Nikita Goyal; GIT
Gold Standard Dx
Diseases of the Oesophagus
Info History/RF Examination Investigation Management
GORD Pathophys – Pressure ↓ and LOS inappropriately Pyrosis (heartburn) Empirical PPI Trial – Sx Lifestyle Changes – lose weight,
Chronic condition in which relaxes or ↑ intra-abdominal p; reflux persists for Regurgitation will improve in GORD avoiding spicy, fatty foods, chocolate,
stomach contents flows longer causing oesophagitis (oedema and erosion), Dysphagia 24hr pH monitoring in coffee, and alcohol, keep head elevated
back into oesophagus scar formation, oesophageal stenosis and Chronic cough or hoarseness lower oesophagus during sleep, smoking cessation
causing irritation to the potentially metaplasia *Worsen when lying down X-Ray w/ barium – (shows Meds - Antacids (Gaviscon, Mylanta),
mucosa Comps – Barrett’s metaplasia, oesophagitis, RF – obesity, fat-rich diet, caffeine, alcohol, comps i.e ulcers or PPI – omeprazole, ranitidine, Prokinetic
bleeding/anaemia, oesophageal strictures, smoking, meds, hiatal hernia, scleroderma, stenosis) medications, GABA agonist baclofen
ulceration, perforation Zollinger-ellison syndrome Endoscopy or biopsy – Surgery – Nissen fundoplication (fundus
Barrett’s oesophagus wrapped around distal oesophagus +
secured w/ sutures)
PUD Ax - H. pylori, NSAID use, conditions which Epigastric pain - gastric ulcers (pain ↑ while Endoscopy - OGD Stop NSAIDs, alcohol, smoking and
Presence of one or more overproduce stomach acid, stress eating, weight loss), duodenal ulcers (pain ↓ after H. pylori urea breath test caffeine
ulcerative lesions in the Pathophys – ulcer formation occurs when eating, weight gain) or stool antigen test If H.pylori – give Abx and PPI’s – triple
stomach or duodenum protective mechanisms are disrupted of the lining of Dyspepsia – indigestion Bloods – FBE (anaemia, ↑ therapy
the stomach/duodenum, or excessive acids/pepsin Bloating platelet count) (esomeprazole, amoxicillin,
Gastric or duodenal are secreted Belching Biopsy – for gastric ulcers clarithromycin)
ulcers H pylori – release of cagA toxin disrupts mucosal Nausea, vomiting to rule out if malignant Quadruple – tetracycline, omeprazole,
barrier; NSAIDs – inhibit COX 1/2 → ↓ PGE2 Haematemesis (if perforated, coffee ground), metronidazole, bismuth
production → erosion of gastric mucosa melaena AXR – gas under If NSAID’s – stop NSAIDs, start PPIs
Comps – left gastric a and gastroduodenal a Usually, asymptomatic diaphragm indicates If bleeding – fluid therapy w/crystalloids
bleeding, perforation (gastric contents spill into perforation Early endoscopic therapy to stop
peritoneal space), gastric outlet obstruction RF – H. pylori, NSAID, smoking, age, PHx, FHx bleeding – cautery, endoclip +
(nausea + vomiting), adrenaline; thermal therapy
Haemospray – mineral salt prep
Surgery – rarely needed
Oesophageal Ca Prognosis – overall poor; 5 yr survival <5% due to Dysphagia L supraclavicular Bedside – ECG ?Lifestyle changes – SNAPW - quit
Dx at advanced presentation; 80% survival rate for Odynophagia lymphadenopathy Bloods – smoking, reflux meds, less hot
SCC – middle 1/3rd > Ca localised to mucosa Weight loss, night sweats, Retrosternal chest FBE – look for anaemia food/beverages
proximal 1/3rd - African Epi – AC – fastest growing in western countries; fever, fatigue or back pain UEC, LFTs, CRP, CMP Stage 0, I, IIa –
AC – distal 1/3rd, most SCC – most common in resource limited countries, Regular heartburn LDH- tumours metabolic Surgical resection +/- pre-op chemo,
