GI & Surgery 1

oelomar's version from 2016-02-27 14:36


Question Answer
What is oropharyngeal dysphagia?Difficulty emptying material from the oropharynx into the oesophagus.
What are the characteristic signs of oropharyngeal dysphagia?Drooling and difficulty in initiating the swallow (aspiration can also occur).
What is oesophageal dysphagia?Difficulty in passing food down the oesophagus.
What percentage of dysphagia is as a result of stroke?50%
What is usually the first line investigation for dysphagia?Upper GI endoscopy and biopsy.
When investigating dysphagia, if the barium swallow is normal, what test should be performed next?Manometry
What are the 5 key questions to ask a dysphagic patient?1- Was there difficulty swallowing solids and liquids from the start? (Yes: suspect motility disorder (e.g. achalasia) or pharyngeal causes) (No: solids then liquids: suspect a stricture (benign or malignant)). 2- Is it difficult to make the swallowing movement? (Yes: suspect bulbar palsy, especially if they cough on swallowing). 3- Is swallowing painful? (Yes: suspect cancer, oesophageal ulcer, or spasm). 4- Is the dysphagia intermittent or is it constant and getting worse? (Intermittent: suspect oesophageal spasm. Constant and worsening: suspect malignant stricture). 5- Does the neck bulge or gurgle on drinking? (Yes: suspect pharyngeal pouch).
When dysphagia is as a result of oesophageal cancer, it may be associated with...Weight loss, anorexia, vomiting during eating, a past history of Barrett's oesophagus, GORD, excessive smoking, or alcohol use.
With oesophagitis (as well as dysphagia) there may be...A history of heartburn; odynophagia (but no weight loss, and systemically well).
With oesophageal candidiasis (as well as dysphagia) there may be...A history of HIV. Oesophageal candidiasis also presents with odynophagia, and can result in weight loss when long-standing. It is also a complication of inhaled steroid therapy.


Question Answer
Achalasia can present with...Dysphagia of both solids and liquids from the start; heartburn; regurgitation of food (may lead to cough, aspiration pneumonia, etc).
Pharyngeal pouch can present with...Dysphagia; regurgitation; aspiration; chronic cough; a midline lump in the neck that gurgles on palpation; halitosis. Pharyngeal pouch is more common in older men.
Myasthenia gravis can present with (as well as dysphagia)...Ptosis; dysphagia with liquids as well as solids.
Globus hystericus (globus pharyngis) can present with...A history of anxiety. Globus hystericus is the persistent sensation of having phlegm, a pill or some other sort of obstruction in the throat when there is none. Swallowing can be performed normally, so it is not a true case of dysphagia, but it can become quite irritating.
What is eagle syndrome?A rare condition caused by an elongated styloid process and/or calcification of the stylohyoid ligament, which interferes with adjacent anatomical structures giving rise to pain. Symptoms include dysphagia, odynophagia, and otalgia.
What is CREST syndrome?A multisystem connective tissue disorder. The acronym "CREST" refers to the five main features: Calcinosis, Raynaud's phenomenon, oEsophageal dysmotility, Sclerodactyly and Telangiectasia. Calcinosis is the formation of calcium deposits in any soft tissue (e.g. tendons, ligaments). Raynaud's phenomenon is excessively reduced blood flow in response to cold or emotional stress, causing discolouration of the fingers, toes, and occasionally other areas. This condition may also cause nails to become brittle with longitudinal ridges. Sclerodactyly is a localised thickening and tightness of the skin of the fingers or toes. Sclerodactyly often leads to ulceration of the skin of the distal digits and is commonly accompanied by atrophy of the underlying soft tissues. Telangiectasia, also known as spider veins or angioectasias, are small dilated blood vessels near the surface of the skin or mucous membranes, measuring between 0.5 and 1 millimeters in diameter. They can develop anywhere on the body but are commonly seen on the face around the nose, cheeks, and chin.
What is the main complication of using a nasogastric tube?There is no satisfactory way of keeping them in place (up to 60% fall out).
Achalasia is characterised by what triad of symptoms?Incomplete LES relaxation, increased LES tone, and aperistalsis of the oesophagus.
When investigating achalasia, a barium swallow will reveal what kind of appearance?Bird's beak appearance.
Diffuse oesophageal spasm presents withRetrosternal chest pain and dysphagia. It can accompany GORD. On barium swallow, the appearance may be that of a "corkscrew" oesophagus.


