Week 6 - Upper Gastrointestinal Disease

Question 1

What is chronic gastritis?

Answer 1

• ongoing inflammation of the stomach mucosa

- can provide an environment in which dysplasia and carcinoma can arise

Question 2

How does chronic gastritis compare to acute gastritis?

Answer 2

Symptoms less severe but more persistent

Question 3

What are the symptoms of chronic gastritis?

Answer 3

• upper abdominal pain
• indigestion or bloating
• N&V
• belching
• loss of appetite or weight loss

-may be asymptomatic

Question 4

What are the causes for chronic gastritis?

Answer 4

Bacterial - helicobacter pylori infection

Chemical - alcohol, tobacco, caffeine

Autoimmune - can lead to pernicious anaemia

Psychological stress

Question 5

What is helicobacter pylori?

Answer 5

• gram -ve bacterium found in the stomach, particularly antrum
• infects over half the worlds population by age 5
• infection probably acquired via faecal-oral route
• if untreated, infection persists throughout life

Question 6

What is the clinical presentation of H.pylori?

Answer 6

• 80% asymptomatic
• 5-15% peptic ulcer disease
• 10% non-ulcer dyspepsia
• 1-3% gastric adenocarcinoma
• 0.5% gastric MALToma

Question 7

What is the importance of H.pylori?

Answer 7

• strongly associated with chronic gastritis
• strongly associated with duodenal ulcer
• fairly strongly associated with gastric ulcer
• associated with gastric carcinoma
• associated with gastric MALT lymphoma

Question 8

What are the effects of H.pylori infection?

Answer 8

• mild pan gastritis - no significant disease
• body-predominant (hypochlorhydria, gastric atrophy, intestinal metaplasia) - gastric cancer phenotype
• antrum-predominant (hyperchlorhydria) - DU phenotype

Question 9

What is peptic ulcer disease?

Answer 9

Painful sores or ulcers in the lining of the stomach or first part of the small intestine, called the duodenum

-most ulcers are solitary

Question 10

Where does peptic ulcer disease usually occur?

Answer 10

-D1 or antrum (4:1)

Question 11

What are common causes of peptic ulcer disease?

Answer 11

• H.pylori (80-100% DU, 65% gastric)

- NSAIDs

Question 12

What are the symptoms of peptic ulcer disease?

Answer 12

• pain (gnawing, burning, aching)
• worse at night
• worse after meals

Question 13

What are the complications of peptic ulcer disease?

Answer 13

• bleeding leading to iron deficiency anaemia
• massive haematemesis - vomiting of blood
• perforation leading to peritonitis
• long term cancer at edge of ulcer

Question 14

What is Barrett’s oesophagus?

Answer 14

Normal lining of the oesophagus = stratified squamous epithelium

• in Barrett’s oesophagus - squamous epithelium is replaced by columnar epithelium with goblet cells (usually found lower in the GI tract)
• thought to be an adaptation to chronic acid exposure from reflux oesophagitis

Question 15

What is the process of dysplasia in Barrett’s oesophagus?

Answer 15

• low grade to high grade to invasive carcinoma

- strong association 0.5% per patient per year) with oesophageal adenocarcinoma - need for surveillance

Question 16

Name the upper GI malignancies

Answer 16

Oesophagus

• squamous carcinoma
• adenocarcinoma (Barrett’s)

Stomach

• adenocarcinoma
• GI stromal tumours (GIST)

Small bowel

• lymphoma
• GI stromal tumours (GIST)
• neuroendocrine tumours

Question 17

What is oesophageal carcinoma and who does it affect?

Answer 17

• squamous cell carcinoma
• adults over 45
• M:F = 4:1

Question 18

What are the risk factors for oesophageal cancer?

Answer 18

-alcohol, tobacco, caustic/corrosive injury, achalasia (muscles of the lower part of the oesophagus fail to relax, preventing food from passing into the stomach)

Question 19

What are the symptoms of oesophageal cancer?

Answer 19

• insidious onset with late symptoms
• dysphagia, weight loss, haemorrhage, sepsis, respiratory fistula with aspiration
• overall 5 year survival of 9%

Question 20

Describe oesophageal adenocarcinoma

Answer 20

-now more common
-largely from dysplastic change in Barrett’s oesophagus
Present with dysphagia, weight loss, haematemesis, chest pain, vomiting
-5 year survival

Question 21

What are the similarities between oesophageal carcinoma and adenocarcinoma?

Answer 21

Both are:
Direct -into surrounding tissues

Lymphatic -to paraoesophageal, paratracheal and cervical node groups

Haematogenous - to liver or lung

Question 22

How common is stomach adenocarcinoma?

Answer 22

• adenocarcinoma- 90% of gastric malignancies
• 2nd most common carcinoma worldwide
• east Asia, South America (Andes), Eastern Europe
• declining incidence

Question 23

What are the precursor lesions of stomach -adenocarcinoma?

Answer 23

• pernicious anaemia (atrophied gastritis)
• intestinal metaplasia
• neoplastic polyps
• h.pylori associated gastritis

Question 24

What are the early symptoms of stomach adenocarcinoma?

Answer 24

Resemble gastritis

Question 25

What are the advanced symptoms of stomach adenocarcinoma?

Answer 25

- weight loss, anorexia, anaemia, haemorrhage - fungating exophytic growth - prognosis depends on depth of invasion - 5 year survival (early) after surgery (90%) - overall 5 year survival 30%

Question 26

How does stomach adenocarcinoma spread?

Answer 26

Direct infiltration -duodenum, pancreas, colon, liver, spleen Lymphatic spread - local and regional nodes - Virchow's node Haematogenous -liver/lungs Transcoelomic (via pleura, peritoneum etc) Omentum (a fold of peritoneum connecting the stomach with other abdominal organs) Mesentary (fold of the peritoneum which attaches the stomach, small intestine, pancreas, spleen, and other organs to the posterior wall of the abdomen) Ovary (Krukenberg tumour)

Question 27

What are the subtypes of small bowel neoplasia?

Answer 27

Different subtypes include: - adenocarcinoma (rare) - GI stromal tumour - lymphoma - carcinoid (neuroendocrine) tumour

Question 28

How common is small bowel neoplasia?

Answer 28

-relatively rare compared to other GI malignancies

Question 29

What are the risk factors for small bowel neoplasia?

Answer 29

- crohn's disease - coeliac disease - radiation exposure - hereditary GI cancer syndromes e.g. familial adenomatous polyposis

Question 30

What is coeliac disease?

Answer 30

- extensive mucosal disease related to sensitivity to gluten - immune mediated villous atrophy and malabsorption - prevalence in white Europeans of 0.5-1%

Question 31

How can coeliac disease be diagnosed?

Answer 31

Via serological blood test (TTG) and biopsy

Question 32

What are the symptoms of coeliac disease?

Answer 32

- pain and discomfort in digestive tract - chronic constipation and diarrhoea - failure to thrive - in children - anaemia - fatigue -intestinal damage begins to heal within weeks of gluten being removed from diet

Question 33

What does coeliac disease increase the risk of?

Answer 33

- adenocarcinoma | - lymphoma of the small bowel

Question 34

What does the upper GI tract consist of?

Answer 34

Oesophagus Stomach Intestines