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Hello, everyone. And welcome to the weekly mind a bleep, A surgical Siris. Thank you very much for joining on today. We're going to talk about gastric reflux disease and upper GI I system cancer. Um, basically feedback. We're going to try something different today. A smidge or it of you are saying that you'd like Teo make the centers more interactive. So today we're going to use a patch form called mental Mita Teo for you to be able to answer the questions and then for you to post questions after the end after after finish the session. So if I could ask everyone, there's going to be a Q and A on this that form later. These don't pose them on the facebook chat. These post them here. Um, but I will. I will have looked at the Facebook chat some later as well, just in case. So when that start. So I just quickly, um, touching on their general format, we're going to go through clocking off the patients who presented upper GI symptoms out briefly. Talk about it in that pathology, um, due to allergy of the disease process and then we'll touch on investigations. Initial management, which is necessary for you as a junior doctor. Teo. I bite some complications and we'll do questions for our dissection. So the key learning points before you to understand the relevant not to me. And I didn't fight common presentations, which you will likely come across when you work in a hospital. So that's going to be very beneficial for you. Um, I'd like to understand the risk practice for gastric reflux disease and upper GI cancer, and then we'll practice application of skill. See, you've learned during a case, so it just quickly but made my name is Saturday. It's enough scar manacled emmick. If we're to doctor and I'm interested in plastics, ask your surgery on, um, research and teaching. So let's start of the case for the purpose of this presentation. Similar to previous sessions, you are the surgical F Y one doctor on take when the patient comes for the door. So just keep this in mind to write the session. So our first patient is His name is John. He's a 68 year old male, he's obese, and he has a very significant smoking history of for two packages. Hey, presents to you with a burning chest pain, which he has had for 14 days Ordina Fajita, which essentially means, um, pain on swallowing vomiting. That's again. Hey, set for seven days and some nocturnal cough. So he has been coughing at night vomiting, has pain on swallowing and has burning chest pain. Okay, so our approach it a case and we're going to Teo this tree, we're going to examine the patient on we're going to do some investigations, but festival I would like to ask you a question. So if you could, um, goatee menti dot com. So it's www dot mental dot com and use the code they can see on the top of the screen. So it's 94 47 097 to load. Wanted a platform. I'll give you a bit of time, but when you do look in, uh, please, if you could answer the question so I can see that you've looked on and if you could, um after the question on same world, are the differential diagnosis in this case. So again, the website is w w w dot menti. That's M e n. See, I don't come. I'll give you a couple of minutes to log in and let me track it. There are no issues, right? Let me posted here. So right. Perfect. All right, so give you a few more minutes. Teo, do your voter, and they don't have to be on a gastro to sign of issues. So you think about it when the patient's presenting with vomiting, burning chest pain and nocturnal cough, What else could be going on? Because this kind of highlights that even notices a session on upper GI problems in real life at the patient present with with loads of difference pathologies, right. Hopefully, more, more people will be able to look in, and we're going to use the same code for our dissection to answer all the questions that please don't look right. Okay. Perfect. So, looking at your answers, um, there are a few pathologies that seem t seem to be very common. Insists eso gas. True. Assefa geo of reflux disease seems to be very, very common. Um, as a vaginitis, as regards malignancy, gastric reflex, these air over guidances, um, adenocarcinoma. It's very good on it. Um really glad they have highlighted it. Could be heart attack. Eso the patient could be having, um, half a problem, which is a very important differential. And and you had mentioned also uses well and pancreatitis. So these are all very good differentials for for register, no burning, Just a So thank you very much for taking part on. Please stay on menti for later. Um, I'm just going to move on in touch briefly on their differentials. So the key differences in here for the burning register no chest pain will indeed be gas or just kind of reflux disease. It could be malignancy, especially at the patient. Has some pain on swallowing, which is me. Eso that could be a PSA for Joe or gastric cancer. It could be peptic ulcer, Asian, as you rightly did Say patient could be having a super Jew maternity. Develop this, um which we're going to investigate for as well. I will discuss with them trinessa gators later. But then, very important differentials. And I'm really glad you have mentioned that Are diseases that are not effective disasterous at the upper gastrointestinal tract. So cardiac disease very important differential because the patient we don't see, Ms um helps occupations that might have reflux on top of that. Or that the pain is just very similar to reflux on biliary disease. So biliary colic, intermittent episodes of biliary colic can be very similar. T two flare ups off gas or to sign of reflux disease. All right, so the next question for you is, um what symptoms are seeing an upper gastrointestinal disorders. So I have given you a few symptoms that the Byetta has presented with and just as a recap patient has registered in band or just that burning chest pain vomiting, Um, and I would