The oesophagus, stomach, and duodenum

Question 1

Sphincters of the Oesophagus

Answer 1

1) Cricopharyngeus
2) 3-5cm at level of hiatus(T10)

Question 2

(Oesophagus) Thickened ligament at hiatus

Answer 2

Phrenoesophageal Ligament

Question 3

(Oesophagus) Blood Supply

Answer 3

1) Cervical: Inferior thyroid arteries
2) Thoracic: Bronchial arteries + thoracic aorta
3) Abdominal: Left gastric + inferior phrenic

Question 4

(Oesophagus) Drainage

Answer 4

1) Cervical: Inferior thyroid veins
2) Thoracic: Hemi-azygous and azygous
3) Abdominal: Left Gastric (portal circulation)

Question 5

(Oesophagus) Sympathetic Nerve Supply

Answer 5

1) Pre-ganglionic: T5-T6
2) Post-ganglionic: Coeliac ganglia and cervical vertebrae

Question 6

(Oesophagus) Parasympathetic Nerve Supply

Answer 6

Glossopharyngeal, laryngeal, and vagus nerves

Question 7

Stomach Borders

Answer 7

Anteriorly: Diaphragm and Left lobe
Posteriorly: Diaphragm, left adrenal, upper left kidney, pancreas, spleen, splenic artery

Question 8

(Stomach) Parts

Answer 8

1) Cardia
2) Fundus
3) Body
4) Antrum

Question 9

(Stomach) Sphincters

Answer 9

1) Oesophagogastric Junction
2) Pylorus

Question 10

Answer 10

Question 11

(Stomach) Nerve Supply

Answer 11

1) Parasympathetic: Anterior and posterior vagal trunks, moving along the greater and lesser curvatures
2) Sympathetic: Coeliac ganglion

Question 12

Parasympathetic effects ont he stomach

Answer 12

1) Motor fibres of stomach wall
2) Inhibitory fibres for pyloric sphincter
3) Secretomotor fibres

Question 13

Sympathetic effetcs on the stomach

Answer 13

1) Motor fibres to pyloric sphincter

Question 14

Nerve Supply Duodenum

Answer 14

Sympathetic + Parasympathetic: Superior mesenteric and coeliac plexuses

Question 15

Dysphagia Onset

Answer 15

1) Sudden: Foreign body
2) Over weeks: Carcinoma
3) Years: Achalasia / Benign strictures

Question 16

Dysphagia Sites

Answer 16

Poor correlation. If high, maybe pharyngeal pouch

Question 17

Dysphagia Progression

Answer 17

1) Progressive: stricture (benign or malignant)
2) Intermittent: motility disorders

Question 18

Dysphagia Severity

Answer 18

1) Solids: initially indicative of carcinoma
2) Solids + Liquids: achalasia/ other motility disorder

Question 19

Intraluminal Causes of Dysphagia

Answer 19

Foreign Body

Question 20

Intramural Causes of Dysphagia

Answer 20

1) Pharynx/ upper oesophagus:

Pharyngitis/tonsillitis
Moniliasis
Sideropenic web
Corrosives
Carcinoma
Myasthenia gravis
Bulbar palsy

2) Body of oesophagus:

Corrosives
Peptic oesophagitis
Carcinoma

3) Lower oesophagus:

Corrosives
Peptic oesophagitis
Carcinoma
Diffuse oesophageal spasm
Systemic sclerosis
Achalasia
Postvagotomy

Question 21

Extrinsic causes of Dysphagia

Answer 21

1) Upper oesophagus:

Thyroid enlargement
Pharyngeal pouch

2) Body of oesophagus:

Mediastinal lymph nodes
Aortic aneurysm

3) Lower oesophagus:

Paraoesophageal hernia

Question 22

Odynophagia

Answer 22

1) Oesophagitis
2) Oesophageal spasm (stricture/dysmotility)

Question 23

Heartburn

Answer 23

Treat with PPIs. Worse on:

1) Bending over
2) Heavy meal
3) Alcohol

Question 24

Red flag symptoms for dyspepsia

Answer 24

1) Weight loss
2) Anaemia (Iron deficiency)
3) Persistent vomiting
4) Mass
5) Progressive Nature

Question 25

Causes of regurgitation

Answer 25

1) Achalasia 2) Hiatus hernia 3) Pharyngeal pouch

Question 26

Causes of vomiting

Answer 26

1) Infection 2) Inflammation 3) Endocrine disorders 4) Obstruction 5) Pregnancy 6) Drugs

Question 27

Types of Ulcers

Answer 27

1) Duodenal: relieved by eating 2) Gastric: aggravated by eating

Question 28

Iron deficiency Anaemia signs

Answer 28

1) Pallor 2) Koilonychia 3) Smooth tongue

Question 29

GI Causes of iron deficiency aneamia

Answer 29

1) Carcinoma 2) Oesophagitis 3) Pulmer-Vinson Syndrome

Question 30

Signs of GI Malignancy on Examination

Answer 30

1) Lymphadenopathy (Virchow's Node, Troisier's sign) 2) Hepatomegaly 3) Abdominal Mass 4) Weight loss 5) Ascites

