Oesophageal Problems Flashcards
1
Q
What is GORD
A
Reflux of gastric contents into the oesophagus
2
Q
What causes GORD [5]
A
Hiatus hernia - size doesn't correlate Increased relaxation of LOS Oesophageal dysmotility Decreased gastric emptying Decreased resistance to bile
3
Q
What can cause oesophagitis (inflammation of oesophagus) [6]
A
GORD, ulcer Hernia Alcohol Biphosphonates, steroid Candida, Herpes Cancer
4
Q
What are the symptoms of GORD [5]
A
Dyspepsia Acid brash Odnyophagia Erosive oesophagitis Sleep disturbance
5
Q
What are the RF for GORD [7]
A
Male, Caucasian Obesity, Pregnancy Alcohol, Smoking Drugs that lower LOS pressure Hypomotility Hypercalcium H.pylori but no role in eradication
6
Q
What drugs affect motility [3]
A
CCB
Nitrate
Anti-cholinergic
7
Q
What drugs cause oesophagitis [4]
A
Biphosphonate
Steroid
NSAID
Theophylline
8
Q
Indications of endoscopy [3]
A
Endoscopy if >55 / alarm symptoms / resistant dyspepsia or refractory to Rx
9
Q
What do you do if endoscopy normal [3]
A
Manometry
pH studies
Barium swallow
10
Q
What is necessary before fundoplication [2]
A
Manometry and pH studies
Barium swallow
11
Q
Oesophageal manometry and pH monitoring
LOS tone
Indications [3]
A
- Oesophageal manometry involves the passage of a thin, pressure sensitive catheter to the lower oesophagus to assess the function of the upper and lower oesophageal sphincter (LOS) and assess oesophageal motility. The normal LOS tone is between 10–30 mmHg.
Indications - Investigation of dysphagia and non-cardiac chest pain.
- Diagnosis and ongoing assessment of patients with GORD.
- Preoperative evaluation of patients with GORD in whom fundoplication or alternative surgery is being considered, to select patients likely to benefit.
12
Q
What does barium swallow look for [2]
A
Motility
Stricture
13
Q
How do you treat GORD [5]
A
Lifestyle measures Alginates - Gaviscon Antacids - PPI - omeprazole H2 - ranitidine if refractory
14
Q
When do you consider fundolipication [2]
A
Refractory to Rx
Severe reflux
15
Q
What are the complications of GORD [6]
A
Oesophagitis
Anaemia if bleed
Strictures
Fibrosis
Impaired motility
Barret’s, Adenocarcinoma
16
Q
What are complications of hernia repair / fundolipication [4]
A
Dysphagia
Diarrhoea
Cant belch / vomit
Bloating
17
Q
What does endoscopy involve: What will the patient need to know? [3]
A
Tube down throat
Can have sedation (midazalam)
Can’t drive for 24 hours or stay by yourself
18
Q
What is Barrets oesophagus [3]
A
Metaplasia
Transformation of squamous to columnar (glandular)
Pre-malignant change to adenocarcinoma
19
Q
What causes Barret
A
Long standing GORD
20
Q
What are the RF for Barret [4]
A
Male
Obesity
Smoking
GORD
21
Q
What is risk of progression to cancer [3]
A
Long segment >3cm vs short segment <3cm
Age
Dysplasia
22
Q
How do you Dx Barret
A
Usually found on endoscopy for upper GI symptoms
23
Q
What reduces risk of transformation. Long term follow up of Barrets? [2]
A
PPI
2 yearly endoscopy + biopsy as surveillance
24
Q
When do you treat Barret [2]
A
If high grade dysplasia or cancer detected
25
How do you treat [3]
Endoscopic mucosal resection
Radiofrequency ablation
Oesophagectomy but high mortality
26
What are the risks of oesophagectomy [2]
Anastomotic leak
| High mortality due to mediastinitis
27
What is dyspepsia [3]
A group of symptoms related to the gut
Non-ulcer if no cause found
Major symptom of GORD
28
What causes dyspepsia: name top 5 causes and 5 others
GORD
Ulcers - duodenal / gastric
Gastritis
Malignancy
Drugs
Other
Pancreatitis
Hepatic / gall bladder
IBS, Celiac
Anxiety
Delayed gastric emptying
29
What symptoms make up dyspepsia [6]
Retrosternal discomfort - related to food / hunger
