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Upper GI Presentations Flashcards

1
Q

What is a Mallory-Weiss tear?

A

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

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2
Q

What generally causes a Mallory-Weiss tear to bleed?

A

Increased abdominal pressure, usually due to vomiting

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3
Q

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

A

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

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4
Q

What is the management for a Mallory-Weiss tear?

A

Usually conservative, as the bleeding will generally resolve

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5
Q

What is a hiatus hernia?

A

When the proximal stomach herniates through the diaphragmatic hiatus

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6
Q

What two kings of hiatus hernia can you get?

A 
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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7
Q

What BMI is associated with hiatus hernias?

A

Over 30 (obesity)

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8
Q

What is the best diagnostic test for a hiatus hernia?

A

Barium swallow

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9
Q

What is the treatment for a hiatus hernia?

A

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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10
Q

What are the risk factors for GORD?

A 
Hiatus hernia 
Smoking 
Alcohol
Pregnancy 
Systemic sclerosis 
Drugs (e.g. nitrates, anticholinergics)
Obesity 
Age
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11
Q

What happens to the lower oesophageal sphincter tone in GORD?

A

It is decreased

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12
Q

What condition can result from long term GORD?

A

Barrett’s Oesophagus

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13
Q

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

A

Metaplastic change from squamous to columnar epithelium

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14
Q

How do nitrates affect the symptoms of GORD?

A

Usually aggravate symptoms

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15
Q

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

A

Serum urea

Due to metabolism of amino acids from protein rich blood contents

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16
Q

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

A

Usually due to increased intra-abdominal pressure

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17
Q

What are the symptoms of GORD?

A 
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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18
Q

What are the potential complications of GORD?

A 
Oesophagitis 
Ulcers 
Benign strictures 
Iron deficiency 
Metaplastic change (Barrett's Oesophagus)
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19
Q

How is damage to the oesophagus by GORD graded?

A

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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20
Q

Which medications can be used to treat GORD?

A

Antacids
H2 receptor antagonists
Proton Pump Inhibitors

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21
Q

How do antacids help in GORD?

A

Relieve reflux by coating the lower oesophageal lining

Only relieve symptoms, do not prevent complications

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22
Q

How do H2 receptor antagonists help in GORD?

A

Cause acid suppression

Symptoms can worsen on stopping medication

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23
Q

How do PPIs help in GORD?

A

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

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24
Q

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

A

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

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25
Q

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

A

Sliding hiatus hernia

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26
Q

What are the symptoms of achalasia?

A

Dysphagia
Regurgitation
Substernal cramps
Weight loss

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27
Q

What caused achalasia?

A

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

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28
Q

How is achalasia diagnosed?

A

Barium swallow = shows dilated tapering oesophagus

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29
Q

How is achalasia treated?

A

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

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30
Q

What are the two types of oesophageal cancer?

A

Adenocarcinoma (reflux->Barret’s)

Squamous Cell Carcinoma (smoking and alcohol)

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31
Q

What types of gastric cancer can occur?

A

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

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32
Q

How might oesophageal cancer present?

A 
Dysphagia 
Odynophagia 
Upper GI haemorrhage 
Anaemia 
Weight loss
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33
Q

How might gastric cancer present?

A 
Subtle, non specific symptoms 
Dyspepsia 
Upper GI haemorrhage 
Anaemia 
Weight loss
Abdominal mass 
Anorexia/early satiety 
Vomiting
34
Q

How is oesophago-gastric caner diagnosed?

A

Upper GI endoscopy

also colonoscopy if presenting symptom is anaemia

35
Q

How do you stage oesophageal cancer?

A

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

36
Q

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

A

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

37
Q

What are the potentially curative options for oesophageal cancer?

A

Surgery with or without NAC

Radical chemoradiotherapy

38
Q

How do you stage gastric cancer?

