Upper GI Presentations Flashcards by Rachel Agnew

What is a Mallory-Weiss tear?

A longitdinal tear in the mucosa around the gastro-oesophageal junction

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What generally causes a Mallory-Weiss tear to bleed?

Increased abdominal pressure, usually due to vomiting

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What is the typical presentation of a Mallory-Weiss tear?

Small amounts of haematemesis after several episodes of vomiting (most commonly due to alcohol)

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What is the management for a Mallory-Weiss tear?

Usually conservative, as the bleeding will generally resolve

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What is a hiatus hernia?

When the proximal stomach herniates through the diaphragmatic hiatus

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What two kings of hiatus hernia can you get?

Sliding hernia (80%) = Gastroesophageal junction slides up into the chest 
Rolling hernia (20%) = Gastroesophageal junction remains in abdomen, portion of stomach herniates into the chest

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What BMI is associated with hiatus hernias?

Over 30 (obesity)

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What is the best diagnostic test for a hiatus hernia?

Barium swallow

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What is the treatment for a hiatus hernia?

H2 antagonists, alginates, antacids, proton pump inhibitors and pro kinetic drugs = relieve reflux symptoms
Surgery = symptoms are intractable or complications develop

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What are the risk factors for GORD?

Hiatus hernia 
Smoking 
Alcohol
Pregnancy 
Systemic sclerosis 
Drugs (e.g. nitrates, anticholinergics)
Obesity 
Age

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What happens to the lower oesophageal sphincter tone in GORD?

It is decreased

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What condition can result from long term GORD?

Barrett’s Oesophagus

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Which change occurs in the epithelium in Barrett’s Oesophagus?

Metaplastic change from squamous to columnar epithelium

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How do nitrates affect the symptoms of GORD?

Usually aggravate symptoms

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Which value is likely to be raised in an Upper GI beed?

Serum urea

Due to metabolism of amino acids from protein rich blood contents

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Why is there a change in lower oesophageal tone in GORD?

Usually due to increased intra-abdominal pressure

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What are the symptoms of GORD?

Heartburn (particularly when lying down, stooping, straining or after meals)
Belching
Acid or bile regurgitation 
Waterbrash (mouth fills with water) 
Odynophagia 
Nocturnal asthma 
Chronic cough 
Laryngitis 
Sinusitis

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What are the potential complications of GORD?

Oesophagitis 
Ulcers 
Benign strictures 
Iron deficiency 
Metaplastic change (Barrett's Oesophagus)

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How is damage to the oesophagus by GORD graded?

Grade 1 = erosions less than 5mm
Grade 2 = erosions more than 5mm
Grade 3 = less than 75% of lower oesophagus involved
Grade 4 = more than 75% of lower oesophagus involved

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Which medications can be used to treat GORD?

Antacids
H2 receptor antagonists
Proton Pump Inhibitors

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How do antacids help in GORD?

Relieve reflux by coating the lower oesophageal lining

Only relieve symptoms, do not prevent complications

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How do H2 receptor antagonists help in GORD?

Cause acid suppression

Symptoms can worsen on stopping medication

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How do PPIs help in GORD?

Effective at both reducing acid secretion and preventing acid related damage
Timing is important for these drugs

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When might surgery be considered for GORD, and what are the aims of surgery?

Ongoing symptoms despite medication, or poor tolerance to medication
Keyhole laparoscopic surgery to physically repair the damaged sphincter

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In which type of hiatus hernia is acid reflux more common?

Sliding hiatus hernia

What are the symptoms of achalasia?

Dysphagia Regurgitation Substernal cramps Weight loss

What caused achalasia?

Lower oesophageal sphincter fails to relax Food cannot easily enter the stomach and so oesophagus fills with food usually accompanied by poor oesophageal motility

How is achalasia diagnosed?

Barium swallow = shows dilated tapering oesophagus

How is achalasia treated?

Endoscopic balloon dilatation Heller's cardiomyotomy Botox injections for a non-invasive treatment

What are the two types of oesophageal cancer?

Adenocarcinoma (reflux->Barret's) | Squamous Cell Carcinoma (smoking and alcohol)

What types of gastric cancer can occur?

Adenocarcinoma (H.pylori, environmental) Lymphoma GISTs (cancers of muscle layer)

How might oesophageal cancer present?

``` Dysphagia Odynophagia Upper GI haemorrhage Anaemia Weight loss ```

How might gastric cancer present?

``` Subtle, non specific symptoms Dyspepsia Upper GI haemorrhage Anaemia Weight loss Abdominal mass Anorexia/early satiety Vomiting ```

How is oesophago-gastric caner diagnosed?

Upper GI endoscopy | also colonoscopy if presenting symptom is anaemia

How do you stage oesophageal cancer?

CT thorax/abdomen CT/PET, EUS, Laparoscopy Search hard for metastatic disease

What are the palliative options for oesophageal cancer and pros/cons?

Stenting - BEST Radiotherapy - can shrink tumour and aid swallowing without need for stent Chemotherapy - almost no benefit

What are the potentially curative options for oesophageal cancer?

Surgery with or without NAC | Radical chemoradiotherapy

How do you stage gastric cancer?