Less severe than ulcer
Cough
Water brash
Early satiety, Bloating
N+V
30
What are red flag symptoms of dyspepsia? [6]
ALARM
- Anaemia
- Loss of weight
- Anorexia
- Recent onset prog of sx
- Malaena
- Swallowing difficulties
31
What do you do for dyspepsia <55 and no alarm symptoms [4]
Stop drugs / review
Lifestyle measure
Antacids
Test for H.pylori - urea breath or stool antigen
32
H. pylori test - caveats [2]
| 2 ways to test for H. pylori
Need to be off PPI for >2w and abx for >4w
- Carbon-13 urea breath test
- Stool antigen test
33
When do you do further tests in dyspepsia [3]
If treatment resistant
Alarm symptoms
Requires endoscopy with rapid urease CLO
34
What bloods should you get for dyspepsia [6]
FBC, Ferritin (anaemia)
U+E (urea elevated in hemorrhage)
LFT
Calcium
Glucose
Coeliac
35
What are lifestyle measures [4]
Diet, Exercise more, lose weight
Alcohol moderation, Stop smoking
Eat 2 hours before sleep
Stop drugs that could cause
36
How do you eradicate H.pylori if +ve [5]
```
Triple therapy
1. Clarithromycin (500mg)
2. Amox (1g) for 1 week
- Metronidazole if no response
3. PPI
H2 antagonist - not always needed
```
37
When do you check for cure
| Will blood test be positive?
3 months - Urea breath test
| Will also have +ve serology
38
What do you do if H.pylori -ve? [2]
H2 or PPI for 4 weeks
| If no improvement = endoscopy
39
When do you treat H.plyori
Even if asymptomatic as carcinogenic
40
What are SE of PPI [4]
Microscopic colitis
C.diff increased risk
Osteoporosis - malabsorption of ca and mg
Hyponatraemia and Mg - muscle aches
41
What does odynophagia suggest [4]
Oesophagitis
Ulceration - malignancy / GORD / candida
Spasm
42
What causes dysphagia [6]
Intrinsic, Extrinsic, Motility, Neuromuscular disorders
43
Forms of dysphagia
Dysphagia can be classified as:
* Oropharyngeal dysphagia: difficulty initiating swallow, which may be accompanied by coughing, choking, regurgitation or aspiration.
* Oesophageal dysphagia: a sensation of food getting stuck in the oesophagus several seconds after initiating a swallow.
44
How do you investigate dysphagia [5]
ENDOSCOPY + BIOPSY = gold standard
FBC
U+E
Manometry / pH
Contrast swallow
All patients with new onset dysphagia should be referred for urgent gastroscopy to be performed within 2 weeks.
45
What is suggestive of oesophagitis [3]
Heartburn after eating
Odynophagia
Systemically well
46
What suggest pharyngeal pouch [7]
```
Elderly
Dysphagia
Regurg
Aspiration
Cough
Smelly breath
Neck swelling
```
47
How do you Dx and Rx pouch
Contrast swallow
| Surgery
48
What suggests myasthenia gravis [3]
Ptosis
Extraocular weakness
Swallowing difficulty
49
How do you treat
Acetylcholinesterase inhibitor
50
What suggest bulbar palsy [6]
```
Difficult to initiate swallow
Dysphagia
Weakness
Drooling
Waste tongue
Dysphonia
```
51
What suggest systemic sclerosis? [5]
```
Calcinosis
Raynaud
Eosphageal issue / decreased pressure LOS
S - sclerodactly
Telengtasia
```
52
What is globus hysterics [2]
Dysphagia caused by anxiety
| Relieved by swallow
53
What is globus pharynges [3]
Feeling of lump in throat
Relieved by food
Worse swallowing saliva
54
What suggest oral candidiasis [2]
| What can confirm a suspicion?
HIV / inhaler / haemophiliac / Ax
| Endoscopy to confirm
55
What does constant and progressive dysphagia suggest
Malignancy
56
What is achalasia [2]
1. Motlity disorder where LOS doesn't relax so increased pressure. Hypertrophy of muscles at LOS
2. Loss of peristalsis
The pathogenesis is thought to be due to decreased ganglionic cells in the myenteric plexus and degeneration in the vagal fibres of the oesophagus with loss of inhibitory denervation of the LOS.
