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Dr Amelia Davies a m e l i a . d a v i e s 9 @ n h s . n e t Menti Code - 5786 3862 UPPER GI A MedED LECTURE PLAN • Who am I? • Case 1 – Dysphasia • Case 2 – Liver • Spot diagnosis quizCase 1 John, 56M, presenting to his GP with difficulty in swallowingHow do you approach a patient with dysphagia? • Urgent consideration • Oropharyngeal or oesophageal • History • Examination • InvestigationsHistory (most important bit!) • Oropharyngeal or oesophageal • Red flag symptoms • Weight Loss • Odynophagia • Regurgitation • Age • Aspiration • Accompanying neurological symptoms • Prev. cancersDifferentials of oropharyngeal dysphagia Common Uncommon • Stroke • Foreign body/ Caustic injury • Pharyngitis • Epiglottitis • Post operative cervical spine • Oropharyngeal carcinoma surgery • Thyromegaly (goitre) • Wilson’s disease • Myasthenia gravis the list goes on…Differentials of oesophageal dysphagia Common Uncommon • GORD – gastro-oesophageal • Oesphageal carcinoma reflux • Achalasia • Hiatus hernia • Scleroderma • Oesophageal candidiasis • Oesophageal web • Diffuse oesophageal spasm • Foreign body/ Caustic injury • OesophagitisExamination • Unlikely to find much… but • Anything around the bed - Stick? • General appearance of the patient – cachectic? Pallor? Tremor? • Hands – Raynaud’s? • Lymph nodes / other neck masses / scars • Face – Conjunctival pallor? Oral candidiasis? Kayser-Fleischer Rings?Investigations • Bed side investigations • Bloods • Imaging • Any other investigationsInvestigations • Bed side investigations • FULL SET OF OBSERVATIONS • Standard bedside swallow test • Bloods • FBC, inflammatory markers, TFTs, LFTs, Caeruloplasmin (Wilson’s), Acetylcholine receptor antibodies (myasthenia gravis), Anti-DNA and antinuclear antibodies (scleroderma), etc. • Imaging • OGD • Barium Swallow / timed oesophogram • Any other investigations • Oesophageal manometryCase 1 • Mr. Doe reports experiencing difficulty swallowing for the past 6 months. He describes the sensation as food getting "stuck" in his chest. He notes that he has trouble swallowing both solid foods and liquids. The difficulty swallowing has progressively worsened over time and is now interfering with his ability to eat comfortably. He reports some weight loss. • PMH – HTN, T2DM, Dyslipidaemia Please do an abdominal examinationCase 1 – investigations • BP: 130/80 mm Hg FBC: • Pulse: 78 bpm • Hb 125 (130–180 g/L) • RR: 16 bpm • Plt 250 (150 and 400 x 109/L) • Temp: 37°C • WCC 7.2 (3.6 - 11.0) • MCV 78 (80–100 fl) • U&Es, LFTs, CRP - normalCase 1 - differentials • Uncommon • Oesophageal carcinoma – needs to be ruled out • Common • Reflux – causing oesophagitis • Hiatus herniaCase 1 – investigations • What investigation would you do? • Gold standard – OGD +/- biopsy if neededCase 1 - Spot Diagnosis 1 Oesophageal CarcinomaCase 1 - Spot Diagnosis 2 Hiatus herniaCase 1 - Spot Diagnosis 3 a. b. Achalasia Diffuse oesophageal spasmCase 2Case 2 John Smith, 68M who has presented to ambulatory care with fatigue, jaundice and abdominal discomfort. Mr. Smith reports progressive fatigue over several months. He noticed yellowing of his eyes and skin (jaundice) over the past 2 weeks. No significant weight changes or changes in bowel habits. PMH: HTN Please do an abdominal examinationDifferential diagnosis of jaundice Pre-hepatic > Hepatic > Post-hepatic Prehepatic – haemolytic anaemias Hepatic – everything going wrong with the liver Post-hepatic – gallbladder/ biliary issuesDifferential diagnosis of jaundice Common Uncommon • Decompensated liver cirrhosis • Gilbert’s syndrome • Alcohol related liver disease • IgG4 disease • Metabolic associated steatotic liver • Primary sclerosing cholangitis disease aka NAFLD • Choledochalithiasis (gallstones) • Primary biliary cirrhosis • Wilson’s disease • Viral hepatitis • Hereditary haemochromatosis • Drug induced liver injury • Alpha-1 antitrypsin deficiency • Cancers – biliary, pancreatic, HCC • Haemolytic anaemia etc.Examination - Pre-hepatic jaundice • What are you expecting to find? • Jaundice/ Icterus • SplenomegalyExamination – Chronic liver disease What are you expecting to find? • Sarcopenia and bruising • Hand and nail features – leukonychia, palmer erythema and spider naevi, needle track marks • Facial features – telangiectasia, icterus, conjunctival pallor • Gynaecomastia • Abdominal features – hepatosplenomegaly (or maybe no hepatomegaly), collaterals (caput medusa)Examination – Chronic liver disease And in a decompensated patient? • Jaundice • Abdominal distension > ascites • Peripheral oedema • Encephalopathy • Haematemesis • Hepatic fetorExamination – post hepatic jaundice • Acute post hepatic jaundice e.g. gallstones • Unlikely to get in PACES • Sick and in pain • Chronic causes e.g. PSC • If advanced, you can develop chronic liver diseaseCase 2 - JohnInvestigations • Bed side investigations • Bloods • Imaging • Any other investigationsInvestigations • Bed side investigations • Full set of observations • Capillary blood glucose – if concerned about liver failure • Bloods • Identify the cause of cirrhosis • Full liver screenNon-invasive liver screen • LFTs , clotting screen • Viral hepatitis bloods – HepB, C, HIV, CMV • Tissue antibodies – ANA, smooth muscle antibodies, anti-mitochondrial antibodies • Immunoglobulins • HbA1c • Copper • Haematinics – incl ferritin • Alpha-1 antitrypsin • AFP, Ca 19-9 • Caerulopasmin • Conjugated bilirubin • FBC, U&Es, CRP, TFTs • Blood culturesInvestigations • Imaging • US liver • Fibroscan • CT AP with contrast if concerns about stones/ portal vein thrombus • MRI liver • Any other investigations • Liver biopsy • ERCP • OGDCase 2 – Spot diagnosis 1 a. b. Dupuytren's contracture Palmer erythemaCase 2 – Spot diagnosis 2 a. b. Koilonychia LeukonychiaCase 2 – Spot diagnosis 3 Angular stomatitisCase 2 – Spot diagnosis 4 Kayser Fleischer ringsManagement of Chronic Liver Disease • Treatment of underlying liver disease • Monitoring for complications • Regular US to monitor for HCC • Ascites – reduced salt diet • Improve nutrition to avoid sarcopenia • Acute on Chronic Liver failure • Liver transplant or Supportive and palliative careCase 2 – Spot diagnosis 5 Hepatic EncephalopathyCase 2 – Spot diagnosis 6 AV fistula – Renal dialysis ?whySummary • Read carefully • Think of differentials before you go in • Investigations – bed side > bloods > imaging > others • Practice summarizing – especially patients with no/ little signsTHANKYOU FOR COMING! PLEASE FILL IN THE FEEDBACK FORM!