Upper GI

Question 1

How long is the Oesophagus

Answer 1

27cm

Question 2

Where does the oesophagus start and end?

Answer 2

C6 to T10, where it enters the diaphragm at the oesophageal hiatus

Question 3

How can the oesophagus be split

Answer 3

Upper third mucosa - non keratinising squamous epithelium
Columnar cells lower down

Question 4

What does the upper sphincter split?
What is it composed of?
What is its function?

Answer 4

Upper oesophagus and pharynx
Mainly composed of thyropharyngeal and cricopharyngeal muscle pressing against the cricoid

Function - prevent acid reflux going into your mouth and things gong into your airway

Question 5

What are the normal constrictions during the course of the oesophagus and when can you see this?

Answer 5

Bariums swallow
-Level of the cricoid
-Level of the left main bronchus/left atrium
-When the oesophagus enters the diaphragm at T10

Question 6

Anatomy of Lower Oesophageal Sphinter?

Answer 6

-Angle of His - Angle at which oesophagus enters the diaphragm at T10
-Lt and Mainly Rt Crux of diaphragm forming a circular muscular ring
-Apposition of the mucosal folds
-Phrenoesophageal ligament, which is connective tissue

3-4cm distal oesophagus within abdomen
Intra-abdominal pressure acting against the abdominal component of oesophagus

Question 7

Describe the phases of swallowing

Answer 7

Oesophageal phase - autonomic

Question 8

How is motility of oesophagus measured?

Answer 8

Manometry - probe passed into oesophagus and pressure readings taken

Peristaltic waves ~ 40 mmHg

LOS resting pressure ~ 20 mmHg
↓<5 mmHg during receptive relaxation
Mediated by inhibitory noncholinergic nonadrenergic (NCNA) neurons of myenteric plexus

Question 9

Functional Disorders of the Oesophagus

Answer 9

Question 10

What is dysphagia?

Answer 10

Red flag symptom for oesophageal cancer if type changes

Question 11

What is odynophagia?

Answer 11

pain on swallowing

Question 12

What is regurgitation?

Answer 12

refers to return of oesophageal contents from above an obstruction
-May be functional or mechanical

Question 13

What is reflex?

Answer 13

passive return of gastroduodenal contents to the mouth

Question 14

Symptoms vs signs

Answer 14

Symptoms - What the patient reports
Signs - What you illicit from examination

Question 15

What is achalasia?
What are the causes?

Answer 15

Hypermotility
-Failure of LOS to relax ; increased resting pressure

Question 16

What is this?

Answer 16

Barium Swallow
-Radio opaque liquid to drink and pacifies the entire oesophagus
-Bird’s beak appearance - tapering of distal oesophagus
-Dilated oesophagus proximally to this
(Shows achalasia- later feature though so clinically manometry diagnoses it)

Question 17

What is achalasia a risk factor or?

Answer 17

Squamous oesophageal cancer
Increases risk 28 fold

Question 18

What else happens in achalasia?

Answer 18

Question 19

Disease course of achalasia?

Answer 19

Has insidious onset - symptoms for years prior to seeking help
Without treatment → progressive oesophageal dilatation of oesophagus.

Question 20

What is pneumatic dilation ?

Answer 20

Risk of perforation

Question 21

What surgical treatment is available for achalasia?
What are the risks?

Answer 21

Second procedure prevents acid reflux

Question 22

What is Scleroderma?
What treatment is available?

Answer 22

Question 23

What is diffuse oesophageal spasm?
Treatment?

Answer 23

Disordered coordination

Question 24

Where are oesophageal perforations?

Answer 24

Cricopharyngeal constriction
Aortic and bronchial constriction
Diaphragmatic

Question 25

Aetiology of oesophageal perforations?

Answer 25

Iatrogenic (OGD) >50% Spontaneous (Boerhaave’s) - 15% Foreign body - 12% Trauma - 9% Intraoperative - 2% Malignant - 1%

Question 26

How does Iatrogenic Oesophageal perforation occur?

Answer 26

Question 27

How does Boerhaave's Oesophageal perforation occur?

Answer 27

Someone has been drinking a lot etc then...

Question 27

How does Foreign Body Oesophageal perforation occur?

