1
Q
Remind yourself of some potential causes of haematemesis
A
- Oesophageal varices
- Gastric ulceration
- Mallory-Weiss tear
- Oesophagitis
- Gastritis
- Gastric malignancy
- Vascular malformations e.g. Dieulafoy lesion
- Mecke;s’ diverticulum
BOLD= emergencies
2
Q
State some key questions/facts to establish in haematemsis history
A
- Timing
- Freqeuncy
- Volume
- What is looks like e.g. coffee ground, clots etc…
- History of dyspepsia, dysphagia or odynophagia
- PMH
- Smoking & alcohol
- Use of steroids, NSAIDs, anticoags, bisphosphonates
3
Q
What investigations are required for someone with haematemsis?
A
Bedside
- VBG:give you Hb quicker
Bloods
- FBC: Hb
- U&Es: urea, renal func
- LFTs: ?cause
- Clotting: bleeding
- Group & save: all should have
- Crossmatch: if significant crossmatch as least 4 units
Imaging
- OGD: within 12-24hrs
- Erect CXR: if ?ruptured peptic ulcer
- ?CT abdomen with IV contrast triple phase: if OGD unremarkabl or pt too unwell for OGD
4
Q
Remind yourself of the Glasgow-Blatchford score
A
Helps us to risk stratify pts with upper GI bleeding to determine how best to manage them
5
Q
What are some other scoring systems, other than Glasgow Blatchford, that can be used in haematemesis?
A
- Rockall (pre and post endoscopic): risk of rebleeding or death in pts with upper GI bleed
- AIMS65: in hospital mortality from upper GI bleeds
6
Q
Discuss the general management of heamatemesis
A
- A-E
- Bloods
- Access (two wide bore cannulas)
- Transfuse (fluids, blood, FFP, prothrombin complex etc…)
- Endoscopy within 12-24hr
- Drugs
- Stop NSAIDs, warfarin etc..
- Start IV terlipresssin & broad spectrum abx in oesophageal varices
- Adrenaline injections in peptic ulcer disease. Some clinicians will give high dose IV PPI (40mg)
Treat the underlying cause!
7
Q
Define a hernia
Define a hiatus hernia
A
- Hernia= protrusion of part of a whole organ through the wall of the cavity that contains it
- Hiatus hernia= protrusion of an organ from the abdominal cavity into the thorax through the oesophageal hiatus
8
Q
Discuss the prevelance of hiatus hernias
A
- ~33% of >50yrs have hiatus hernia
- Majority are asymptomatic
9
Q
State and describe the 4 subtypes of hiatus hernia
A
- Type 1/Sliding hiatus hernia (80%): the gastroesophageal junction (GOJ), abdominal part of oesophagus & frequenlty the cardia of the stomach moves or ‘slides’ upwards through the diaphragmatic hiatus into the thorax
- Type 2/Rolling or para-oesophageal hernia (20%): upward movement of the gastric fundus to lie alongside a normally positioned GOJ.
- Type 3/mixed type
- Type 4: large opening with additioan abdominal organs passing through diaphragm opening e.g. bowel, omentum, pancreas etc…
**NOTE: mixed type hernias can also occur
10
Q
State some risk factors for hiatus hernias- highlighted the biggest risk factors
A
- Age
- Pregnancy
- Obesity
- Ascites
11
Q
Why is age a risk factor for hiatus hernia?
Why is pregnancy, obesity & ascites a risk factor for hiatus hernia?
A
Age:
- Loss of diaphragmatic tone
- Increased intraabdominal pressure
- Increase in size of diaphragmatic hiatus
Pregnancy, obesity & ascites:
- Increase intraabdominal pressure
- Superior displacement of viscera
12
Q
The majority of hiatus hernias are asymptomatic; however, if a pt does get symptoms what symptoms & signs may they present with
A
- GORD
- Hiccups (large enuogh to irritate diaphragm)
- Palpitations (large enough to irritate pericardium)
- Bleeding &/or anaemia (secondary to oesophageal ulceration)
- Vomiting & weight loss (rare. If gastric outflow becomes blocked can lead to early satiety & vomiting)
- Swallowing difficulties (usually due to oesophageal stricture but rarely due to incarceration of hernia)
13
Q
What investigations are required if you suspect a hiatus hernia?