CT thorax/abdomen Laparoscopy Search hard for metastatic disease

What are the palliative options for gastric cancer and pros/cons?

Radiotherapy - generally reserved for bleeding | Chemotherapy - almost no benefit

What are the potentially curative options for gastric cancer?

Surgery with or without NAC

What is the prognosis for oesophageal cancer?

Dismal | 11% 5 year survival, most die within 1 year

What are the adverse prognostic factors for oesophageal cancer?

Oesophageal obstruction Tumour longer than 5cm Metastatic disease

What is the prognosis for gastric cancer?

15% 5 year survival

What are the adverse prognostic factors for gastric cancer?

``` Metastatic disease Short history Advanced age Proximal lesion Locally advanced lesion Superficial gross appearance ```

What is the definition of dyspepsia?

Epigastric pain or burning Postprandial fullness Early satiety

What are the organic causes of dyspepsia?

Peptic ulcer disease Drugs (NSAIDs, COX2 inhibitors) Gastric cancer

What are the function causes of dypepsia?

Idiopathic No evidence of causative structural disease Accounted with other functional gut disorders (IBS etc)

What might be found on examination of uncomplicated dyspepsia?

Epigastric tenderness only

What might be found on examination of complicated dyspepsia?

Cachexia Mass Evidence gastric outflow obstruction Peritonism

What is the management of dyspepsia in the absence of alarm symptoms?

Check H.pylori status Eradicate if infected If negative, treat with acid inhibition as needed

What are the causes and risk factors for peptic ulceration?

``` H. Pylori NSAIDs Steroids Aspirin Zollinger Ellison Syndrome Stress ```

What is the common presentation of peptic ulcer disease?

Epigastric pain Usually occurring at night or before meals Relieved by drinking a glass of milk

How are peptic ulcers diagnosed?

Endoscopy

What is the treatment for H.Pylori +ve peptic ulcers?

PPI | Amoxicillin or metronidazole and clarythromycin for 1 week

What is the treatment for H.Pyori -ve peptic ulcers?

H2 receptor antagonist | PPI

What is H.Pylori and how is it spread?

Gram negative microaerophilic flagellated bacillus Oral-Oral/faecal oral spread Usually acquired in infancy, with complications arising after in life

What are the consequences of H.Pylori infection?

Majority = No pathology 20-40% = Peptic ulcer disease 1% =Gastric cancers

How are H.Pylori and duodenal ulcers connected?

Increase in gastrin release leads to increased acid secretion This increases duodenal acid load, causing gastric metaplasia, H.Pylori colonisation and ulceration

How is H.Pylori infection diagnosed?

Gastric biopsy Urease breath test Faecal antigen test Serology (less accurate in older patients)

What are the complications of peptic ulcer disease?

Anaemia Bleeding Perforation Gastric outlet/duodenal obstruction

What is the follow up for duodenal ulcers?

None needed if uncomplicated | Only follow up with ongoing symptoms

What is the follow up for gastric ulcers?

Endoscopy at 6/8 weeks | Ensure healing and no malignancy

What is the most likely cause of haematemesis in a jaundiced patient?

``` Oesophageal varices (due to portal hypertension) ```

What is the most likely cause of haematemesis in a young patient with a sore knee?

Peptic ulcer | due to NSAIDs

What is the most likely cause of haematemesis in a patient with a two month history of increasing dysphagia?

Oesophageal cancer

Which factors indicate a severe upper GI bleed?

Low BP Tachycardia Postural hypotension

What is the initial management of an upper GI bleed?

``` Resuscitation: Airway protection Oxygen IV access Fluids HDU Senior review ```

What drugs should you consider giving someone with an upper GI bleed?

IV terlipressin = Management of portal hypertension | IV septrin = Prophylactic antibiotics

What fluids should be given to someone with an upper GI bleed?

Cross matched blood | may give gelofusine or O -ve in the meantime if urgent

How do you treat an upper GI bleed due to oesophageal varices?

Endoscopic banding

If endoscopy fails to treat bleeding oesophageal varices, what would be done next?

C Sengstaken Blakemore Tube

How does eating affect gastric pain caused by peptic ulcers?

``` Duodenal = Pain relieved by eating Gastric = Pain worsened by eating ```

What is the more likely cause of dysphagia to solids and liquids from the start?

Motility disorder | Achalasia, CNS or pharyngeal causes

What is the more likely cause of worsening dysphagia (e.g. solids then liquids)?

Stricture - benign or malignant

What is the more likely cause of dysphagia where there is difficulty in making the swallowing movement?

Bulbar palsy, especially if the patient coughs on swallowing

What are the more likely causes of dysphagia if there is accompanying odynophagia?

Cancer Oesophageal ulcer - benign or malignant Candida Spasm

What is the more likely cause of intermittent dysphagia?

Oesophageal spasm

What is the more likely cause of constant and worsening dysphagia?

Malignant stricture

What is the more likely cause of dysphagia where the neck bulges or gurgles on drinking?

Pharyngeal pouch

What are the alarm symptoms associated with dyspepsia and peptic ulcer disease?

``` Anaemia Loss of weight Anorexia Recent onset or progressive symptoms Melaena/haematemesis Swallowing difficulty ```

Upper GI Presentations Flashcards

(80 cards)