A

CT thorax/abdomen
Laparoscopy
Search hard for metastatic disease

39
Q

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

A

Radiotherapy - generally reserved for bleeding

Chemotherapy - almost no benefit

40
Q

What are the potentially curative options for gastric cancer?

A

Surgery with or without NAC

41
Q

What is the prognosis for oesophageal cancer?

A

Dismal

11% 5 year survival, most die within 1 year

42
Q

What are the adverse prognostic factors for oesophageal cancer?

A

Oesophageal obstruction
Tumour longer than 5cm
Metastatic disease

43
Q

What is the prognosis for gastric cancer?

A

15% 5 year survival

44
Q

What are the adverse prognostic factors for gastric cancer?

A 
Metastatic disease 
Short history 
Advanced age
Proximal lesion 
Locally advanced lesion 
Superficial gross appearance
45
Q

What is the definition of dyspepsia?

A

Epigastric pain or burning
Postprandial fullness
Early satiety

46
Q

What are the organic causes of dyspepsia?

A

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

47
Q

What are the function causes of dypepsia?

A

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

48
Q

What might be found on examination of uncomplicated dyspepsia?

A

Epigastric tenderness only

49
Q

What might be found on examination of complicated dyspepsia?

A

Cachexia
Mass
Evidence gastric outflow obstruction
Peritonism

50
Q

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

A

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

51
Q

What are the causes and risk factors for peptic ulceration?

A 
H. Pylori 
NSAIDs 
Steroids
Aspirin 
Zollinger Ellison Syndrome 
Stress
52
Q

What is the common presentation of peptic ulcer disease?

A

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

53
Q

How are peptic ulcers diagnosed?

A

Endoscopy

54
Q

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

A

PPI

Amoxicillin or metronidazole and clarythromycin for 1 week

55
Q

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

A

H2 receptor antagonist

PPI

56
Q

What is H.Pylori and how is it spread?

A

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

57
Q

What are the consequences of H.Pylori infection?

A

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

58
Q

How are H.Pylori and duodenal ulcers connected?

A

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

59
Q

How is H.Pylori infection diagnosed?

A

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

60
Q

What are the complications of peptic ulcer disease?

A

Anaemia
Bleeding
Perforation
Gastric outlet/duodenal obstruction

61
Q

What is the follow up for duodenal ulcers?

A

None needed if uncomplicated

Only follow up with ongoing symptoms

62
Q

What is the follow up for gastric ulcers?

A

Endoscopy at 6/8 weeks

Ensure healing and no malignancy

63
Q

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

A 
Oesophageal varices 
(due to portal hypertension)
64
Q

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

A

Peptic ulcer

due to NSAIDs

65
Q

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

A

Oesophageal cancer

66
Q

Which factors indicate a severe upper GI bleed?

A

Low BP
Tachycardia
Postural hypotension

67
Q

What is the initial management of an upper GI bleed?

A 
Resuscitation:
Airway protection 
Oxygen 
IV access
Fluids 
HDU 
Senior review
68
Q

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

A

IV terlipressin = Management of portal hypertension

IV septrin = Prophylactic antibiotics

69
Q

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

A

Cross matched blood

may give gelofusine or O -ve in the meantime if urgent

70
Q

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

A

Endoscopic banding

71
Q

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

A

C Sengstaken Blakemore Tube

72
Q

How does eating affect gastric pain caused by peptic ulcers?

A 
Duodenal = Pain relieved by eating 
Gastric = Pain worsened by eating
73
Q

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

A

Motility disorder

Achalasia, CNS or pharyngeal causes

74
Q

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

A

Stricture - benign or malignant

75
Q

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

A

Bulbar palsy, especially if the patient coughs on swallowing

76
Q

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

A

Cancer
Oesophageal ulcer - benign or malignant
Candida
Spasm

77
Q

What is the more likely cause of intermittent dysphagia?

A

Oesophageal spasm

78
Q

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

A

Malignant stricture

79
Q

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

A

Pharyngeal pouch

80
Q

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

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

GI (24 decks)

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