arise from Barret’s – 1400 incidence in Au, men 3x more likely, >60yrs Dyspepsia Uncommon Sx – Imaging – radiation (provide ++ benefit)
Caucasian Comps – metastasis, obstruction of windpipe, CP, radiating to back hoarse voice, Barium swallow Stages IIb, III –
oesophageal stenosis, tracheoesophageal fistula, Appetite hiccups, post CT Thorax/Abdo - mets Surgical resection alone not enough; +
SE of treatment – N/V, hair loss, radiation burns Vomiting prandial cough MRI Thorax/Abdo pre-op chemo/raduatuib
Metastasis usually to RF – male, low SES, achalasia Haematemesis or melaena Endoscopy – OGD w/ Pts who don’t want surgery –
lung/liver; sometimes SCC - tobacco, alcohol, FHx, non-white race, high biopsy, cytology chemo/radio - ?some benefit
distant sites temp drinks/foods, low intake of fruit + veggies; Endoscopic US to
drinking mate (south America), Plummer Vinson determine size of tumour Stage IV –
Syndrome Palliation
AC - GORD, Barrett’s, hiatus, obesity Size of primary tumour, Refer – speech therapist (swallowing),
, Nikita Goyal; GIT
local invasion, mets dietician
Stomach Ca Adenocarcinomas – Asia, less common in Dysphagia Bloods – FBE, UEC, Lifestyle – SNAPW
Western populations; Types – Indigestion LFTs, CRP, CMP, LDH
Metastasis Cx → intestinal type – punched out lesion Persistent N/V w/ no cause Gastrectomy
Local spread – omentum → diffuse type – signet ring cells, diffusely Post-prandial fullness Imaging – Cx – dumping syndrome – less stomach
or adjacent organs thickened stomach → linitus plastica Bloating Gastroscopy + biopsy to digest simple sugar leads to cramps,
Lymphatic – Virchow’s Diffuse large B-cell lymphoma – aggressive, Haematemesis tachy, sweating, diarrhoea, dizziness
node needs chemo, good cure rate Melaena, haematochezia
Haematogenous – liver, MALT lymphoma – H pylori causes it; low-grade B Sx – weight loss, night sweats, fatigue Chemo +/- radiotherapy
lungs, bone Epi – 2100 incidence in Au, men 2x, >60 yrs
Trans-coelomic – Ax/RF of adenocarcinomas – H pylori,
mesenteric surfaces, autoimmune gastritis w/ pernicious anaemia,
ovaries, umbilicus smoking, diet – nitrates, smoked foods, pickled
vegetables, FHx
Oesophageal motility
disorders
Diseases of the Pancreas
Info History/RF Examination Investigation Management
Acute Pancreatitis Types – Interstitial oedematous (85-90%) – Epigastric pain radiating to Epigastric tenderness on Bedside – Lifestyle changes – SNAPW
Sudden inflammation significant swelling of pancreatic parenchyma the back palpation ECG, BSL (^glycaemia), VBG Fluid Resus – Hydration,
and haemorrhaging of and surrounding retroperitoneal structures – Severe, constant Distention, Guarding (lactic acidosis) Electrolytes
the pancreas due to interstitial fluid + inflammatory cell; fat Pain worse after meals Ascites Analgesia titrating to effect
destruction by its own stranding; Haemorrhagic/necrotising – when supine; alleviated by Tachycardia, fever, hypoxic Bloods - ↑ amylase/lipase (x3 Bowel rest - NBM, IV for
digestive enzymes bleeding into parenchyma + retroperitoneal leaning forward Cullen’s; Grey Turner’s sign of normal upper limit), FBE (↑ food; paraenteral nutrition
Ax – “I GET structures; ICU; SIRS; sepsis; multi-organ Nausea Fluid status WBC), CRP (>200 – greater risk Oxygen + Abx if
SMASHED” – idiopathic, dysfunction (non-enhancing areas ) Vomiting ARDS of pancreatic necrosis), ABG, haemorrhagic, antiemetic
