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upper GI tract Flashcards

1
Q

anatomical contributions to LOS

A

3/4cm distal oesophagus within abdomen
diaphragm surrounds LO
phrenoesophageal ligament
angle of His

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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

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4
Q

functional disorders of the oesophagus

A

Abnormal contractions: Hypermobility
Hypomobility
Disordered coordination
Failure of protective mechanisms: GORD

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5
Q

regurgitation vs reflux

A

return of oesophageal content from above an obstruction (functional or mechanical) (regurg)
passive return of gastroduodenal contents to the mouth (reflux)

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6
Q

achalasia hypermotility pathophysiology

A

Increasing rested pressure of LOS
Receptive relaxation sets in late and is too weak (during reflex phase pressure in LOS is much higher than stomach)
Swallowed food collects in oesophagus (Increases oesophageal pressure)
Dilatation of the oesophagus
Peristalsis ceases

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7
Q

What is the angle of his

A

Angle between distal oesophagus and the fundus

Compresses distal oesophagus from lateral to medial

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8
Q

What is the relaxation of the LOS mediated by

A

Mediated by inhibitory neurons of myenteric plexus

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9
Q

What causes Achalasia

A

Loss of ganglion cells in aurebach’s myenteric plexus in LOS wall
decreased inhibitory neuron activity (non-cholinergic, non-adrenergic)

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10
Q

What diseases is hypermotility seen in

A 
Chagas disease
Protozoa
Amyloid
Sarcoma
Eosinophilic oesophagitis
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11
Q

disease course of achalasia

A
  • insidious onset,
  • enlarged oesophagus
  • oesophageal cancer increased 28-fold
  • aspiration pneumonia is a risk
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12
Q

treatment of achalasia

A

pneumatic dilation to stretch muscles of the LOS

SURGICAL - hellers myotomy, dor fundoplication

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13
Q

What is pneumatic dilatation

A

Weakens LOS by circumferential stretching and in some cases, tearing of its muscles fibres
may relapse

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14
Q

What is Heller’s myotomy

A

A continuous myotomy performed for 6cm on the oesophagus and 3 cm onto the stomach

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15
Q

What is dor fundoplication

A

anterior fundus folded over oesophagus and sutured to right side

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16
Q

what type of disease is scleroderma

A 
autoimmune disease - hypomotility
neuronal defects (atrophy of smooth muscle)
peristalsis in the distal oesophagus stops
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17
Q

name for pain on swallowing

A

odynophagia

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18
Q

treatment of scleroderma

A

exclude organic obstruction first

  • prokinetics
  • can use pneumotatic dilatation
  • usually irreversible - may have to have oesophagus removed
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19
Q

conditions causing disordered coordination

A

corkscrew oesophagus

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20
Q

What is scleroderma?

A 
Autoimmune disease
Hypomotility due to neuronal defects
Atrophy of smooth muscle of oesophagus
Peristalsis in the distal portion ceases
Decreases LOS resting pressure
GORD develops
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21
Q

corkscrew oesophagus treatment

A

forceful pneumatic dilation of cardia

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22
Q

Where are iatrogenic oeseophgeal perforations normally

A

cricopharyngeal constriction

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23
Q

where are the areas of oesophagus prone to perforation

A

cricopharyngeal constriction
aortic and bronchial constriction
diaphragmatic and sphincter constriction

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24
Q

What is Boerhaave’s

A

Sudden increase in intra-oesophageal pressure with negative intra thoracic pressure
Vomiting against a close glottis
usually left posterolateral aspect of distal oesophagus