Question Answer
A diverticulum found just above the UES is referred to asZenker's diverticulum/pharyngeal pouch.
A diverticulum found just above the LES is referred to asEpiphrenic diverticulum (it is associated with achalasia).
What is an oesophageal web?Oesophageal webs are thin membranes located in the middle or upper oesophagus. Its main symptoms are pain and dysphagia.
What are the causes of a benign oesophageal stricture?Reflux (most common cause), ingestion of corrosives, radiotherapy, sclerosis of varices, prolonged nasogastric intubation.
How are benign oesophageal strictures treated?Endoscopic dilatation.
Nystatin - an anti-fungal medication - has what adverse effects?Diarrhoea, abdominal pain, hypersensitivity reactions.
Amphotericin - an anti-fungal medication - has what adverse effects?Serious acute reaction after infusion (1-3 hours later) constituting high fever, shaking chills, hypotension, vomiting; multiple organ damage (particularly kidneys).
What is a Mallory-Weiss tear?Gastro-oesophageal laceration syndrome refers to bleeding from tears (a Mallory-Weiss tear) in the mucosa at the junction of the stomach and oesophagus produced by a sudden increase in intra-abdominal pressure. Most bleeds are minor and discharge is usually within 24 hours.
What are the causes of a Mallory-Weiss tear?It often occurs after a bout of coughing or retching. It is often associated with alcoholism.
When does oesophageal perforation most commonly occur?At the time of endoscopic dilatation.


Question Answer
What is Boerhaave syndrome?Oesophageal rupture which occurs with violent vomiting producing severe chest pain. It is the most lethal rupture of the GI tract.
What does an x-ray show with someone who has Boerhaave syndrome?Hydropneumothorax.
What does GORD present with?Heartburn, regurgitation upon lying down, nocturnal cough, dyspnoea.
What is Plummer-Vinson syndrome?A rare disease characterised by a triad of symptoms: iron deficiency anaemia, glossitis, and oesophageal webs (giving rise to dysphasia).
Cancer of the oesophagus is the _____ most common cancer in the worldSixth.
Barrett's oesophagus predisposes to what type of cancer?Adenocarcinoma.
Achalasia predisposes to what type of cancer?Squamous cell carcinoma.
What are the risk factors for developing adenocarcinoma?Longstanding severe GORD, Barrett's oesophagus, tobacco smoking, obesity, breast cancer treated with radiotherapy.
What are the risk factors for developing squamous cell carcinoma?Achalasia, tobacco smoking, high alcohol intake, Plummer-Vinson syndrome, coeliac disease, breast cancer treated with radiotherapy.
What are the clinical features of a carcinoma of the oesophagus?Weight loss, anorexia, lymphadenopathy, progressive dysphagia, initially difficulty in swallowing solids but liquids too in the following weeks, pain due to impaction of food.


Question Answer
How is carcinoma of the oesophagus diagnosed?Endoscopy (provides histological proof).
What is the treatment for carcinoma of the oesophagus?Surgery (provides the best chance of a cure but should only be used when imaging has shown that the tumour has not infiltrated beyond the oesophageal wall), chemoradiation. Sometimes palliative is the only realistic possibility.
What are the "alarm" symptoms for a patient presenting with dyspepsia (alarm symptoms = urgent specialist referral)?Anaemia (iron deficiency), Loss of weight (unexplained), Anorexia, Recent onset of progressive symptoms, Melaena or haematemesis, Swallowing difficulty (dysphagia), persistent vomiting, epigastric mass.
How does omeprazole work?Irreversibly inhibits the H+K+ATPase therefore reducing gastric secretion.
What are the adverse effects of omeprazole?Headache, dizziness, impotence, gynaecomastia. Chronic users are at increased risk of fractures.
What are the side effects of magnesium and aluminium salts (used as antacids)?Magnesium: diarrhoea. Aluminium: constipation.
Is H. Pylori gram positive or gram negative?Negative.
Does H. Pylori require oxygen for survival?Yes.
What properties of H. Pylori make it mobile within the gastric mucosa?Helical/spiral shape and flagella.
H. Pylori is capable of producing ammonia which acts as a buffer against the acid in the stomach. How is this so?H. Pylori expresses urease which catalyses urea hydrolysis. This produces ammonia.


