Summary MRCP Gastro related diseases

TOC

 Upper GI – Esophageal + Gastric
o Dysphagia
o Esophageal tumours
o General epigastric pain (GORD, PUD, etc)
o Barrett’s
o ZE Syndrome
o Gastric tumours
 Upper GI – Small Bowel
o Intestinal obstruction (small AND large bowel)
o Acute + Chronic mesenteric ischemia
o Small bowel tumours
 Lower GI
o IBD + other colitis
o Diverticular disease + Meckel’s
o Colonic polyps + cancer
 Anorectal disease
 Other abdominal
o Jaundice
o Biliary disease (gallstones, cholecystitis, cholangitis; liver, biliary tree, pancreatic cancer)
o Pancreatic disease (acute, chronic pancreatitis)
o Appendicitis
o Hernias

,Colorectal Investigations

 Faecal Occult Blood
o Commonly used in community for colorectal cancer screening
o Positive results undergo colonoscopy

 Rigid Proctoscopy + Sigmoidoscopy

 Flexible Sigmoidoscopy
o Low risk (perforation 1/5000), IP or OP procedure, no sedation needed
o Visualise up to splenic flexure
o Allows minor therapeutic procedures (polypectomy, biopsy)

 Colonoscopy
o Low risk (perforation 1/1000), more often OP procedure, sedation NEEDED (usually)
o Visualise entire colon up to terminal ileum (if not this constitutes “incomplete” colonography)
o Allows minor therapeutic procedures (polypectomy, biopsy, as well as endoscopic mucosal
resection and endoscopic submucosal dissection)

o Typical uses  Assessment of colitis, diagnosis and assessment of colon cancer, assessment of
PR bleed

 AXR
o Intestinal obstruction
o Renal stones
o Intra-abdominal fluid

 Barium Enema
o Contrast
 Single  Contrast only – fills the colon  For strictures and obstructions
 Double  Dilute contrast and air – lines the colon  For cancers and colonic anatomy

NB: Water-soluble enema can be substituted for barium if perforation is concern

o Bowel prep required + mobile patients

 Intestinal Transit Studies  Serial X-rays following ingested radio-opaque dye to assess intestinal motility

 Upright CXR  Pneumoperitoneum

 Trans-abdominal USS

 CT Scan
o Abdominal pain of unknown origin
o Intestinal obstruction

o Assessment of intra-abdominal masses
o Virtual CT colonoscopy
o Staging cancer

 PET Scanning (assess mets from cancer)

,GI Surgery
Upper GI Diseases – Oesophageal + Gastric
Dysphagia – Causes***

 Intramural
o Schatzki ring or Web
o Esophagitis
o Cancer
 Mural
o Pharyngeal pouch
o Achalasia
o Diffuse esophageal spasm
o Scleroderma
 Extramural
o Cancers:
 Retrosternal thyroid
 Bronchial carcinoma
 Mediastinal carcinoma
o Neurological:
 Bulbar palsy
 Myasthenia gravis
o Other (LA enlargement)

, Dysphagia*** (SPINS – solid/liquid, pain, intermittent/constant/worsening, neck bulge/regurg/halitosis, swallow
movement)

 All present with difficulty swallowing and weight loss (but perhaps cancer = more weight loss)
 Do BLOOD + CXR + BARIUM + ENDOSCOPY (except in PharPouch)
 Causes
o Achalasia  ↑ LES tone, ↓ LES relaxation, ↓ Peristalsis
 History
 Younger (25-40 – if older ?cancer)
 Non-smoker + non-drinker (otherwise ?cancer)
 Solid+liquid dysphagia @ SAME TIME w/ regurgitation (80%), chest pain (40%)
o May be intermittent, and progressively gets worse
o May regurgitate food + have GORD

 Investigations
 Initial Tests:
o CXR  Widened mediastinum

o Barium swallow
 Tapering of esophagus/rats tail
 Dilated proximal esophagus (“mega-esophagus”)
 Lack of/reduced peristalsis

 Best Test: Manometry (decides whether Rx needed)
o High LOS pressure which fails to relax on swallowing

 Additional tests which SHOULD be performed:
o Endoscopy required to rule out malignancy (5% risk!)
o 24 pH monitor (GORD may coincide, pneumatic dilation CI’d if does)

 Treatment
 Initial treatment:
o First: Pneumatic dilation (w/ balloon – analogous to angioplasty)
 Effective in 80%; 5% risk perforation, ↑GORD

o Second: Botox injection (intrasphincteric)
 50% need repeat injection at 6 months; 100% at 2 years

 Best treatment: Heller Myotomy + PPI  Removal of LES (↑↑GORD)