Week Ten - Case Two

Question 1

according to the NICE guidelines, how should you organise an urgent direct access upper GI endoscopy

Answer 1

1.3
Referral guidance for endoscopy links to NICE guidelines on suspected cancer: recognition and referral for patients with dysphagia or those over the age of 55 with weight loss and either upper abdominal pain, reflux or dyspepsia

Question 2

what is GORD

Answer 2

describes the symptomatic passing of gastric contents back up into the oesophagus.

Question 3

what is the pathophysiology of GORD

Answer 3

the pathology is complex and can involve the abnormal transient relaxation of the LOS, impaired oesophageal clearance and delayed gastric emptying that increase gastric pressure

Question 4

what is GORD also associated with

Answer 4

also associated with hiatus hernia where a weakness in the curial diaphragm allows the proximal stomach to pass upwards into the chest

Question 5

what are the risk factors for GORD

Answer 5

Smoking and alcohol
Obesity
Stress
Hiatus hernia
Pregnancy
Trigger foods
Medications that reduce the lower oesophageal sphincter tone (such as NSAIDS and beta-blockers)

Question 6

for patients where cancer is not suspected, what is organised?

Answer 6

a routine upper GI endoscopy can be organised for patents who do not respond to acid suppression therapy such as proton pump inhibitors

Question 7

what can objectively assess the degree of reflux as well as the motility of the oesophagus for those who are being considered for surgery

Answer 7

oesophageal manometry and ambulatory 24 hour oesophageal pH monitoring

Question 8

what are the surgical options used to treat GORD

Answer 8

Nissen fundoplication

this is usually performed laparoscopically and involves wrapping the funds of the stomach around the lower oesophagus to reinforce the lower oesophageal sphincter

Question 9

what are the potential complications resulting from untreated GORD

Answer 9

benign stricture
Barrett’s oesophagus
oesophagi’s
chronic cough
recurrent chest infections

Question 10

what are the indications for surgery in GORD treatment

Answer 10

failure of medical therapy, desire to discontinue medical therapy or the presence of a hiatus hernia

Question 11

what kind of lining does the oesophagus have

Answer 11

a squamous epithelial lining that makes it more sensitive to the effects of stomach acid

the stomach has a columnar epithelial lining that is more protected against stomach acid

Question 12

what are the causes and triggers of GORD

Answer 12

Greasy and spicy foods
Coffee and tea
Alcohol
Non-steroidal anti-inflammatory drugs
Stress
Smoking
Obesity
Hiatus hernia

Question 13

what is dyspepsia

Answer 13

non-specific term used to describe indigestion

Question 14

what symptoms does dyspepsia cover

Answer 14

Heartburn
Acid regurgitation
Retrosternal or epigastric pain
Bloating
Nocturnal cough
Hoarse voice

Question 15

what are the red flags

Answer 15

Dysphagia (difficulty swallowing) at any age gets an immediate two week wait referral
Aged over 55 (this is generally the cut-off for urgent versus routine referrals)
Weight loss
Upper abdominal pain
Reflux
Treatment-resistant dyspepsia
Nausea and vomiting
Upper abdominal mass on palpation
Low haemoglobin (anaemia)
Raised platelet count

Question 16

what is the most critical red flag

Answer 16

dysphagia is a critical red flag, any patient presenting with the feeling that food is getting stuck on the way down needs an urgent two week wait referral for an endoscopy

Question 17

what is an OGD

Answer 17

involves inserting a camera through the mouth down to the oesophagus, stomach and duodenum

Question 18

what can OGD be used to assess for

Answer 18

Gastritis
Peptic ulcers
Upper gastrointestinal bleeding
Oesophageal varices (in liver cirrhosis)
Barretts oesophagus
Oesophageal stricture
Malignancy of the oesophagus or stomach

Question 19

patients with what symptoms, need admission and urgent endoscopy?

Answer 19

patients with evidence of upper GI bleeding - melaena or coffee ground vomiting

Question 20

what does hiatus hernia refer to

Answer 20

a herniation hernia is when the stomach goes up through the diaphragm

Question 21

where should the diaphragm opening be

Answer 21

at the LOS level and fixed in place. a narrow opening helps to maintain the sphincter and stops acid and stomach contents from refluxing into the oesophagus

when the opening of the diaphragm is wider, the stomach can enter through the diaphragm and the contents of the stomach can reflux into the oesophagus

Question 22

what are the four types of hiatus hernia

Answer 22

Type 1: Sliding
Type 2: Rolling
Type 3: Combination of sliding and rolling
Type 4: Large opening with additional abdominal organs entering the thorax

Question 23

what is a sliding hiatus hernia

Answer 23

A sliding hiatus hernia is where the stomach slides up through the diaphragm, with the gastro-oesophageal junction passing up into the thorax.

Question 24

what is a rolling hiatus hernia

Answer 24

A rolling hiatus hernia is where a separate portion of the stomach (i.e., the fundus), folds around and enters through the diaphragm opening, alongside the oesophagus.

Question 25

what is type 4 hiatus hernia

Answer 25

Type 4 hiatus hernia refers to a large hernia that allows other intra-abdominal organs to pass through the diaphragm opening (e.g., bowel, pancreas or omentum).

Question 26

what is the management of GORD

Answer 26

Lifestyle changes
Reviewing medications (e.g., stop NSAIDs)
Antacids (e.g., Gaviscon, Pepto-Bismol and Rennie) – short term only
Proton pump inhibitors (e.g., omeprazole and lansoprazole)
Histamine H2-receptor antagonists (e.g., famotidine)
Surgery

Question 27

what is the usual medical stragety when someone presents for the first time

Answer 27

The usual medical strategy when someone presents for the first time is to exclude red flags, address potential triggers, offer a 1 month trial of a proton pump inhibitor and consider H. pylori testing.

Question 28

what is the surgery for reflux called

Answer 28

Surgery for reflux is called laparoscopic fundoplication. This involves tying the fundus of the stomach around the lower oesophagus to narrow the lower oesophageal sphincter.

Question 29

what is Zollinger-Ellison syndrome

Answer 29

is a rare conditon where a duodenal or pancreatic tumour secretes excessive quantities of gastrin.

Question 30

what Is gastrin

Answer 30

it is a hormone that stimulates acid secretion in the stomach.

Question 31

what are gastrin secreting tumours associated with

Answer 31

multiple endocrine neoplasia type 1 (MEN1), an autosomal dominant genetic condition, which can also cause hormone-secreting tumours of the parathyroid and pituitary glands