like ET to think about what other symptoms are seeing upper gastrointestinal disorders again. If you go t men to have come and the Kurds is the same on, just if you could think of any other symptoms. Perfect. I'll give you a few minutes. Perfect. And the reason why this is important is because when the patient presents with with one of the symptoms off the upper gastrointestinal problem, and it's very important for you to ask all the other, the other question is just to be able to dive Motivations, um, more precisely entries, your investigations appropriately, and so likely. So um, other upper gi I symptoms will include dysphasia and and that is a side will touch on later is a red flag symptom. So the patient presents with when you in ability to swallow or difficulty in swallowing. That is a very worrying symptom, but some of the other symptoms you have mentioned, um, abdominal pain is a very common presentation. And Upper gi I problems, um, the steps here. So it's feeding off indigestion, um, pain and symptoms, which are worse after eating. These are all very, very good dances. And so you have, um I think I have listed almost all of them, but I just tried to go briefly free the upper GI I symptoms were going to ask a bite. All right, um, so some of the symptoms you did mention mention dysplasia. So difficulty swallowing, or June aphasia? That's pain on swallowing hematemesis. So when the patients are bringing up blood for your life, um, vomiting also. So the indigestion, um, will be the symptom off Actigall stories. And also the patients with the upper GI I symptoms might have drawn desk so they might have a yellowing of the scarer and off their skin. Um, it's really important in desperation to also ask about it. Systemic problems because those good 0.2 you towards the underlying problems. Such a small ignorance see? So it's really important to ask about any weight loss under Xia. Nausea, fatigue, fever, confusion A Z patient is presenting presenting with retrosternal burning chest pain. We're going to try to quantify the pain so we're going to use the sokrati separation of pain, which is a, um, essentially used in any any history taking it when the patient's presenting with with pain, we're going to ask about patient's past medical history of past surgical history on um, in the family, history is really important to ask about malignancy as some cancers. Um, the risk of a patient having a cancer is going to be increased if there is a family history of cancer on important for the upper GI disorders. We're also going to ask about a smoking history, patients, alcohol intake, diet and exercise tolerance. All right, say, going back to our patient and John, his 68 years old. He's a male, and he works as a banker, and he tells us that, as I did mention he has a very significant smoking history off 30 pack years. Um, he drinks free whiskey today and he's a beast. This chest pain that he has told you. Bite has been going on for two weeks, and he does have some acid taste in his life. And the pain is worse when he's lying, dying and it's West after after he's eaten on as previously mentioned, he's been vomiting for seven days and has had this cough. It's night for seven days. He's never had anything like this in the past on his past medical history, um, includes Type two diabetes, hypertension, high cholesterol, gout, Helicobacter pylori, infection and peptic ulcers. Very importantly, the symptoms on my right hand side of the of the screen the patient does not experience. So those are your symptoms ever called red flags. So in any patient presenting with upper GI problems, it's really important to ask those questions because those cute mean that the patient might have underlying cancer. So the way we manage the patient, the way we investigate the patient might have to be very different, and that there is going to be, um, we might need some urgent investigations. If that's the case, So in this case, the red flag symptoms would be weight loss. This Basia, um so new labor to swallow or don't aphasia pain on solid a, um, voice, hoarseness and early satiety malaise or loss of appetite, hematemesis or fatigue so drunk doesn't have any of those. Um, so we, um we're pleased to hear that on, um, we're now going to move on to the examination. So we're going to use the 80 approach. We're going to perform the abdominal examination to look for any masses on there. Palpable. We're going to look for abdominal distention for any palpable organs. So in particular for organomegaly, we're going to feel for peripheral lymphadenopathy. So we're going to feel, um so for the upper GI I cancers in particular, we'd like to feel in the super clavicular for PSA. In particular lymph nodes there, in large in the left supraclavicular for PSA could be in keeping with, uh, metastatic gastric cancer. Um, which I will go back to you later. When we examine the patient. Will you also drink for signs of anemia? Um, such as conjunctiva parlor and card, a nickel or ankles dermatitis. And to complete the abdominal examination. We should do a digital rectal exam and check external hair in your orifice is all right. So on examination. And John is hemodynamically stable. He doesn't have his, doesn't have a fever. His observations all or are all normal, has Abdomen is soft on probation and there were no masses. But he's tender in the gastric region, there's no guarding and the patient declined PR exam because he felt that there is no indication for it. All right, so what investigations? Based on what we have found so far, you think we need to order? I'll give you again. Couple of minutes. Perfect. That's perfect. And so, as we have previously mentioned during our surgical revenue Aires, and it's really good to try to divide investigations into the better investigations than blood in the radiology and then for the tests. And so indeed, we're going to do some blood desperate, a patient on the patient's