A 45 year old woman presents with a 2 month history of upper abdominal pain, occurring 2 – 3 hours after meals. The GP orders some blood tests, with the relevant results shown below: RBC 3.88 (4.2 - 5.4) HCT 28 (36 - 46) MCV 70 (78 - 98) ALP 84 (40 – 126) ALT 32 (7 – 41) AST 26 (12 – 38) GGT 29 (9 – 58) Total Bilirubin 0.4 (0.3 – 1.3) Direct Bilirubin 0.1 (0.1 – 0.4)
Which of these is the most likely diagnosis?
A) GORD B) Duodenal ulcer C) Gastric ulcer D) Biliary colic E) Cholecystitis
B) Duodenal ulcer
- microcytic anaemia = blood loss somewhere (ulcer)
- LFTs normal rule out biliary cause (would also present 2-3 hrs after meals)
- 2-3 hours after meals = duodenal over gastric (v soon after meals)
A 61 year old man presents to his GP with a 3 month history of upper abdominal pain following meals. On questioning, he describes this pain as burning and is able to point to the pain on his abdomen. He reports having noticed his clothes have been looser recently, and has a long standing history of headaches. Which of these is the most important investigation to arrange?
A) H. Pylori breath test B) Full Blood Count C) OGD Endoscopy D) Trial of Proton pump inhibitor (PPI) E) Abdominal X-ray
C) OGD Endoscopy - over 55 - weight loss (these are indications for endoscopy to rule out gastric cancer) Diagnosis is likely an ulcer - pointing sign - burning pain following meals
A 40 year old lady presents to her GP with heartburn and problems swallowing. She reports that the heartburn worsens at night, and is often accompanied by a ‘funny taste’ in her mouth and cough. She reports no change in weight or systemic symptoms. Which of these should be the next step?
A) OGD endoscopy B) Barium Swallow C) Manometry D) Serum gastrin levels E) Trial of Proton pump inhibitor (PPI)
E) Trial of Proton pump inhibitor (PPI)
- classical symptoms of GORD (heartburn, dysphagia, regurgitation (worse on lying down) + cough)
- she is under 55 and has no red flags therefore endoscopy is not currently required and PPI trial is both diagnostic and therapeutic (if it works)
A 59 year old man presents with severe retrosternal burning pain. Upper GI endoscopy shows ‘metaplastic changes within the epithelium’. Which of these is the most likely diagnosis?
A) Gastric ulcer B) Gastric carcinoma C) Oesophageal carcinoma D) GORD E) Barrett’s oesophagus
E) Barrett’s oesophagus
- over 55 + severe retrosternal pain = endoscopy reasoning
- metaplasia indicates Barrett’s (squamous to columnar epithelium)
A 28 year old lady presents with a 2-year history of mild dysphagia to both solids and liquids. She has no weight loss, but symptoms of heartburn and nocturnal cough. PPIs and bronchodilators haven’t helped. She is systemically well, and her examination is unremarkable. A “bird’s beak” appearance is noted on barium swallow. What is the most likely diagnosis?
A) Achalasia B) Benign stricture C) Plummer-Vinson syndrome D) Oesophageal spasm E) Stroke
A) Achalasia
- “Bird’s beak” = achalasia (corkscrew appearance on oesophageal spasm)
- dysphagia to both solids and liquids = functional cause (rules out stricture/Plummer-Vinson - no signs of IDA or glossitis)
- stroke is very unlikely at a young age and esp with a 2 year Hx
- PPIs and bronchodilators suggest previous misdiagnosis of GORD and asthma
A 76-year old retiree visits her GP with difficulty swallowing solids. She says this has been getting progressively worse over 1 month. There is no coughing, choking or heartburn. She reports food getting “stuck” 2-3 seconds after swallowing. She attributes her weight loss to not eating properly, and also thinks this has caused loose, brown-black stools. She feels tired. Bloods show a microcytic anaemia. Select the likely diagnosis:
A) Stroke B) Oesophageal cancer C) Pharyngeal pouch D) Plummer-Vinson syndrome E) Benign stricture
B) Oesophageal cancer
- progressive dysphagia of solids indicates obstructional cause, rather than functional (no cough/choking supports this)
- tiredness, IDA, and weight loss all point towards malignancy, including the melaena
- P-V syndrome might explain anaemia but not the malaena nor the progressive nature of it
- age + red flags = cancer
A 53-year old man staggers into A&E having vomited 6 times in 2 hours. He is intoxicated and jaundiced. His friend said his vomit was initially “normal”, but after the first couple of episodes had fresh blood in it. His blood pressure is 120/90 and HR 70 bpm. What is the most likely diagnosis?
A) Ruptured oesophageal varices B) Mallory-Weiss tear C) Ruptured peptic ulcer D) Boerhaave syndrome E) Oesophagitis
B) Mallory-Weiss tear
- haematemesis following normal vomiting characteristic of MW tear
- varices would have hypotensive shock most likely, as well as fresh blood present in vomit (although jaundice may indicate portal hypertension which causes varices)
- ulcer would have coffee ground vomit due to digested blood
- boerhaave’s would be sudden onset and hypotension
- oesophagitis is unlikely to cause bleeding
A 47 year old man is brought into A&E having vomited blood. His wife reports he developed food poisoning 2 days ago. Suddenly this morning he experienced extreme chest pain and began to vomit blood. His HR is 110 and BP 85/60. On auscultation of his chest you hear a crackling sound and his CXR shows pneumomediastinum. What is the most likely diagnosis?
A) Ruptured oesophageal varices B) Mallory-Weiss tear C) Ruptured peptic ulcer D) Boerhaave syndrome E) Myocardial Infarction
D) Boerhaave syndrome
- sudden onset chest pain + haematemesis + pneumomediastinum = classical Boerhaave
- the hypovolaemic shock (elevated HR with low BP) is classic too
- likely occurred following damage to oesophagus wall when vomiting from food poisoning
- varices - no chest pain
- MI - no haematemesis
- MW tear - no shock/chest pain
- peptic ulcer - no pneumomediastinum (pneumoperitoneum instead) + ‘coffee ground’ appearance
