleed

Answer 50

omeprazole (or other PPI)

Question 51

what artery is the cause for most bleeding due to duodenal ulcers

Answer 51

posterior duodenal ulcers cause bleeding from the gastroduodenal artery most commonly

Question 52

secondary prevention for peptic ulcer bleeding

Answer 52

stop NSAIDs stop smoking stop drinking

Question 53

which symptom indicated gastric cancer rather than any other upper GI cancer

Answer 53

stomach pains (constant burning sensation)

Question 54

what criteria does the glasgow blatchford scale take into account

Answer 54

Hb BUN (urea nitrogen) initial systolic BP sex heart rate over 100 melena present recent syncope hepatic disease cardiac failure

Question 55

what score is considered high risk GI bleed which is likely to require medical intervention on glasgow blatchford

Answer 55

score above 0