Upper GI Conditions

 

• Upper GI bleed

  Causes

  By frequency (can be multiple causes):

  • Peptic ulcer disease (PUD) (50%): ulcer erosion into blood vessel. Commonly posterior duodenal ulcer.
  • Inflammation: oesophagitis (25%), gastritis (25%), or duodenitis (15%).
  • Oesophageal or gastric varices (15%).
  • Mallory-Weiss tear (5%) following severe vomiting.
  • Upper GI cancer (5%).

  Signs and symptoms

  • Epigastric pain and/or diffuse abdo pain.
  • Haematemesis: red if active, coffee-ground if settled.
  • Melena: black and foul smelling stool. Can also be caused by ascending colon cancer. Iron therapy can cause black stool, but it is less foul-smelling.
  • Shock

  Investigations

  Bloods:

  • ↓Hb. May be normal before fluid resus.
  • Cross-match and coag.
  • ↑Urea due to GI absorption and metabolism of blood.
  • LFTs

  Imaging:

  • Erect CXR and abdo XR.
  • Consider CT abdo-chest.

  Risk assessment

  • Blatchford score at first assessment: considers bloods (urea, Hb), obs (SBP, HR), symptoms (melena, syncope), and co-morbidities (liver disease, HF). Score of 0 can be safely managed as an outpatient.
  • Rockall full score post-endoscopy: considers age, shock, co-morbidities, endoscopic signs of acute bleeding, and endoscopic diagnosis.

  Management

  If unstable:

  1. Resuscitate. ABC including O2, fluids, and consider transfusion. Stop any NSAIDs in the short-term.
  2. {Terlipressin (ADH analogue) or somatostatin} plus {prophylactic antibiotics} if variceal. Continue terlipressin/somatostatin post-endoscopy (alternative: octreotide).
  3. Keep nil by mouth and send for urgent endoscopic diagnosis and repair. Clipping or thermal coagulation with adrenaline if non-variceal, band ligation if oesophageal variceal, cyanoacrylate (glue) if gastric variceal.
  4. If endoscopy unsuccessful: surgery (suture ligation), or transjugular intrahepatic portosystemic shunt (TIPS) if variceal, with a Sengstaken-Blakemore tube inserted until TIPS performed.
  5. PPIs post-endoscopy for PUD bleeding. Initially IV to increase gastric pH and aid ulcer healing. Then PO as part of H. pylori eradication or as a protective measure if re-starting NSAIDs.

  If stable:

  • Endoscopy within 24h.

• Achalasia

  Definition

  Failure of smooth muscle relaxation in lower oesophagus, due to impaired nerve supply.

  Signs and symptoms

  • Fluid regurgitation.
  • Aspiration pneumonia.
  • 5% risk of oesophageal squamous cell carcinoma.

  Investigations

  • Upper GI endoscopy.
  • Barium swallow shows bird beak sign.
  • Oesophageal manometry: measurement of pressure in upper and lower oesophageal sphincters.

  Management

  Medical:

  • Calcium channel blockers (nifedipine, verapamil) can be used until definitive treatment.
  • Botulinum toxin for those unfit for interventional treatment.

  Interventional treatment:

  • Endoscopic (pneumatic) dilatation of lower oesophageal sphincter.
  • Heller myotomy (cardiomyotomy): longitudinal cut of lower oesophagus and stomach cardia, relieving the grip of the non-relaxing muscle around the outside.

• Pharyngeal pouch

  Aka Zenker's diverticulum.

  Definition

  Pouch at anatomically weak point of pharynx, Killian's dehiscence, above the cricopharyngeus muscle.

  Symptoms

  • Dysphagia
  • Regurgitation
  • Bad breath.
  • Nocturnal cough.

  Management

  2 options:

  • Open excision.
  • Endoscopically opening the bridge with stapling.

• Hiatus hernias

  A common type of diaphragmatic hernia.

  Types

  • Sliding hernias (85%) involve the oesophagogastric junction moving into thorax.
  • Rolling hernias (10%) are just the stomach rolling up next to the oesophagus.
  • 5% are mixed.

  Signs and symptoms

  • GORD
  • Bowel sounds heard in left chest.

  Management

  • Lifestyle: lose weight, stop smoking, avoid large meals in late evening, raise head of bed.
  • Medical: PPIs.
  • Surgical: floppy Nissen fundoplication, in which stomach fundus is wrapped around lower oesophagus. Carry out pH and manometry tests first.

• Oesophageal perforation

  Causes

  • Iatrogenic: endoscopy.
  • Swallowed sharp foreign body e.g. fish bone.
  • Boerhaave's syndrome: post-vomiting.
  • Chest trauma.

  Presentation

  • Neck, chest or epigastric pain.
  • Dysphagia or dyspnoea.
  • Subcutaneous emphysema.
  • Vomiting
  • Haematemesis and/or melena.

  Investigations

  • CXR and contrast swallow
  • Endoscopy
  • CT

  Managemennt

  • Nasogastric decompression and nasojejeunal feeding.
  • Antibiotics and PPIs.
  • Debridement of mediastinum and T-tube for oesophagocutaneous drainage.

  Complications

  • Mediastinitis
  • Pneumonia
  • Sepsis
  • Oesophagopleural fistula.