Question Answer
True or false: The majority of individuals infected with H. Pylori are asymptomatic.True.
What non-invasive tests can be used to diagnose H. Pylori infection?Blood antibody test to detect IgG, stool antigen test, carbon urea breath test (measurement of isotope labelled carbon dioxide after swallowing urea labelled with either radioactive carbon-14 or non-radioactive carbon-13.
What invasive tests can be used to diagnose H. Pylori infections?Culture, histology, rapid urease test (also known as the CLO test, it is performed at the time of gastroscopy. A biopsy of mucosa is taken from the antrum of the stomach, and is placed into a medium containing urea and an indicator such as phenol red. The urease produced by H. pylori hydrolyses urea to ammonia, which raises the pH of the medium, and changes the color of the specimen from yellow (NEGATIVE) to red (POSITIVE)).
What is important to bear in mind before testing for H. pylori with a breath test or a stool antigen test?A 2 week washout period following PPI use is necessary, otherwise false negative.
What medications and what doses are given for treatment of H. Pylori?Omeprazole 20mg + amoxicillin 1g + clarithromycin 500mg - all twice daily - PAC500.
What medications and what doses are given for treatment of H. Pylori?Omeprazole 20mg + metronidazole 400mg + clarithromycin 250mg - all twice daily - PMC250.
If initial treatment for H. Pylori infection fails, what is given instead?Bismuth chelate, metronidazole, tetracycline, and a PPI for 2 weeks.
What is the mechanism of action of metronidazole?Forms free radical toxic metabolites in the bacterial cell that damage DNA.
What can metronidazole be used to treat?Giardia, Entamoeba, Trichomonas, Gardnerella vaginalis, Anaerobes (bacteroides, C. difficile), h. Pylori (GET GAP on the METRO).
Burning epigastric pain exacerbated by fasting and improved with meals is a symptom complex associated with ___PUD (peptic ulcer disease).


Question Answer
In which portion of the duodenum do duodenal ulcers most oftenly occur?First.
How is the epigastric pain associated with peptic ulcer disease described?Burning or gnawing.
Dyspepsia that becomes constant, no longer relieved by food or antacids, or radiates to the back may indicate what?Penetrating ulcer (gastric ulcer penetrating into pancreas).
Sudden onset of severe, generalised abdominal pain may indicate what?Perforation.
Pain worsening with meals, nausea, and vomiting of undigested food suggests what?Gastric outlet obstruction.
Tarry stools or coffee-ground vomiting indicates what?Bleeding.
What is the most frequent finding in patients with peptic ulcer disease?Epigastric tenderness.
What is the most common complication of peptic ulcer disease and what does it present as?GI bleeding. It presents as melaena or haematemesis.
Perforation - a complication of peptic ulcer disease - can result in the contents of the stomach emptying into __________ giving rise to ___________Peritoneum; peritonitis.
What is the most striking symptom of GI perforation?Sudden, severe pain - its distribution follows the spread of the gastric contents over the peritoneum.
Where is pain felt with peritonitis?Initially in the upper abdomen but then rapidly becomes generalised; shoulder tip (due to irritation of the diaphragm).
With peritonitis, bowel sounds are absent or present?Absent.
With GI perforation, liver dullness percussion increases or decreases?Decreases (due to presence of gas under diaphragm).
What does an erect chest x-ray show in someone with a GI perforation?Free air beneath the diaphragm.
What is the least common ulcer-related complication?Gastric outlet obstruction.
What are the symptoms of gastric outlet obstruction?Vomiting (main symptom), nausea, new onset of early satiety, increase of postprandial abdominal pain, and weight loss.