A
- OGD (passmed says most pts often have this first due to nature of symptoms. Teach me surgery says it is gold standard)
- Barium swallow (passmed says most sensitive)
14
Q
What would you find on OGD of someone with hiatus hernia?
A
Upward displacement of Z line
Z line= GOJ
15
Q
Discuss the management of hiatus hernias, include:
- Conservative
- Surgical
A
Conservative (similar to GORD)
- Weight loss
- Low fat diet
- Smaller portions
- Sleep with head raised
- Reduce alcohol
- Smoking cesssation
Medical
- First line= PPI
Surgical
- Curoplasty: hernia is reduced back into abdomen and the hiatus reapproximated to approprite size
- Fundoplication: gastric fundus wrapped around lower oesophagus and stitched in place to help keep GOJ in place below diaphragmn and prevent reflux
16
Q
Why is reduction in alcohol and smoking cessation advised in hiatus hernias & GORD?
A
Alcohol and nicotine thought to inhibit LOS function and hence worsen symptoms
17
Q
Which pts, with hiatus hernias, are considered for surgery?
A
- Symptomatic despite max medical therapy
- Increased risk of strangulation or volvulus
- Nutritional failure
NOTE: any pt with suspected strangulation of volvulus should have stomach decompressed with NG tube prior to surgery
18
Q
Why are PPIs given to pts with hiatus hernias?
When must you take a PPI and why?
A
- Reduce gastric acid and symptom control (may have GORD)
- Must take PPI in morning before food (30 mins or so). Eating stimulates stomach acid secretion and hence if you take before eating the drug can have maximal effect as when you eat all H+/K+ ATPase will be working and the PPI can have effect. If you take just before eating by the time the PPIs work stomach will have stopped producing stomach acid.
19
Q
State some complications of surgery to correct hiatus hernias
A
Despite complications success rate of repair is excellent. Some complications include:
- Recurrence of hernia
- Abdominal bloating (due to inability to belch secondary to improved anti-reflux mechanism)
- Dysphagia (if repair made oesophagus too narrow. Common after surgery due to oedema. Usually settles in most but may persist and need revision)
- Fundal necrosis (surgical emergency requirng major gastric resection)
20
Q
Which type of hernia (out of the sliding or rolling/para-oesophageal) are more prone to incarceration & strangulation?
A
Rolling/para-oesophageal type
21
Q
A gastric volvulus (stomach twists on itself by 180 degrees) can occur as a result of a hiatus hernia leading to obstruction of gastric passage and tissue necrosis. It requires prompt surgical intervention.
What triad does this clinically present with?
A
Borchardt’s triad:
- Severe epigastric pain
- Retching without vomitting
- Inability to pass NG tube
22
Q
Remind yourself what a petic ulcer is
A
Breach in lower oesophagus, gastric or duodenal muscosa that extends through muscularis mucosa
23
Q
State risk factors for peptic ulcer disease- highlighting which are most common
A
- H pylori infection
- Prolonged NSAID use
- Corticosteroid use (when used with NSAIDs)
- Previous gastric bypass surgery
- Physiological stress e.g. severe burns
- Head trauma
- Zollinger-Ellison syndrome
24
Q
For H-pylori state:
- Gram stain
- Shape
- Where found
- How it survives
- Prevelance
- How it leads to ulceration
A
- -ve
- Spiral/helix shaped bacillus
- Mucous layer
- Secretes urease which converts urea in stomach into ammonium to increase pH andn allow survival
- 33% people are infected with H.Pylori but only causes problems for 1 or 2 in 10 people
- Ulceration caused by:
- Cytokine and interleukin driven inflammatory response
- Increases gastric acid secretion by inducing histamine release which acts on parietal cells
- Degrades surface glycoproteins and down-regulates bicarbonate production to damage host mucous membranes
*GO REVISE SEM 3 GI FOR MORE
25
70% of peptic ulcers can be asymptomatic. State some clinical features of peptic ulcer disease
* Epigastric or retrosternal pain
* Gastric- pain exacerbated by eating
* Duodenal- pain worse 2 to 4 hrs after eating or even alleviated by eating
* Nausea
* Bloating
* Post-prandial discomfrot
* Early satiety
* May present with the complications of peptic ulcer e.g. perforation, haemorrhage etc...
26
What is Zollinger-Ellison syndrome?