presenting of the chest pain. So we're going to do the Easter to you as well. And the most important test in here would be the endoscopy, which I'm going to Teo talk you free and and there is also there also another tests, which you have right identified. So sfr jewel Manometry. That's a very important test as well. Um, on these are all very, very good answers. So I'm going to tol you what we're going to do for John in just a second. Great. So in this particular case, we're going to start with the blood tests on you Like it? So you have identified that apart from our base and surgical bloods, which I hope everyone is aware aware of, So those would be for blood kind of left. He's using these CRP clotting and group and safe. We might want to add amylase. We might want to add Strattera in because the patient presented of chest pain on a bone profile just to see for any electrolyte disturbances as the patient has been vomiting. So we're going to do their, um, the SED as a bedside test. We're going to do the bloods and then the very important test are specific for for this presentation. If we're thinking that the patient, um, might have passed on to sign a reflux disease and so that's all you did say previously, our differences would be gastric to sign the reflux disease. Um, upper GI cancer. So most likely stomach or esophagus or esophageal dysmotility so important test in here would be a safer geo manometry. So you can see it's, um, in here, um, on the bottom left side of the screen. And this is a patient he's undergoing, um, a sexual manimal tree so that ph monitoring catheter is inserted. If I do nose and to do yourself a guess, and it's monitors the pH for continuously for 24 hours a day on dear is a monitoring monitoring device which, of course, the pH in the esophagus. Um, and if the PH is less than four majority of the time, then that is a diagnostic off off gastrointestinal reflux disease. Um, the most in this testis may or may not be done because most of the time, if we don't suspect any red flag symptoms, then we can, um, we can diagnose gusting to sign of reflux disease based on the clinical on picture. Only on be mind not needs to do, um, the manometry testing. However, if we are worried about red flag symptoms, we might think the patient I have cancer or the patient has had symptoms for a very long time, and they don't seem to be getting better. Then the most important task is going to be the endoscopy. So you're looking on the the right bottom hand corner and which is supposed to show a patient undergoing and Oscar Bay So the and just go piss boot for your patients, my life and the light sedation on de static might be used like a topical anesthetic. T make it more pleasant for the patient. And then the scope goes dying divisional eyes, the stomach. This offer guests and, ah, part of the duodenum on this test is the most useful and most suitable innovation. He we suspect my half a napper. Gee, I melatonin See, It's also very useful in visualize ing potential complications of the gustatory on a safari, a reflex disease, such a strictures, or is a vaginitis. Um, and then other tests that we do have in here. Um, so at the top in the center, um, in an investigation we could do is set for June manometry. So this is a test used to exclude, and it's if I do this maturity disorder. So essentially it looks, um, there's a catheter. But it's ideas, uh, forgets. And it looks at they're at the pressure inside your esophagus. So, um, to see if they're normal, video contraction and relaxation sequence is intact. Um, and again, if we are, if the history does not sign typical of gastrointestinal reflux disease alone, then we can do the manometry. Studies the try and exclude the that this motility disorder and other tests that, um you might think about is there just at the top in here in the right hand corner. You might think about doing a CT off the chest, abdomen and pelvis, but they're on the back seat of a wimp. A Schintzius in In whom festival You do suspect a malignancy. Um, teeter Look for this, and metastases or depression is not suitable for endoscopy. Okay, that's minute on. I would just briefly touch on the relevant anatomy. So, um, if you can have a quick look at the picture on the right hand side is just a brief outline off the upper GI. I, um average I tract. So it goes from the oral cavity on Ben, you have the you have your firings, and then the esophagus. Um which is then connected to the stomach. And then the important part of here is the gastroesophageal junction, which I'm good soccer bite in a second and have your stomach, then this is connected to do the, um okay. And then, um, the border between the upper gastrointestinal tract in the lower to sign a contract is the Isn't here at the third part off the duodenum. So just in here at the bottom on gets along the suspensory ligament off tracks. So just oriented yourself in here. This is the duodenum. This is the diaphragm. This is the aorta, and the back and the esophagus would be here at the front. Okay, So the third part of the duodenum, which is connected to the suspensory ligament, demarcated the transition between the upper gastrointestinal system and the lower gastrointestinal system. And then, if you could focus for a second on their top left hand corner, there's going to be relevant t do the bath. Or that you were going to discuss in a second, Um, that gastroesophageal reflux disease. So if you look in here, you have the sulfa guess, and that is joined to the stomach at the gastroesophageal junction on this is surrounded, or it contains that lower esophageal sphincter. And for the patient Teo for their gastric acid to stay in the stomach and not to leak into the esophagus, this has to be paid, didn't and open when the food is coming through and then stay closed when the when the food is being digested in the stomach and mix it with their stomach acid. All right, So, as I did say, um, about from