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BRS Year 2 > Upper GI tract > Flashcards

Upper GI tract Flashcards

1
Q

anatomical contributions to LOS

A

3/4cm distal oesophagus within abdomen

Diaphragm surrounds LO

An intact phrenoesophageal ligament: has 2 limbs: 1 attached to the oesophagus and other attached to diaphragm- allows movement of oesophagus and diaphragm

Angle of His- between abdominal oesophagus and fundus of stomach- stops acid reflux

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2
Q

stages of swallowing

A 
4 (0-3)
oral
pharyngeal
upper oesophageal
lower oesophageal
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3
Q

how to determine motility of oesophagus

A

manometry- pressure measurements

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4
Q

functional disorders of the oesophagus

A
  • abnormal oesophageal contraction (hypomobility, hypermobility and disordered coordination)
  • failure of protective mechanisms of reflux
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5
Q

dysphagia

A

difficulty in swallowing

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6
Q

What do we call pain on swallowing?

A

odynophagia

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7
Q

regurgitation

A

return of oesophageal content from above an obstruction (functional or mechanical)

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8
Q

reflux

A

passive return of gastroduodenal contents to the mouth

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9
Q

is reflux the same as vomiting?

A

no

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10
Q

example of oseophageal hypermotility and causes?

A

achalasia
- Due to loss of ganglion cell in Aurebach’s myenteric plexus
Primary cause aetiology is unknown
Secondary cause:
-Diseases causing oesophageal motor abnormalities similar to primary achalasia
• Chagas’ Disease
• Protozoa infection
• Amyloid/Sarcoma/Eosinophilic Oesophagitis

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11
Q

features of achalaisa hypermotility

A
  • increased resting pressure of LOS
  • receptive relaxation sets in late and is too weak -> during reflex phase, pressure in LOS is markedly higher than stomach
  • swallowed food collects in the oesophagus causing increased pressure throughout with dilation of the oesophagus
  • Propagation of peristaltic wave ceases
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12
Q

disease course of achalasia

A
  • insidious onset: symptoms for years without seeking help
  • without treatment you get progressive oesophageal dilation
  • oesophageal cancer risk increased 28-fold
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13
Q

treatment of achalasia

A

pneumatic dilation (PD) to stretch muscles of the LOS:
-uses endoscopy, guide wire with PD
-balloon inserted and inflated to expand LO
- restored flow in LO
Efficacy of 90%, but usually relapses

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14
Q

surgical treatment of achalasia and risks?

A
  • heller’s myotomy : myotomy (muscle cut) for 6cm of oesophagus and 3cm of stomach
  • Dor fundopilation: anterior fundus folded over oesophagus and sutured to right side of myotomy

Risks include:

  • Esophageal and gastric perforation
  • Division of vagus nerve
  • splenic injury
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15
Q

What is an example of a cause of oesophageal hypomotility ?

A

Scleroderma-autoimmune disease
Hypomotility in its early stages due to neuronal defects → atrophy of smooth muscle of oesophagus
Peristalsis in the distal portion ultimately ceases
Decreased resting pressure of LOS
Leads to development of GORD- often associated with CREST syndrome (calcinosis, Raynaud’s phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia)

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16
Q

treatment of scleroderma

A

Exclude organic obstruction
Improve force of peristalsis with prokinetics
Once peristaltic failure occurs, this is usually irreversible - may have to have oesophagus removed

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17
Q

conditions causing disordered coordination

A

corkscrew oesophagus
Incoordinate contractions → dysphagia & chest pain
• Pressures of 400-500 mmHg
• Marked hypertrophy of circular muscle
• Corkscrew oesophagus seen on Barium x-ray scan

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18
Q

treating corkscrew oesophagus

A

forceful PD of cardia

results not as predictable as achalasia

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19
Q

What are causes of oesophageal perforation (most common to least common?

A 
latrogenic - usually due to OGD (Oesophago-Gastro-Duodenoscopy)
Spontaneous (Boerhaave's)
Foreign body
Trauma
Intraoperative
Malignant
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20
Q

what causes spontaneous oesophageal perforation

A

aka. Boerhaave’s
Sudden increase in intraesophageal pressure with negative intrathoracic pressure
Vomiting against a closed glottis
Usually left posterolateral aspect of distal oesophagus

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21
Q

foreign bodies causing oesophageal perforation

A

Disk batteries is growing problem- cause electrical burns if impact in mucosa

  • magnets
  • sharp objects
  • dishwasher tablets
  • acid/alkali
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22
Q

oesophageal perforation from trauma signs

A

Neck - caused by penetrating trauma
Thorax - caused by blunt force

Symptoms:

