Upper GI Tract Disorders

Question 1

what are the types of oesophageal cancers, and what’s most likely to cause each type?

Answer 1

squamous carcinoma - smoking, alcohol, diet

adenocarcinoma - obesity, Barrett’s oesophagus

Question 2

what is Barrett’s oesophagus?

Answer 2

metaplasia of epithelium from stratified squamous to simple columnar due to recurrent acid reflux

Question 3

what are the muscle types found in the oesophagus?

Answer 3

top third - skeletal
middle third - skeletal and smooth
bottom third - smooth

Question 4

what nervous input controls oesophageal peristalsis and relaxation of the LOS?

Answer 4

vagus nerve - parasympathetic input

Question 5

what are the two groups of oesophageal motility disease, and what are examples of each?

Answer 5

hypermotility - oesophageal spasm

hypomotility - caused by diabetes, neuropathy, connective tissue disorders

Question 6

what are the main investigations for oesophageal disorders? (3)

Answer 6

1. Endoscopy
2. Barium swallow
3. Oesophageal pH and manometry

Question 7

what are the main symptoms of oesophageal disorders?

Answer 7

Dysphagia (with or without pain - odynophagia)

Heartburn (with or without water brash)

Question 8

what is the surgical option for oesophageal cancer?

Answer 8

Oesophagectomy

Question 9

what are the non-surgical treatment options for oesophageal cancer in patients with resectable tumours?

Answer 9

adjuvant chemo/radiotherapy following surgery

neoadjuvant radiotherapy prior to surgery

Question 10

what are the non-surgical treatment options for oesophageal cancer in patients who are unfit for surgery/metastatic?

Answer 10

palliative radio/chemotherapy

oesophageal stenting

Question 11

define water brash

Answer 11

acid taste in back of throat

Question 12

define odynophagia

Answer 12

pain when swallowing

Question 13

what is achalasia, what is it caused by and what is an important complication?

Answer 13

motility disorder of oesophagus, LOS doesn’t open so food sits in oesophagus
caused by loss of myenteric plexus
can cause respiratory infections due to food escaping oesophagus and lodging down trachea

Question 14

what is GORD and what are its causes?

Answer 14

gastro-oesophageal reflux disorder
possible causes: 
- diet
- certain drugs 
- obesity

Question 15

what are possible causes of dysphagia?

Answer 15

oesophageal cancer (malignant stricture)
benign stricture (fibrosis, foreign object)
compression from other structures (cancer)
motility disorders
reflux
esinophilic oesophagitis

Question 16

what are the causes, symptoms and treatment for oesophageal hypermobility disorders?

Answer 16

causes: normally idiopathic
symptoms: periodic dysphagia and chest pain
treatment: smooth muscle relaxants

Question 17

what are the main symptoms of achalasia?

Answer 17

progressive dysphagia
regurgitation
recurrent chest infections
chest pain (not always)

Question 18

what are the two main signs of achalasia to make a diagnosis?

Answer 18

absence of peristaltic waves in lower oesophagus

inability of LOS to relax after swallowing

Question 19

what are the treatment options for achalasia?

Answer 19

pharmaceutical - nitrates, CCB’s

radiology/endoscopy - balloon dilation, surgical incision in LOS

Question 20

what are some of the risk factors for developing GORD?

Answer 20

smoking
obesity
alcohol
pregnancy
hypomotility

Question 21

what are the three important symptoms that warrant the need of an endscopy in patients with oesophageal disorders?

Answer 21

dysphagia
weight loss
vomiting

Question 22

what is the treatment of Barrett’s oesophagus?

Answer 22

depends on dysplasia

high grade dysplasia treated endoscopically/laparoscopically to remove dysplastic glandular epithelium

Question 23

what is the surgical treatment for GORD?

Answer 23

fundoplication

Question 24

what investigations are done for oesophageal cancer and what is the general purpose?

Answer 24

endoscopy/biopsy - diagnostic

EUS/CT scan/Xray/PET - staging

Question 25

what is eosinophilic oesophagitis?

Answer 25

inflammation of oesophagus epithelium allergic response to a particular food/stimulant

Question 26

what are the treatment options for achalasia?

Answer 26

nitrates, calcium channel blockers endoscopic balloon widening of oesophagus myotomy

Question 27

what complications can arise from GORD? (4)

Answer 27

strictures ulceration Barrett's oesophagus carcinoma

Question 28

why does oesophageal cancer often present with lymphatic spread?

Answer 28

because the lymph supply of the oesophagus is in the lamina propria of the mucosa

Question 29

what are some of the common symptoms of oesophageal cancer?

