GORD, Oesophageal Ca, Hiatus Hernia

Question 1

What are the long-term complications of reflux?

Answer 1

Oesophagitis
Strictures
Barrett’s

Question 2

What are the symptoms of GORD?

Answer 2

Heartburn: Postprandial, lying, relieved by antacids
Belching
Acid brash: acid/bile regurg
Water brash: ↑↑salivation 
Odynophagia: Painful swallowing = ulcers/oesophagitis
Nocturnal asthma/Chronic cough
Laryngitis/hoarseness
Sinusitis

Question 3

What symptoms of GORD would be a cause for concern?

Answer 3

ALARMS:
Anaemia
Loss of weight
Anorexia
Recent/refractory/progressive symptoms
Melaena/haematemesis
Swallowing difficulty

Question 4

What investigations would you do for GORD?

Answer 4

Trial of PPI- if Sx don't improve then:
Endoscopy- Stop PPI 2 weeks prior
Bloods: FBC (anaemia)
Barium swallow (screening for hiatus hernia)

Question 5

How is GORD managed?

Answer 5

CONSERVATIVE: Raise, bed head, weight loss, stop smoking, dietary changes
MEDICAL: Antacids, PPI
SURGICAL: radio frequency ablation (aim to ↑resting LGOS)

Question 6

How is PPI dose changed depending on endoscopy results?

Answer 6

\+ve OGD: Oesophagitis
PPI 30mg dose 1-2m
Good response = low dose PRN
No response = Double dose for 1m
-ve OGD: Symptomatic
PPI 30mg dose 1m
Response = low dose PRN
No response = H2 antagonist or pro-kinetic 1m

Question 7

What is the Los Angeles classification of GORD?

Answer 7

Endoscopy findings:
 Grade A: breaks of ≤5 mm
 Grade B: breaks >5 mm
 Grade C: breaks extending between the tops of ≥2 mucosal folds, but <75% of circumference
 Grade D: circumferential breaks

Question 8

What is the most common type of oesophageal cancer? Where is it commonly found?

Answer 8

Adenocarcinoma- Lower 1/3rd (Distal) + Barrett’s

Question 9

Where is SCC most commonly found?

Answer 9

Upper 2/3rds (Proximal)

Question 10

What are the RFs of oesophageal cancer?

Answer 10

Male
Diet- ↓in vit.A/C, nitrosamine exposure
Alcohol
Smoking
Achalasia
Obesity
Reflux
Barrett's!

Question 11

What is the clinical presentation of oesophageal cancer?

Answer 11

Progressive dysphagia (solids then liquids)
Odynophagia
Regurg + vomiting (haematemesis/melaena)
Retrosternal chest pain
Hiccups
Lymphadenopathy
↓Weight, ↓Appetite, Fatigue (LATE)

Question 12

What clinical signs are specific to upper oesophageal disease?

Answer 12

Hoarse voice (pressure on recurrent laryngeal nerve/larynx)
Cough (consider aspiration)

Question 13

What investigations need to be done when considering oesophageal Ca?

Answer 13

2WEEK WAIT FOR ENDOSCOPY- Brushing + biopsy = diagnostic

CT/MRI- Staging

Question 14

What are the indications for 2week referral for endoscopy w/regards to oesophageal Ca?

Answer 14

Dysphagia OR age >55
WITH
Weight loss
AND any of
Upper abdo pain, reflux, dyspepsia

Question 15

What is the management for oesophageal Ca?

Answer 15

Radical oesophagectomy
Chemo/RT
Palliative

Question 16

What is a hiatus hernia?

Answer 16

Herniation of the stomach (usually cardia) through oesophageal aperture of diaphragm

Question 17

What are the RFs for a hiatus hernia?

Answer 17

Obesity
Pregnancy
Ascites
↑Age
Trauma: chest/abdo
Skeletal deformities

Question 18

What are the 3 possible mechanisms of a hiatus hernia?

Answer 18

1. Widening diaphragmatic hiatus
2. Oesophageal shortening pulls the stomach up
3. ↑Intra-abdominal pressure Pushes stomach up

Question 19

What are the types of hiatus hernia?

Answer 19

Rolling- GOJ remains in abdo but other part of stomach (cardia) herniates into thorax
Sliding (80%)- GOJ slides into thorax

Question 20

What are the clinical features of a hiatus hernia?

Answer 20

SLIDING:
↑↑↑Reflux – LOS less competent
Dysphagia
ROLLING:
Dysphagia
Chest/epigastric pain
Nausea

Question 21

How is a hiatus hernia investigated?

Answer 21

Barium Swallow: DIAGNOSTIC

Upper GI endoscopy

Question 22

How is a hiatus hernia managed?

Answer 22

Same as GORD to Tx Sx

Surgery: Laparoscopic fundoplication, Gastropexy