  • dysphagia
  • blood in saliva
  • haematemsis
  • surgical emphysema
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23
Q

surgeries that can cause oesophageal perforation

A
  • hiatus hernia repair
  • hellers myotomy
  • pulmonary surgery
  • thyroid surgery
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24
Q

investigating oesophageal perfortion

A
  • CXR
  • CT
  • Swallow (gastrograffin)
  • OGD
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25
initial management of oesophageal perforation
``` NBM (nil by mouth) IV fluids Broadspec AB and antifungal Bloods ICU/ HDU level care tertiary care (specialist) referral ```
26
definitive management of the oesophageal perforation
Perforation is a surgical emergency (2x increase in morality if 24hr delay in diagnosis) ``` Operative management is default unless: -there's minimal contamination -it's contained -patient unfit In this case you can use conservative management with a covered metal stent ```
27
why is LOS normally closed?
barrier against reflux to protect from gastric juice
28
is sporadic reflux normal?
yes, occurs when: pressure on full stomach swallowing transient sphincter opening (spontaneous)
29
3 mechanisms for protection following reflux
- volume clearance (oesophageal peristalsis reflex) - pH clearance (saliva) - epithelial barrier properties
30
what are failed protective mechanisms against reflux and what can this cause?
Decreased sphincter pressure Transient sphincter opening Decreased saliva production- leads to decreased pH clearance Decreased buffering capacity of saliva (e.g. by smoking) - leads to decreased pH clearance Abnormal peristalsis- leads to decreased volume clearance Hiatus hernia Defective mucosal protective mechanism These can lead to GORD -> reflux oesophagitis -> epithelial metaplasia -> carcinoma
31
what often happens with GORD?
sliding hiatus hernia- Ligament gives way and stomach slides up
32
rolling hiatus hernia
Bit of stomach squeezes through next to oesphagus
33
how to investigate GORD
``` OGD - exclude other cause like cancer - look for oesophagitis, peptic stricture and barrett's oesophagus Oesophageal manometry 24 hr oesophageal pH recording ```
34
types of gastritis
- erosive and hemorrhagic - nonerosive chronic active gastritis - atrophic gastritis - reactive gastritis
35
What are causes of nonerosive, chronic active gastritis, what does it lead to and what is treatment?
helicobacter pylori in the antrum Leads to increased gastrin and inc/normal acid secretion -> gastric and duodenal ulcer -> reactive gastritis -> epithelial metaplasia -> carcinoma Treatment: triple therapy - amoxicillin and clarithromycin and a PPI for up to 14 days
36
cause of atrophic gastritis
autoantibodies attacking gastric receptor/ carbonic anhydrase/ H+/K+NATPase/ IF Atrophic gastritis leads to dec pepsinogen, dec acid secretion (-> inc gastrin -> ECL cell hyperplasia -> carcinoid OR G-cell hyperplasia -> carcinoma) and dec IF secretion (-> dec cobalamin absorption -> cobalamin deficiency -> pernicious anaemia)
37
What are causes of erosive and hemorrhagic gastritis and what does it lead to?
``` NSAIDs Alcohol Multi-organ failure Trauma Ischaemia ``` Leads to acute ulcer- gastric bleeding and perforation
38
methods of mucosal protection (4)
1. mucus film 2. HCO3- secretion 3. Epithelial barrier 4. mucosal blood perfusion
39
What are the stages of epithelial repair and wound healing?
Migration Gap closed by cell growth Acute wound healing
40
How does H Pylori cause virulence? (8)
Urease: to neutralise gastric acid Flagella: for mobility and chemotaxis Lipopolysaccharides: adhere to host cells and inflammation Outer proteins: Adhere to host cell Exotoxins: vacuolating toxin for gastric mucosal injury Secretory enzymes: mucinase, protease, lipase for gastric mucosal injury Type IV secretion system: for injection of effectors Effectors: for actin remodelling, IL-8 induction, host cell growth and apoptosis inhibition
41
neural stimulation of gastric secretion?
ACh -> postganglionic transmitter of vagal parasympathetic fibres
42
endocrine stimulation of gastric secretion?
Gastrin (G cells of antrum)
43
paracrine stimulation of gastric secretion?
Histamine (from ECL cells & mast cells of gastric wall)
44
endocrine inhibition of gastric secretion?
Secretin (small intestine)
45
paracrine inhibition of gastric secretion?
Somatostatin (SIH)
46
paracrine and autocrine inhibition of gastric secretion?
Prostaglandins (E2 & I2), TGF-α & | adenosine
47
What occurs in the migration stage of epithelial repair and wound healing