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25
what foreign bodies may cause oesophageal perforation
``` Disk batteries Magnets Sharp objects Dishwasher tablets Acid/Alkali ```
26
What operations can cause perforations
Hiatus hernia repair Hellers cardiomyotomy Pulmonary surgery Thyroid surgery
27
signs of trauma causing oesophageal perforation
dysphagia blood in saliva haematemesis surgical emphysema
28
investigations for perforated oesophagus
CXR CT swallow gastrograffin OGD
29
presentation of oesophageal perforation
pain fever dysphagia emphysema
30
what to avoid doing for a suspected oesophageal perforation
endoscopy
31
initial management of oesophageal perforation
``` nil by mouth IV fluids broad spectrum ABs ITU bloods taken transferral to tertiary care ```
32
management of oesophageal perforation
primary repair 1st line oesophagectomy - definitive solution conservatively - metal stent
33
3 mechanisms that protect against reflux
Volume clearance - oesophageal peristalsis reflex pH clearance - saliva Epithelium - barrier properties
34
What increases LOS pressure
``` Acetylcholine Alpha-adrenergic agonists Hormones Protein-rich food Histamine High intra-abdominal pressure INHIBITS REFLUX ```
35
what decreases LOS pressure and promotes reflux
acidic food fats NO smoking
36
Why is sporadic reflux normal
Pressure on full stomach Swallowing Transient sphincter opening
37
What are sliding hiatus hernias
Portion of stomach herniated | Squeezes through diaphragm
38
What is a rolling hiatus hernia
Junction is in place and the stomach herniates alongside the oesophagus
39
How do you investigate GORD
OGD - to exclude cancer or confirm oesophagitis, peptic stricture and barretts Oesophageal manometry 24hr oesophageal pH recording
40
treatments for GORD
``` Lifestyle changes (weight loss, smoking, EtOH) PPIs ```
41
surgical treatments are available for GORD
Dilation peptic strictres | Laparascopic Nissen's fundoplication
42
which is worse sliding or rolling hiatus hernia
rolling | risk of strangulation greater
43
What are the different types of gastritis
erosive and haemorrhagic Nonerosive, chronic active gastritis Atrophic (fundal gland) gastritis Reactive gastritis
44
features of erosive and haemorrhagic gastritis
Numerous causes, NSAIDs, ischaemia, vasculitis, stress etc | Acute ulcer - gastric bleeding and perforation
45
What are the features of Nonerosive, chronic active gastritis
Antrum usually | Helicobacter pylori - treat with amoxcillin, clarithromyocin, pantoporzole for 7-14 days
46
features of Atrophic (fundal gland) gastritis
Fundus Autoantibodies vs parts and products of parietal cells Parietal cells atrophy Decreased acid and IF secretion
47
methods of mucosal protection in stomach
Mucus film HCO3- secretion Epithelial barrier (tight junctions, strong apical membrane) Mucosal blood perfusion (good blood supply can get rid of H+ quickly)
48
functions of stomach
breaks food into smaller particles holds food, releases it at steady rate kills parasites and bacteria
49
what is produced in the cardia and pyloric region
mucus
50
what is produced in the body and fundus
mucus | HCl pepsinogen
51
what is produced in the antrum
gastrin
52
stimulation of gastric secretion
ACh - vagal parasympathetic fibres gastrin from G cells of antrum histamine from ECL cells and mast cells
53
chemicals for inhibition of gastric secretion
secretin - small intestine somatostatin PGs, TGF-a + adenosine
54
mechanisms repairing epithelila defects in stomach
Migration Gap closed by cell growth Acute would healing
55
How does migration repair epithelium
Adjacent epithelial cells flatten to close gap | via sideward migration along BM
56
stages of epithelial repair and wound healing
migration - Adjacent epithelial cells flatten to close gap via sideward migration along BM gap closed by cell growth - Stimulated by EGF, TGF-α, IGF-1, GRP & gastrin acute 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
57
How are ulcers formed
``` H. Pylori Increased gastric juice secretion Decreased bicarbonate secretion Decreased cell formation Decreased blood perfusion ```
58
primary medical treatment ulcer
``` PPI or H2 blocker Triple Rx (amoxicillin, clarithromycin, pantoprazole) for 7-14 days ```
59
indications for surgery for ulcers
``` Intractability (after medical therapy) Haemorrhage Obstruction Perforation Relative: continuous requirement of steroid therapy/NSAIDs ```
60
When would you opt for elective surgery for ulcers
Rare - most uncomplicated ulcers heal within 12 weeks if not - change medication, observe additional 12 weeks Check serum gastrin (antral G-cell hyperplasia or gastrinoma [Zollinger-Ellison syndrome]) OGD: biopsy all 4 quadrants of ulcer (rule out malignant ulcer) if refractory
61
how to distinguish mechanical from neurological cause of dysphagia
liquids and solids hard to swallow - likely neuro | solids difficult/painful alone or solids first and then slowly liquids got harder to swallow - likely mechanical
62
how to distinguish mechanical from neurological cause of dysphagia
liquids and solids hard to swallow - likely neuro | solids difficult/painful alone or solids first and then slowly liquids got harder to swallow - likely mechanical
63
what is riglers sign
free air under diaphragm/intraperitoneal air
64
most common site of perforation of duodenum
anterior/superior surface of first part of duodenum (D1)
65
where in the gut is most likely to perforate
duodenum - 10x more than stomach
66
what subsequent infection is likely after abdominal surgery
pneumonia taking deep breaths after surgery is painful, so not filling with air lungs fill with fluid, gets infected, get chest infection
67
what is an intraabdominal collection
fluid from lavage during surgery hasn't been fully washed out causes a collection of contaminated fluid, subsequent infection
68
what score is used for severity of pancreatitis
modified glasgow criteria | PANCREAS
69
modified glasgow criteria
``` pancreatitis scoring (PANCREAS) Po2 Age (>55) Neutrophil/WBC Calcium (low) Renal (urea increased) Enzymes AST, LDH Albumin low Sugar high ```
70
what are the indicators for severe pancreatitis
over 3 modified glasgow within 48hrs or CRP over 200
71
principles of management of pancreatitis
ABC ``` Fluid resuscitation (iv fluids, monitoring) Analgesia Pancreatic rest (NJ feeding, TPN) Determine underlying cause go to HDU if severe ```
72
investigation for gallstones
ultrasound then if issue persists, MRCP (not ERCP as is too invasive, too risky)
73
intervention for persistent pancreatitis due to gallstones
ERCP once confirmed by MRCP
74
what is murphys sign
cholecystitis - inflammation of gallbladder | palpation of right costal margin upon holding a deep breath elicits pain (hand comes into contact with gallbladder)
75
what structures need to be divided and removed for a laparoscopic cholecystectomy
cystic duct and cystic artery
76
investigation of suspected achalasia
oesophageal manometry

BRS Year 2 (67 decks)

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