What is the characteristic finding?
What are the symptoms?
What disease do 1/3 of pts have?
Triad of:
* Severe peptic ulcer disease
* Gastric acid hypersecretion
* Gastrinoma
Characteristic finding is high fasting gastrin level of \>1000pg/ml.
One third are discovered as part of MEN 1 syndrome therefore further investigations for MEN syndrome are required
27
What investigations are required if you suspect peptic ulcer disease?
Most pts don't need OGD initially and can be investigated via:
* **Non-invasive H-pylori testing**
* ****Carbon-13 urea breath test
* Serum antibodies to H pylori
* Stool antigen test
* **FBC:** *check for anaemia*
**Some pts may require OGD** (NICE guidance already discussed) or if not responding to empirical treatment. During OGD do **biopsy then send for histolog**y to look for:
* **malignancy**
* **rapid urease test (CLO test)**
28
What medications must pt's stop taking prior to any H-pylori testing and how long prior to testing must they stop?
* Abx: 4 week before
* PPI: 2 week before
* H2 antagonist: 3 days before
* Alginates: 24hrs before
* On day:
* No smoking
* No eating or drinking 6hrs before test
*\*To prevent false positives*
29
How does carbon-13 urea breath test work?
Following ingestion of carbon-labeled urea (13 C or 14 C), H. pylori -produced urease in the stomach metabolizes the urea into ammonia and carbon dioxide. The carbon isotope is then exhaled as a labeled carbon dioxide and can be directly measured.
30
How does the rapid urease test/CLO test work?
* Take biopsy during OGD
* Place in medium containing urea and an indicator e.g. phenol red
* If H-pylori present it will convert urea into CO2 and ammonia
* Medium becomes more alkaline due to ammonia
* Colour change to red
31
Discuss the management of peptic ulcers, include:
* Conservative
* Medical
* Surgical
_Conservative_
* Smoking cessation
* Weight loss
* Reduce alcohol
* Avoid NSAIDs
_Medical_
* No H-pylori= PPI for 4-8 weeks
* H-pylori= eradication/triple therapy
_Surgical_
* RARE only in:
* emergencies such as perforation or Zollinger-Ellison syndrome
* severe or replasing disease may do gastrectomy or selective vagotomy
32
What follow up should pts with peptic ulcers have?
* Should be reassessed after treatment to see if there has been resolution of symptoms
* If persistence of symptoms post PPI +/- eradication therapy do OGD to exclude other causes e.g.malignancy
* If had endoscpy repeat endoscopy 6-8 weeks later to check ulcer healing
33
State some potnential complications of peptic ulcers
* Perforation
* Haemorrhage
* Pyloric stenosis (rare)
34
Remind yourself of the triple/eradication therapy for H-pylori
All of following for 7 days:
* PPI
* Amoxicillin
* Metronidazole or clarithromycin
35
Gastric cancer usually presents early and has a good prognosis; true or false?
False; presents with advanced disease
36
What type of cancer are \>90% of gastric cancers?
Adenocarcinomas
37
State some risk factors for gastric cancer- highlight major ones
* **H pylori infection**
* **Smoking**
* **Age**
* **Male**
* Alcohol
* High salt diet
* Positive family history
* Pernicious anaemia
38
State clinical features of gastric cancer
Often vague:
* Dyspepsia
* Dysphagia
* Early satiety
* Vomiting
* Melena
* Anorexia
* Lethargy
* Epigastric mass
* Troisier sign *(palpable left suprclavicular lymph node)*
* Signs of metastatic disease e.g. hepatomegaly, ascites, jaundice etc..
39
What investigations are required if you suspect gastric cancer, include:
* Bloods
* Imaging
_Bloods_
* **FBC**
* **LFTs**
* **U&Es**
* **Clotting**
_Imaging_
* **OGD & biopsies** which are sent for:
* Histology
* CLO test
* HER2/neu protein expression
* **CT chest abdomen pelvis:** *ALL need for staging*
* **Staging laparoscopy:** *ALL need for staging*
40
Discuss the management of gastric cancer
_All require:_
* MDT discussion
* Adequete nutrition; may need NG or RIG tube
_If curative treatment possible:_
* Neoadjuvant chemotherapy
* Followed by surgery:
* Total (proximal ca) or subtotal (distal ca) gastrectomy
* Roux-en-Y reconstruction
* Adjuvant chemotherapy
_Most pts have palliative care due to advanced presentation:_
* Chemotherapy
* Stenting (if causing gastric outlet obstruction)
* Palliative surgery if the above fails
41
What is a Roux-en-Y reconstruction?