gall stones, ethanol Pathophys – acinar cell injury causes release Decreased appetite Hypocalcaemia signs – LFTs (gall stone Ax), UEC prn
consumption, trauma, of enzymes; autodigestion – activation of Steatorrhea Trousseau (^calcaemia (cause) Consider Ca/Mg
steroids, mumps, proteolytic enzymes (starts w/ trypsin) leading Diminished bowel sounds, Hypocalcaemia (result)) + replacement therapy
autoimmune disease, to local/systemic inflammation RF – Any of the Ax, middle Possible jaundice >urea/Cr suggests Gall stone associated:
scorpion stings, Comps – pancreatic pseudocyst/abscess, aged women, young to Dullness to percussion – dehydration/hypovolaemia ECRP, cholecystectomy
hypertriglyceridemia or haemorrhage, DIC, ARDS, sepsis middle aged men pleural effusion Autoimmune – IgG + ANA Alcohol related: alcohol
^calacaemia, Epi – gall stones > EtOh > idiopathic, 2% CT scan – shows inflammation, abstinence program
ERCP/emboli/ischaemia mortality History + high lipase + necrosis, pseudocyst Surgery
, drugs imaging - 2/3 Trans-abdominal US – is
Glasgow score – PaO2, >55yrs, WBC, Ca, suspicion for gall stones
Reversible BUN, LDH, Albumin, glucose
Chronic Pancreatitis Ax – Chronic EtOH, pancreatic ductal Epigastric abdo pain Muscle wasting Bedside – BSL (↑) Lifestyle – SNAPW (Alcohol
Persistent inflammation obstruction (strictures – trauma, stones), radiating to the back Skin nodules cessation + good nutrition)
of the pancreas usually tobacco, idiopathic, hereditary (PRSS1 gene), N/V, anorexia Painful joints Bloods – FBE, UEC, LFTs, Meds – analgesia, pancreatic
due to repeated bouts autoimmune, systemic – CF, Steatorrhea – cramping Abdominal distention lipase/amylase (↑ or normal), enzymes, PPIs, +/- insulin
Gold Standard Dx
Diseases of the Oesophagus
Info History/RF Examination Investigation Management
GORD Pathophys – Pressure ↓ and LOS inappropriately Pyrosis (heartburn) Empirical PPI Trial – Sx Lifestyle Changes – lose weight,
Chronic condition in which relaxes or ↑ intra-abdominal p; reflux persists for Regurgitation will improve in GORD avoiding spicy, fatty foods, chocolate,
stomach contents flows longer causing oesophagitis (oedema and erosion), Dysphagia 24hr pH monitoring in coffee, and alcohol, keep head elevated
back into oesophagus scar formation, oesophageal stenosis and Chronic cough or hoarseness lower oesophagus during sleep, smoking cessation
causing irritation to the potentially metaplasia *Worsen when lying down X-Ray w/ barium – (shows Meds - Antacids (Gaviscon, Mylanta),
mucosa Comps – Barrett’s metaplasia, oesophagitis, RF – obesity, fat-rich diet, caffeine, alcohol, comps i.e ulcers or PPI – omeprazole, ranitidine, Prokinetic
bleeding/anaemia, oesophageal strictures, smoking, meds, hiatal hernia, scleroderma, stenosis) medications, GABA agonist baclofen
ulceration, perforation Zollinger-ellison syndrome Endoscopy or biopsy – Surgery – Nissen fundoplication (fundus
Barrett’s oesophagus wrapped around distal oesophagus +
secured w/ sutures)
PUD Ax - H. pylori, NSAID use, conditions which Epigastric pain - gastric ulcers (pain ↑ while Endoscopy - OGD Stop NSAIDs, alcohol, smoking and
Presence of one or more overproduce stomach acid, stress eating, weight loss), duodenal ulcers (pain ↓ after H. pylori urea breath test caffeine
ulcerative lesions in the Pathophys – ulcer formation occurs when eating, weight gain) or stool antigen test If H.pylori – give Abx and PPI’s – triple
