Upper GI Symptoms

 

• Dysphagia

  Difficulty swallowing.

  Causes

  Intraluminal:

  • Infection: candidiasis, pharyngitis, retropharyngeal abscess.
  • Oesophagitis
  • Foreign body.
  • Polyps

  Intramural:

  • Benign strictures (GORD) or malignant strictures.
  • Achalasia
  • Oesophageal web (Plummer Vinson syndrome): iron deficiency anaemia leads to desquamated epithelium. Commonest in middle-aged women.
  • Oesophageal ring (Schatzki ring): ring of mucosal tissue.
  • Oesophageal spasm.
  • Systemic sclerosis.

  Extramural:

  • Pharyngeal pouch.
  • Rolling hiatus hernia.
  • Malignancy
  • Retrosternal goitre.
  • Thoracic artery aneurysm.

  Neurological:

  • Stroke, myasthenia gravis, MS, MND, Parkinson's.
  • See bulbar and pseudobulbar palsy.

  Key questions in history

  MUNCH LOT:

  • Difficulty making swallow Movement? Bulbar/pseudobulbar palsy.
  • Underweight? Consequence of poor intake or sign of malignancy.
  • Neck bulges when drinking? Pharyngeal pouch.
  • Cough on lying? Achalasia, pharyngeal pouch.
  • Heartburn? GORD.
  • Problems with Liquids and solids from the start? Yes = motility problem – systemic sclerosis, myasthenia gravis, bulbar palsy, or achalasia – or pharyngeal problem. No (solids then liquids difficult) = stricture (benign or malignant).
  • Odynophagia (painful swallow): cancer, ulcer, oesophageal spasm (relieved by GTN).
  • Time pattern: intermittent (spasm), constant/worsening (malignant stricture), or both (achalasia)?

• Dyspepsia

  Definition

  • Epigastric and/or retrosternal discomfort/pain/burning due to an upper GI (oesophageal, gastric, or duodenal) problem.
  • May be accompanied by feeling of fullness, belching, or nausea.
  • Aka heartburn, indigestion.

  Causes

  • Non-ulcer dyspepsia (aka functional dyspepsia).
  • Peptic ulcer disease (PUD).
  • Oesophageal: GORD, oesophagitis, oesophageal cancer.
  • Gastric: gastritis, gastric cancer.

• Nausea and vomiting

  GI causes

  • Gastroenteritis
  • Acute cholecystitis or pancreatitis.
  • Intestinal obstruction.
  • Gastric cancer.
  • PUD

  Non-GI causes

  ABCDEFGHI:

  • AKI, Addison's.
  • Brain: migraine, ↑ICP.
  • Cardiac: MI.
  • DKA
  • Ears: labyrinthitis, Meniere's.
  • Foreign substance: alcohol, drugs.
  • Gravidity: nausea and vomiting in pregnancy, hyperemesis gravidarum.
  • Hypercalcaemia, Hyponatraemia, Hyperthyroidism.
  • Infection e.g. UTI, sepsis.

• Antiemetics

  A wider number of agents are available, but there is little consistent evidence that any one is better than others.

  Anti-histamines

  • Drugs: cyclizine, promethazine, dimenhydrinate, diphenhydramine.
  • Acts centrally on vomiting centre. Also has anti-cholinergic effects.

  Anti-dopaminergics

  Most are D2 receptor antagonists.

  Metoclopramide

  Mechanism:

  • Acts centrally in chemoreceptor trigger zone, and also a GI prokinetic.
  • In addition to antidopaminergic effects, it is a 5-HT3 antagonist and 5-HT4 agonist.

  Side effects:

  • Confusion
  • Dyskinesia and parkinsonism, especially in pregnancy, so avoid.

  Levomepromazine

  • Has anti-dopaminergic, anti-histaminergic, anti-cholinergic, and anti-serotonergic effects, making it highly effective and a good choice when other agents fail.
  • Can cause sedation, though generally not a problem at antiemetic doses (e.g. 6.25 mg).
  • In palliative care, can also help with terminal agitation.

  Prochlorperazine

  Useful for nausea and vertigo, including from labyrinthine problems such as Meniere's disease and vestibular neuritis.

  Domperidone

  Peripherally acting, including upper GI prokinetic, and does not cross blood-brain barrier.

  Pros:

  • Safe in Parkinson's.
  • Useful for upper GI problems: gastric stasis, early satiety, nausea relieved by vomiting.
  • Routes: PO or PR.

  Cons:

  • Lack of central activity makes it less useful for opioid nausea.
  • Side effects: prolonged QT.

  Other agents

  Haloperidol and droperidol can both be used to treat nausea and vomiting.

  Anti-serotonergics

  • Drugs: ondansetron, granisetron, palonosetron.
  • 5-HT3 antagonists that acts in the chemoreceptor trigger zone and GI tract.
  • In some cases (e.g. post-op, chemotherapy), dexamethasone is added.
  • Cons: constipation, QT prolongation.

  Other agents

  • Sniffing isopropyl alcohol swabs can provide rapid relief from nausea, with both post-op and ED-based RCTs showing efficacy.
  • Dexamethasone: often used as an adjunct anti-emetic in post-op and chemotherapy settings.