Answer 27

Question 28

How does Trauma Oesophageal perforation occur?

Answer 28

Question 29

What is the presentation of Oesophageal perforation?

Answer 29

Pain 95 % Fever 80 % Dysphagia 70 % Emphysema 35 %

Question 30

What investigations are done for oesophageal perforation?

Answer 30

CXR CT Swallow (gastrograffin) OGD

Question 31

Answer 31

Pneumo-mediastinum Black shows air

Question 32

What is the initial management for oesophageal perforation?

Answer 32

NBM IV fluids Broad spectrum A/Bs & Antifungals -- due to high burden of fungi in oesophagus ITU/HDU level care Bloods (including G&S) Tertiary referral centre

Question 33

What is the definitive management for oesophageal perforation?

Answer 33

Chest drain, stent and then ITU

Question 34

Why is the LOS usually closed?

Answer 34

As a barrier against reflux of harmful gastric juice (pepsin & HCL)

Question 35

What is LOS pressure increase by ?

Answer 35

Question 36

What is LOS decreased by?

Answer 36

Question 37

When does sporadic reflux occur

Answer 37

Is normal -pressure on full stomach -swallowing -transient sphincter opening

Question 38

What are 3 mechanisms protect following reflux

Answer 38

Volume clearance - oesophageal peristalsis reflex pH clearance - saliva Epithelium - barrier properties

Question 39

What is chronic acid reflux a risk factor for?

Answer 39

Oesophageal Adenocarcinoma

Question 40

What are failures of protective mechanisms in GORD?

Answer 40

Question 40

What are failures of protective mechanisms in GORD?

Answer 40

Question 41

What is sliding hiatus hernia?

Answer 41

Stomach is herniating through the hiatus of the diaphragm

Question 42

What is a hernia?

Answer 42

Protrusion of a viscous of a defect of its walls of its containing cavity in abnormal position

Question 43

What is a rolling/paraesophageal hiatus hernia?

Answer 43

GOJ is in the correct position but a portion of stomach that is herniated alongside that Theoretical risk that is can strangulate - therefore surgery

Question 44

In a GP, if a patient comes in with acid reflux and no red flags, what do you do?

Answer 44

Treat them there

Question 45

If referred to secondary care, what investigations do you do for acid reflux?

Answer 45

OGD ---To exclude cancer ---Oesophagitis, peptic stricture & Barretts oesophagus confirm ∆ Oesophageal manometry --Important for those with difficult to control reflux to check whether achalasia first 24-hr oesophageal pH recording (Last two are standard investigations for those considering anti acid surgery)

Question 46

What are the treatments for acid reflux?

Answer 46

Medical ---Lifestyle changes (wt loss, smoking, EtOH) ---PPIs Surgical ---Dilatation peptic strictures ---Laparoscopic Nissen’s fundoplication

Question 47

What are the functions of the stomach?

Answer 47

Breaks food into smaller particles (acid & pepsin) Holds food, releasing it in controlled steady rate into duodenum Kills parasites & certain bacteria

Question 48

Anatomy of Stomach

Answer 48

cells?

Question 49

What is erosive & haemorrhagic gastritis?

Answer 49

Numerous causes Acute ulcer – gastric bleeding & perforation

Question 50

What is Atrophic (fundal gland) gastritis?

Answer 50

Fundus Autoantibodies vs parts & products of parietal cells Parietal cells atrophy ↓acid & IF secretion

Question 51

What is reactive gastritis?

Question 52

What is Nonerosive, chronic active gastritis?

Answer 52

Antrum Helicobacter pylori - Triple Rx (amoxicillin, clarithromycin, pantoprazole) for 7-14/7

Question 53

How is gastric secretion stimulated

Answer 53

Question 54

How is gastric stimulation inhibited?

Answer 54

Question 55

What is the natural mucosal protection composed of? What can non-steroidal drugs like ibroprofen do?

Answer 55

-They can inhibit bicarbonates so they should be taken with an acid suppressant

Question 56

What are the mechanisms for epithelial repair and wound healing?

Answer 56

Question 57

What is the biggest reason for ulcer (break in epithelium) formation?

Answer 57

Question 58

What are the treatment of ulcers?

Answer 58