Answer 29

``` dysphagia weight loss/anorexia chest pain voice box paralysis haematemesis odynophagia ```

Question 30

what is a common finding in eosinophilic oesophagitis?

Answer 30

concentric rings with white patches in oesophageal lining

Question 31

what are the three main management steps in eosinophilic oesophagitis?

Answer 31

remove toxic stimulant corticosteroids to reduce inflammation endoscopic dilatation

Question 32

what are two common presentations of eosinophillic oesophagitis?

Answer 32

dysphagia | food obstruction

Question 33

what are the three main pathologies of gastritis?

Answer 33

autoimmune gastritis bacterial gastritis chemically induced gastritis

Question 34

which cells are affected in autoimmune gastritis?

Answer 34

parietal cells

Question 35

what is the most common cause of bacterial gastritis?

Answer 35

Helicobacter Pylori

Question 36

what are common causes of chemically induced gastritis?

Answer 36

drugs (eg NSAIDS) | alcohol

Question 37

what are complications of peptic ulcers?

Answer 37

bleeding (acute and chronic) perforation (peritonitis) fibrosis (obstruction)

Question 38

what is the pathology behind peptic ulcers?

Answer 38

imbalance between mucous secretion and gastric acid secretion

Question 39

where can peptic ulcers occur?

Answer 39

anywhere that has contact with acid - lower oesophagus - stomach - first part of duodenum

Question 40

what is a common cause for gastric ulcers, and how does it come about?

Answer 40

H Pylori infection. causes increased acid production, leads to imbalance

Question 41

what type of cancer is stomach cancer?

Answer 41

adenocarcinoma

Question 42

what is a difference in tumour spread between oesophageal and stomach cancer?

Answer 42

stomach cancer can spread through transcoelomic spread. oesophageal cancer doesn't normally cross into other peritoneal structures

Question 43

what is a common area of metastasis for oesophageal and gastric cancer, and through what type of spread?

Answer 43

liver | through blood spread

Question 44

how does previous H Pylori infection increase risk of gastric cancer? what can the process be compared to?

Answer 44

- because of the metaplasia of gastric epithelium following H Pylori infection - similar to Barrett's metaplasia causing higher risk of oesophageal cancer

Question 45

what are the two types of hiatus hernia which may cause GORD?

Answer 45

sliding hernia | para-oesophageal hernia

Question 46

what are the symptoms of para-oesophageal hernia?

Answer 46

chest pain when swallowing | vomiting

Question 47

what are the preferred cancer staging investigations for oesophageal cancer and gastric cancer respectively?

Answer 47

oesophageal cancer - PET scan | gastric cancer - laparoscopy

Question 48

what are some side effects of fundoplication?

Answer 48

``` dysphagia belching/vomiting issues gas bloating flatulence diarrhoea ```

Question 49

what are the important symptoms of gastric disease?

Answer 49

``` ALARMS Anaemia Loss of weight Anorexia Recent onset/ >55yo Malaena/haematemesis or Mass Swallowing problems (Dysphagia) ```

Question 50

what should be the next step in diagnosing a gastric problem after establishing that there are no ALARMS symptoms?

Answer 50

Test for H Pylori

Question 51

what are the invasive and non-invasive tests for H Pylori infection?

Answer 51

invasive: biopsy and CLO test | non-invasive: urease breath test, IgG serology, stool test

Question 52

how does H Pylori cause gastric inflammation?

Answer 52

by sitting in gastric mucous layer and causing an inflammatory response in the underlying mucosa

Question 53

how does H Pylori survive acidic environment in stomach?

Answer 53

secretes urease, forms an alkaline bubble around it | burrows into mucous layer with flagellum

Question 54

what are possible H Pylori complications based on the location of the infection?

Answer 54

stomach antrum - risk of duodenal ulcers | stomach body - risk of stomach cancer

Question 55

what three main problems can H Pylori infection cause?

Answer 55

bacterial gastritis gastric ulcer gastric cancer

Question 56

how is a peptic ulcer treated?

Answer 56

- antacids - eradication of H Pylori if infection present - stop NSAIDs/other precipitants - deal with complications as they arise

Question 57

what does the H Pylori eradication treatment involve?

Answer 57

7 day course dual antibiotic treatment - clarythromycin - amoxycillin* or metronidazole * tetracycline if penicillin allergy

Question 58

what are the main antacid treatments and which ones are most used?

Answer 58

H2 Receptor Antagonists - ranitidine, cimetidine Proton Pump Inhibitors - omeprazole, lansoprazole PPIs more effective than H2RA

Question 59

which type of oesophageal cancer is more responsive to radiotherapy?

Answer 59

squamous cell carcinoma

Question 60

what is the surgical treatment for gastric cancer?

Answer 60

gastrectomy (total or partial, depending on where the tumour is)

Question 61

why can peptic ulcers appear in lower oesophagus and upper duodenum?

Answer 61

because those are areas within reach of stomach acid

Question 62

what should be the main line investigation for gastric symptoms in patients under and over 55?

Answer 62

under 55 - H Pylori testing | over 55 - Endoscopy to look for malignancy

Question 63

list some common symptoms of peptic ulcers

Answer 63

``` dyspepsia epigastric pain night pain/hunger pain if bleeding ulcer, anaemia/haemorrage/haematemesis/malaena nausea and vomiting early satiety anorexia ```

Question 64

what symptoms often present with gastric outlet obstruction?

Answer 64

``` vomiting (no bile) early satiety metabolic alkalosis low Cl, low Na, low calcium, low K bloating dehydration acute kidney injury ```

Question 65

what could be some causes of gastric outlet obstruction?

Answer 65

cancer fibrosis from healed peptic ulcer inflammation/oedema from peptic ulcer

Question 66

what is malaena?

Answer 66

black tarry stools, made of digested blood from upper GI

Question 67

what is haematemesis?

Answer 67

vomiting blood

Question 68

what are possible aetiology factors for gastric cancer?

Answer 68

``` smoking diet H Pylori infection genetics environment ```

Question 69

what bloods should be taken if someone presents with dyspepsia?

Answer 69

``` FBC U&E LFT ferritin calcium glucose coeliac serology H Pylori serology ```

Question 70

what is the definition of metaplasia?

Answer 70

transformation of one mature cell type (stratified squamous) to another mature cell type (simple columnar)

Question 71

what investigation is used for gastric cancer staging?

Answer 71

laparoscopy

Question 72

name two structural characteristics of the oesophageal wall lining that make it more likely to spread to local lymph nodes and nearby structures

Answer 72

- no serosal lining (more likely to spread into mediastinum) | - lymphatics in lamina propria (more likely to present with lymph node spread)

Question 73

where are the lymphatics found in the oesophagus compared to elsewhere in the GI tract?

Answer 73

in oesophagus - in lamina propria | rest of GI - submucosa