• Adjacent epithelial cells flatten to close gap | via sideward migration along BM
48
gap closed by cell stage of epithelial repair and wound healing
• Stimulated by EGF, TGF-α, IGF-1, GRP & gastrin
49
acute wound healing by cell stage of epithelial repair and wound healing
- BM destroyed - attraction of leukocytes & macrophages; phagocytosis of necrotic cells; angiogenesis; regeneration of ECM after repair of BM - epithelial closure by restitution & cell division.
50
What factors contribute to ulcer formation? | look at slide on this and slide after!!
- helicobater pylori - secretion of gastric juice increased - HCO3- secretion decreased - cell formation decreased - blood prefusion decreased
51
primarily medical treatment ulcer
- PPI or H2 blocker • Triple Rx (amoxicillin, clarithromycin, pantoprazole) for 7-14 days)
52
Elective Surgical Rx for ulcers
``` Rare - most uncomplicated ulcers heal within 12 weeks • If don’t, change medication, observe additional 12 weeks • Check serum gastrin (antral G-cell hyperplasia or gastrinoma [ZollingerEllison syndrome]) • OGD: biopsy all 4 quadrants of ulcer (rule out malignant ulcer) if refractory ```
53
surgical indication ulcers
- Intractability (after medical therapy) - Haemorrhage -Obstruction -Perforation -Relative: continuous requirement of steroid therapy/NSAIDs
54
main disorders of the stomach (8)
``` • Failure of protective mechanisms • Gastrooesophageal reflux (GORD) • Hiatus hernia • Gastritis • Failure in regulation of gastric secretion, mucosal protection & epithelial repair • GIT ulcer formation • H. pylori • Treatment ```
55
What happens in the oral phase of swallowing?
* Chewing & saliva prepare bolus | * Both oesophageal sphincters constricted
56
What happens in the pharyngeal phase of swallowing?
• Pharyngeal musculature guides food bolus towards oesophagus • Upper oesophageal sphincter opens reflexly • LOS opened by vasovagal reflex (receptive relaxation reflex)
57
What happens in the upper oesophageal phase of swallowing?
• Upper sphincter closes • Superior circular muscle rings contract & inferior rings dilate • Sequential contractions of longitudinal muscle
58
What happens in the lower oesophageal phase of swallowing?
• Lower sphincter closes as food passes through
59
What is the pressure of a normal oesophagus during a peristaltic wave?
40 mmhg
60
What is the lower oesophageal resting pressure normally and how does this change with receptive relaxation?
20 mmhg | decreased by 5 mmhg during receptive relaxation
61
What mediates the pressure within the oesophagus?
Mediated by inhibitory noncholinergic nonadrenergic (NCNA) neurons of myenteric plexus
62
How is dysphagia classified?
Location: cricopharyngeal sphincter or distal | Type of dysphasia: solids or fluids/ intermittent or progressive/ precise or vague in precision
63
What is an endoscopic treatment of achalasia?
Peroral endoscopic myotomy (POEM): 1. Mucosal incision mae 2. Submucosal tunnel is creates 3. Myotomy 4. Closure of mucosal tunnel
64
What are iatrogenic causes of oesophageal perforation?
Usually occurs at OGD Incidence (low to high) OGD alone Stricture dilatation Sclerotherapy Achalasia dilatation
65
How do you treat malignancies that cause esophageal perforation?
• Radiotherapy • Dilatation • Stenting Has poor prognosis
66
What are symptoms of oesophageal perforation?
Pain Fever Dysphagia Emphysema
67
What surgery would be used to repair an oesophageal perforation?
Primary repair is optimina: • +/- Vascularised pedicle flap • +/- Gastric fundus buttressing (e.g. Dor) Oesophagaectomy is a definitive soloution: - With reconstruction or oesophagostomy & delayed reconstruction
68
What are things that can increase LOS pressure and what is their effect?
Acetylcholine, α-adrenergic agonists, hormones, protein-rich food, histamine, high intra-abdominal pressure, PGF2α, etc. Inhibit reflux
69
What are things that can decrease LOS pressure and what is their effect?
VIP, β-adrenergic agonists, hormones, dopamine, NO, PGI2 , PGE2 , chocolate, acid gastric juice, fat, smoking, etc. Promote reflux
70
What are treatments of GORD?
Medical: - lifestyle changes (wt loss, smoking) - PPIs Surgical: - Dilatation peptic strictures - Laparoscopic Nissen’s fundoplication (close where stomach enters diaphragm and wrap fundus around oesophagus)
71
What are the clinical outcomes of a H Pylori infection?
``` Asymptomatic or chronic gastritis e.g. Chronic atrophic gastritis Intestinal metaplasia Gastric or duodenal ulcer Gastric cancer e.g MALT lymphoma ```

BRS Year 2 (110 decks)

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