Question 31

Crepitus in the neck of the vomiting patient

Answer 31

Surgical emphysema - perforation of the oesophagus

Question 32

Acid-Base balance in chronic outlet obstruction

Answer 32

Hypochloraemic, hypokalaemic, hyponatraemic metabolic alkalosis

Question 33

Blood tests in metastatic Disease

Answer 33

1) Elevated enzymes 2) Low protein 3) Deranged clotting + Portal hypertension

Question 34

CXR findings in aspiration

Answer 34

1) Pulmonary consolidation 2) Fibrosis Think: 1) Motility Disorders 2) Carcinoma

Question 35

Air-fluid level behind heart shadow

Answer 35

Intrathoracic stomach

Question 36

Indications for barium meal

Answer 36

1) Alternative to endoscopy when contra-indicated 2) Exclude pharyngeal pounch prior to endoscopy 3) Complement endoscopy (e.g. hiatus herniae) 4) Diagnose upeer G.I. perforation

Question 37

Requirements for endoscopy

Answer 37

1) 4 hour fast 2) Light sedation/ local anaesthetic spray 3) Pulse and Sat monitoring (to identify resp depression)

Question 38

Presentation: GORD/ Barrett's Oesophagus

Answer 38

1) Heartburn 2) Regurgitation 3) Epigastric Pain 4) Vomiting 5) Hypersalivation 6) Nausea

Question 39

Diagnosis of GORD

Answer 39

1) History 2) Endoscopic Studies 3) Lower oesophagus pH studies (sometimes)

Question 40

Treatment of GORD

Answer 40

1) Lifestyle advice: weight loss, stop smoking, avoid spicy/fatty foods, alcohol and caffeine 2) OTC medications (antacids, alginates, low dose H2 antagonists) 3) PPIs as definitive treatment

Question 41

Diagnosis of Barrett's Oesophagus

Answer 41

Histological diagnosis following biopsy

Question 42

Treatment of Barrett's Oesophagus

Answer 42

Surveillance programme to detect and treat early neoplastic changes (squamous to columnar)

Question 43

Types of hiatus hernia

Answer 43

1) Sliding (90%): stomach slides through the hiatus leading to an intrathoracic gastroesophageal junction 2) Rolling : gastoesophageal sphincter remains intact - stomach rolls anteriorly

Question 44

Hiatus hernia clinical features

Answer 44

1) Heartburn and regurgitation: aggravated by posture, respond to antacids 2) Oesophagitis: can cause bleeding, anaemia , fibrosis, stricture formation 3) Epigastric and lower chest pain: can lead to strangulation of the stomach 4) Palpitations and hiccups

Question 45

Hiatus hernia management

Answer 45

1) Treat as with GORD 2) if obstructive symptoms, consider surgical repair 3) If emergency: decompress using an NG tube

Question 46

Achalasia Clinical Features

Answer 46

1) Typically female (3:2) aged 30-40 2) Progressive dysphagia, liquids\>solids 3) Patient prefers to eat standing 4) Retrosternal pain, weight loss, halitosis, regurgitation 5) Barium swallow reveals proximal dilatation with inverted bird beak sign

Question 47

Achalasia Management

Answer 47

1) Balloon dilatation: 80-90% effective, risk of perforation 2) Surgical (Heller's) myotomy:

Question 48

Pouches Clinical Features

Answer 48

1) Elderly male 2) Regurgitation 3) Halitosis 4) Dysphagia 5) Gurgling 6) Aspiration 7) Lump

Question 49

Pouches Investigations

Answer 49

1) Barium swallow 2) Avoid endoscopy - risk of perf

Question 50

Pouches treatment

Answer 50

1) Stapling 2) Surgical myotomy

Question 51

Types of perforation

Answer 51

1) Intraluminal: commonly iatrogenic (dilatation procedures, endoscopies) 2) Extrinsic: typically stab wounds 3) Spontaneous: following vomiting (Booerhaave's Syndrome). Simple tears are Mallory-Weiss

Question 52

Perforation Investigation

Answer 52

Consider in every patient presenting with chest pain, shortness of breath, vomiting 1) Erect chest xray: likely to show surgical emphysema 2) Chest CT or water soluble swallow: confirm diagnosis. Can show whether the perforation is localised to the mediastinum or involves the pleural/peritoneal cavities Important to exclude spontaneous pneumomediastinum which presents similarly and is treated conservatively

Question 53

Perforation Management

Answer 53

1) Cervical: conservative. IV fluids Abx and anti-fungals. If abscess, surgically drain it 2) Thoracic: Small perforations can be managed conservatively, larger ones require surgery

Question 54

Benign Oesophageal Tumours

Answer 54

\<1% of neoplasms. Typically asymptomatic, treated with local enucleation. Most are leiomyomas

Question 55

Oesophageal Carcinoma

Answer 55

1) 15/100,000 2) Male: Female 3:1 3) Reverse thirds: 2/3 in bottom 1/3 (adenocarcinomas) and 1/3 in top 2/3 (squamous carcinomas) 4) Spread: haematogenously, direct invasion, lyphatics

Question 56

Oesophageal Carcinoma Clinical Features

Answer 56

1) Progressive dysphagia (liquids--\>solids) 2) Regurgitation 3) Weight loss 4) Odynophagia 5) Fistula formation 6) Horner's Syndrome 7) Hoarseness of voice Typically late presentation (3-9 months)

Question 57

Oesophageal Carcinoma Investigations

Answer 57

1) Initially barium swallow 2) Must always be confirmed by endoscopy and biopsy (endoscopy is the best 1st line investigation for dysphagia)