stomach or duodenum protective mechanisms are disrupted of the lining of Dyspepsia – indigestion Bloods – FBE (anaemia, ↑ therapy
the stomach/duodenum, or excessive acids/pepsin Bloating platelet count) (esomeprazole, amoxicillin,
Gastric or duodenal are secreted Belching Biopsy – for gastric ulcers clarithromycin)
ulcers H pylori – release of cagA toxin disrupts mucosal Nausea, vomiting to rule out if malignant Quadruple – tetracycline, omeprazole,
barrier; NSAIDs – inhibit COX 1/2 → ↓ PGE2 Haematemesis (if perforated, coffee ground), metronidazole, bismuth
production → erosion of gastric mucosa melaena AXR – gas under If NSAID’s – stop NSAIDs, start PPIs
Comps – left gastric a and gastroduodenal a Usually, asymptomatic diaphragm indicates If bleeding – fluid therapy w/crystalloids
bleeding, perforation (gastric contents spill into perforation Early endoscopic therapy to stop
peritoneal space), gastric outlet obstruction RF – H. pylori, NSAID, smoking, age, PHx, FHx bleeding – cautery, endoclip +
(nausea + vomiting), adrenaline; thermal therapy
Haemospray – mineral salt prep
Surgery – rarely needed
Oesophageal Ca Prognosis – overall poor; 5 yr survival <5% due to Dysphagia L supraclavicular Bedside – ECG ?Lifestyle changes – SNAPW - quit
Dx at advanced presentation; 80% survival rate for Odynophagia lymphadenopathy Bloods – smoking, reflux meds, less hot
SCC – middle 1/3rd > Ca localised to mucosa Weight loss, night sweats, Retrosternal chest FBE – look for anaemia food/beverages
proximal 1/3rd - African Epi – AC – fastest growing in western countries; fever, fatigue or back pain UEC, LFTs, CRP, CMP Stage 0, I, IIa –
AC – distal 1/3rd, most SCC – most common in resource limited countries, Regular heartburn LDH- tumours metabolic Surgical resection +/- pre-op chemo,
arise from Barret’s – 1400 incidence in Au, men 3x more likely, >60yrs Dyspepsia Uncommon Sx – Imaging – radiation (provide ++ benefit)
Caucasian Comps – metastasis, obstruction of windpipe, CP, radiating to back hoarse voice, Barium swallow Stages IIb, III –
oesophageal stenosis, tracheoesophageal fistula, Appetite hiccups, post CT Thorax/Abdo - mets Surgical resection alone not enough; +
SE of treatment – N/V, hair loss, radiation burns Vomiting prandial cough MRI Thorax/Abdo pre-op chemo/raduatuib
Metastasis usually to RF – male, low SES, achalasia Haematemesis or melaena Endoscopy – OGD w/ Pts who don’t want surgery –
lung/liver; sometimes SCC - tobacco, alcohol, FHx, non-white race, high biopsy, cytology chemo/radio - ?some benefit
distant sites temp drinks/foods, low intake of fruit + veggies; Endoscopic US to
drinking mate (south America), Plummer Vinson determine size of tumour Stage IV –
Syndrome Palliation
AC - GORD, Barrett’s, hiatus, obesity Size of primary tumour, Refer – speech therapist (swallowing),
, Nikita Goyal; GIT
local invasion, mets dietician
Stomach Ca Adenocarcinomas – Asia, less common in Dysphagia Bloods – FBE, UEC, Lifestyle – SNAPW
Western populations; Types – Indigestion LFTs, CRP, CMP, LDH
Metastasis Cx → intestinal type – punched out lesion Persistent N/V w/ no cause Gastrectomy
Local spread – omentum → diffuse type – signet ring cells, diffusely Post-prandial fullness Imaging – Cx – dumping syndrome – less stomach
or adjacent organs thickened stomach → linitus plastica Bloating Gastroscopy + biopsy to digest simple sugar leads to cramps,
Lymphatic – Virchow’s Diffuse large B-cell lymphoma – aggressive, Haematemesis tachy, sweating, diarrhoea, dizziness