* Distal oesphagus end to end anastomosd directly with small bowel
* Proximal small bowel end to side anastomosed to small bowel
42
State some potential complications of gastric cancers
* Gastric outlet obstruction
* Fe deficiency anaemia
* Perforation
* Malnutrition
43
State some potential complications of gastrectomy
* Anastomotic leak
* Dumping syndrome
* Vit B12 deficiency (need 3monthly B12 injections)
* Re-operation
* Death
44
Why does melena usually occur?
Upper GI bleeding
Due to breakdown of RBCs
45
Remind yourself of some possible causes of upper GI bleeding and therefore melena
* Peptic ulcer disease
* Variceal bleeds
* Upper GI malignancy
* Mallory-Weiss tear
* Meckel's diverticulum
* Vascular malformations (e.g. Dieulafoy lesion)
46
Alongside history and abdo exam what other examination should you do in pts with melena?
DRE
47
What investigations are required in pts with melena, include:
* Bedside
* Bloods
* Imaging
_Bedside_
* **ABG**: *Hb quicker, pH, lactate and signs of hypoperfusion*
_Bloods_
* **FBC**: *anaemia*
* **LFTs:** *?liver disease- varices*
* **U&Es:** *rise in urea:creatinine ratio= indicate upper GI bleed. HB produces urea as by-product, absorbed, raised urea*
* **Clotting:** *?abnormalities ?worsening*
* **Group & save/crossmatch:** *dependent on how unwell pt is*
_Imaging_
* **OGD:** *_definitive investigation_ & can be part of management in unstable bleeding*
* **CT abdo with contrast triple phase:** *useful in active bleeding if pt too unwell for invasive or OGD inconclusive*
48
Discuss the management of melena
* A-E if critically unwell
* Blood product transfusion if required
* Blood
* FFP
* Platelets
* OGD
* Treat underlying condition
49
Discuss the management of acute bleeding due to peptic ulcers
*\*NOTE: if someone presents with haematemesis manage as mentioned previously (ABATED). This is specific management once know bleeding due to peptic ulcer*
* **ABC approach** as with any upper gastrointestinal haemorrhage
* **IV proton pump inhibitor**
* the **first-line treatment is endoscopic intervention**
* if this fails (approximately 10% of patients) then either:
* urgent interventional angiography with transarterial embolization or
* surgery
50
How may patient with perforated peptic ulcer present?
* Epigastric pain that later becomes more generalised
* Syncope
* Signs of peritonism
51
What would be your investigation of choice if a patient presents with suspected peptic ulcer perforation?
Erect CXR
52
What is the 2WW referral criteria for oesophageal or gastric cancer?
* All patients who've got **dysphagia**
* All patients who've got an **upper abdominal mass** consistent with stomach cancer
* Patients aged **\>= 55 years** who've got **weight loss AND any of the following:**
* Upper abdominal pain
* Reflux
* Dyspepsia
53
Define dyspepsia
The term 'dyspepsia' is used to describe a complex of upper gastrointestinal tract symptoms, which are typically present for four or more weeks, including upper abdominal pain or discomfort, heartburn, acid reflux, nausea and/or vomiting.
54
Which patients should be referred for non-urgent OGD?
* Patients with **haematemesis**
* Patients aged \>= 55 years who've got:
* **treatment-resistant dyspepsia**
* upper abdominal pain with low haemoglobin levels
* **raised platelet count** with any of the following: nausea, vomiting, weight loss, reflux, dyspepsia, upper abdominal pain
* **nausea or vomiting with any of the following:** weight loss, reflux, dyspepsia, upper abdominal pain
55
Discuss how you should manage dyspepsia in patients who don't meet criteria for referral (GP based)
This can be summarised at a step-wise approach
1. Review medications for possible causes of dyspepsia
2. Lifestyle advice
3. Trial of full-dose proton pump inhibitor for one month OR a 'test and treat' approach for *H. pylori*
* if symptoms persist after either of the above approaches then the alternative approach should be tried