57
How does achalasia present [6]
Dysphagia - solid and liquid from start over long periods of time
Weight loss
Regurg, Vomit
Aspiration, Choking
Chest pain
Systemically well
58
How do you Dx achalasia and what do they show [4]
Endoscopy 1st line to exclude cancer, would be normal
Barium swallow - dilated tight sphincter, birds beak deformity
CXR - wide mediastinum
Oesophageal manometry demonstrates aperistalsis in the distal two-thirds of the oesophagus and impaired relaxation of the LOS (pressure readings of >8 mmHg).
59
How do you Rx achalasia [5]
1. Endoscopic pneumatic dilatation involves forceful disruption of the muscular fibres of the LOS using a balloon. It carries a significant risk of perforation (2–4%).
2. Laparoscopic myotomy (Heller’s myotomy) involves longitudinal surgical incision of the muscles of the LOS.
3. Peroral endoscopic myotomy (POEM) is an endoscopic method for performing myotomy of the LOS.
4. Botulinum toxin injection into the LOS can provide temporary symptomatic benefit (lasting
~6 months), thus requiring repeat procedures. It is generally reserved for patients who are poor
surgical candidates.
5. Pharmacological therapy, such as nitrates or short-acting calcium channel blockers are the least
effective in treating achalasia. Their use is limited by side effects (such as headache and dizziness) with nitrates and tachyphylaxis (loss of response) with calcium channel blockers.
60
What are complications of achalasia [3]
SCC
Aspiration pneumonia
Lung disease
61
What does oesophageal spasm present like [4]
Intermittent chest pain and dysphagia
Like angina
Odynophagia
This is a severe, but rare form of oesophageal dysmotility that typically presents with chest pain and dys- phagia in middle-aged patients.
62
How do you Dx spasm [2]
Contrast swallow - cork screw
Oesophageal manometry classically demonstrates >20% simultaneous contractions of the LOS of
>30 mmHg amplitude.
| Manometry - exaggerated contraction
63
Rx spasm [2]
Nitrates and CCB to relax
TCA
64
What causes hypo motility [4]
Failed relaxation of LOS sphincter
DM
Neuropathy
Connective tissue disease
65
How do hypo motility present [3]
Dysphagia
Regurg
Dyspepsia
66
What is a sliding hiatus hernia [2]
Gastro-oesophageal junction slides into chest
| Acid reflux / GORD as no sphincter
67
What is a para-oesophageal hernia [2]
Junction stays below diaphragm
| Part of stomach into chest
68
Who is at risk of hernia [3]
Age
Obese
Female
69
How do you dx hernia [3]
1. Endoscopy for GORD
2. Contrast swallow for reflux - gastric seen above diaphragm
3. CXR (gastric fundus above diaphragm)
70
How do you treat hernia [3]
Lose weight
Treat GORD
Fundolipication for severe complications / strangulated
71
What is a strangulated hernia
| What are other complications [2]
Necrosis = urgent surgery
Complications of hernia:
Incarcerated - stuck and unable to reduce
Abscess in sac
72
What do you need to do before considering fundoplication [2]
Manometry and pH studies
73
What are other indications for endoscopy apart from dysphagia [5]
Haematemesis
Treatment resistant dyspepsia
H.pylori -ve
Abdo pain and low Hb
Raised platelet + N+V, weight loss, dyspepsia, abdominal pain
74
Eosinophilic Oesophagitis
Aetiology
Endoscopic features & diagnosis
Management [2]
* Patients often have a history of atopy (e.g. eczema, allergic rhinitis or asthma). Food impaction is common
Aetiology
* Chronic immune/antigen-mediated oesophageal disease characterised by symptoms related to oesophageal dysfunction and histologically eosinophilic predominant inflammation.
Endoscopic features
- include linear furrowing, circular rings (trachealisation) and stricturing.
* Mid-oesophageal biopsies in patients with suspected EoE.
Management
* Initially acid suppression with proton pump inhibitors (in treatment naïve patients) followed by topical glucocorticoid therapy (e.g. swallowed fluticasone).
* Allergy testing is often advocated in EoE to determine foods that may present a risk for acute allergic reactions and identify EoE triggers.
Patients may present with oesophageal strictures which require therapeutic dilatation.