node needs chemo, good cure rate Melaena, haematochezia
Haematogenous – liver, MALT lymphoma – H pylori causes it; low-grade B Sx – weight loss, night sweats, fatigue Chemo +/- radiotherapy
lungs, bone Epi – 2100 incidence in Au, men 2x, >60 yrs
Trans-coelomic – Ax/RF of adenocarcinomas – H pylori,
mesenteric surfaces, autoimmune gastritis w/ pernicious anaemia,
ovaries, umbilicus smoking, diet – nitrates, smoked foods, pickled
vegetables, FHx
Oesophageal motility
disorders
Diseases of the Pancreas
Info History/RF Examination Investigation Management
Acute Pancreatitis Types – Interstitial oedematous (85-90%) – Epigastric pain radiating to Epigastric tenderness on Bedside – Lifestyle changes – SNAPW
Sudden inflammation significant swelling of pancreatic parenchyma the back palpation ECG, BSL (^glycaemia), VBG Fluid Resus – Hydration,
and haemorrhaging of and surrounding retroperitoneal structures – Severe, constant Distention, Guarding (lactic acidosis) Electrolytes
the pancreas due to interstitial fluid + inflammatory cell; fat Pain worse after meals Ascites Analgesia titrating to effect
destruction by its own stranding; Haemorrhagic/necrotising – when supine; alleviated by Tachycardia, fever, hypoxic Bloods - ↑ amylase/lipase (x3 Bowel rest - NBM, IV for
digestive enzymes bleeding into parenchyma + retroperitoneal leaning forward Cullen’s; Grey Turner’s sign of normal upper limit), FBE (↑ food; paraenteral nutrition
Ax – “I GET structures; ICU; SIRS; sepsis; multi-organ Nausea Fluid status WBC), CRP (>200 – greater risk Oxygen + Abx if
SMASHED” – idiopathic, dysfunction (non-enhancing areas ) Vomiting ARDS of pancreatic necrosis), ABG, haemorrhagic, antiemetic
gall stones, ethanol Pathophys – acinar cell injury causes release Decreased appetite Hypocalcaemia signs – LFTs (gall stone Ax), UEC prn
consumption, trauma, of enzymes; autodigestion – activation of Steatorrhea Trousseau (^calcaemia (cause) Consider Ca/Mg
steroids, mumps, proteolytic enzymes (starts w/ trypsin) leading Diminished bowel sounds, Hypocalcaemia (result)) + replacement therapy
autoimmune disease, to local/systemic inflammation RF – Any of the Ax, middle Possible jaundice >urea/Cr suggests Gall stone associated:
scorpion stings, Comps – pancreatic pseudocyst/abscess, aged women, young to Dullness to percussion – dehydration/hypovolaemia ECRP, cholecystectomy
hypertriglyceridemia or haemorrhage, DIC, ARDS, sepsis middle aged men pleural effusion Autoimmune – IgG + ANA Alcohol related: alcohol
^calacaemia, Epi – gall stones > EtOh > idiopathic, 2% CT scan – shows inflammation, abstinence program
ERCP/emboli/ischaemia mortality History + high lipase + necrosis, pseudocyst Surgery
, drugs imaging - 2/3 Trans-abdominal US – is
Glasgow score – PaO2, >55yrs, WBC, Ca, suspicion for gall stones
Reversible BUN, LDH, Albumin, glucose
Chronic Pancreatitis Ax – Chronic EtOH, pancreatic ductal Epigastric abdo pain Muscle wasting Bedside – BSL (↑) Lifestyle – SNAPW (Alcohol
Persistent inflammation obstruction (strictures – trauma, stones), radiating to the back Skin nodules cessation + good nutrition)
of the pancreas usually tobacco, idiopathic, hereditary (PRSS1 gene), N/V, anorexia Painful joints Bloods – FBE, UEC, LFTs, Meds – analgesia, pancreatic
due to repeated bouts autoimmune, systemic – CF, Steatorrhea – cramping Abdominal distention lipase/amylase (↑ or normal), enzymes, PPIs, +/- insulin