our initial work up and the blood tests the ACG the bedside investigations As a junior doctor, you have to be aware off winter affair patient for urgent Upper GI I and oscopy. So this is this is very boat, and this is why you have to make sure you ask all the right questions, which I, um, briefly talked about before on. But they have Teo then decide if it's going to be an urgent or non urgent upper GI endoscopy over. The patient needs Upper gi endoscopy at all so and the nice. So the institute off care accidents in DKA suggest that's another guy endoscopy on a two week wait pathway. Should be, um, should be aggressive for a patient who presents with this patient. So this new difficulty in swallowing, um, or in a patient who's aged over 55 or Ava and does have weight loss on dust have any of the following, And so they have to be free components. So and it's either Justice, Asia or the patient is a 55 forever headway clothes and has any of the following the operator abdominal pain, reflux or dyspepsia? Um, the guidelines also suggest that you should go to their non urgent upper GI endoscopy in patients who present with him a tennis is. So they're bringing up blood, um, in patients who are aged 55 and over. Hey, also, do you have, um, any of the following? So they're dyspepsia. It's indigestion is resistant to treatment, um, where they had upper abdominal pain. We've low hemoglobin, or they have nausea, vomiting, which is associated with any off weight loss reflux the steps here and upper abdominal pain. So you can see why it's really important about to ask about all of those symptoms because it's let you decide if the patient needs an urgent viral known and ribavirin. Referable does not need to and and endoscopy at all. So these are very important rashes because essentially knowing about patient symptoms will will let you decide if this is something that we have to worry about imminently. Is it another line concept or is it had been nine gastric reflux disease. All right, So based on what you have plentiful, are you going to refer Joan for endoscopy? And if so, are you going to a fair? It wanted to week wait halfway. Are you going to affirm on unknown urgent pathway or you think that the movement there's no need to refer him for upper jaw and oscopy? It's again. I'll give you few minutes to himself. So so far in Madrid, if you have sets that yes, you like to refer John for and oscopy. But you'd like to request on a non urgent halfway there, just give you bit more time. Teo Custer votes. All right, So majority of you did say that you like to refer John for non urgent and upper GI endoscopy on, but this is indeed what should happen. So just going back, um, the urgent referral would be necessary if John had this major. He doesn't have dysplasia. He is aged 55 years and over, but he doesn't have any weight loss. So he doesn't have those free components. Old war in origin. Urgent and referral. But highlighted in here in orange are John symptoms. So and he is a 55 years and over on he does have nausea and vomiting. And he also does have reflux, dyspepsia and upper abdominal pain. So he does have symptoms that do warrant no energy into Referrer for upper gi endoscopy. Right. So we have some drunk for, um for a project endoscopy on a known Sergent pathway. And And we have also performed some blood, so his blood tests came back is absolutely normal. Um, And on endoscopy, this is what we're seeing. So there are three different pictures from Johns and Oscopy. If you have ah, brief Look, I'll give you few more seconds on. If you could give me a diagnosis, what do you think could be happening? So just e help you orientate yourselves. This is D and the view from the inside of the gastro on a separate your junction, which is, uh, just around here this again is a picture of the gastro a separate your junction. And this is the view off John stomach. So what do you think? What do you think? The diagnosis. I think we're going to go to next. Yeah, perfect. So so far, we have said they could be cancer, or it could be barred to suffer guests. Still, my cancer. Okay, ulcer and the other suggestions. All right. And so let me just show it to you again. Well, don't do those who said that's part esophagus. Um, so this Ah, there's a few in here on in here, to a lesser extent, is a classical picture of Barrett's esophagus on going to explain what what that means in a second. But if you just look in here, there is this white mucosa and then this rectal mucosa around here, which is abnormal and and then same. And he can see the streaks off this red velvety appearance, which is abnormal. And in here on the right hand side, this is just a view of a normal stomach mucosa. Is it there and actually them that torture's lines in here, called Rudy, are normal parts of the stomach and they stretch when the stomach is full s. So this is a normal view of an empty stomach. So there is No, there are no tumors, no signs of cancer here on seven. Here. This is, um this is Bart esophagus. And this in here is just Ah, this is not a tumor. This is a normal appearance of the athletes, at least on the microscopic a level. This is not cancer. This is just a gastro gastroduodenal. Oh, um, esophageal gastric junction. All right. Perfect. So, um, we have diagnosed, um, John with bart esophagus, which I will get to next. But he also does have gastroesophageal reflux disease based on his symptoms. So the gastroesophageal reflux disease and it's caused by gastric acid in gastric contents leaking after the esophagus. And that results in pain and damage of the mucosa in the Indus off against because essentially the makers in just in the esophagus, it's not, um, it's no well suited for the acidic environment. This is why, in normal people that gastroesophageal sphincter should be tight to prevent the Esther acid reflex because the stomach lining is is way better suited to deal with this acidic environment and so invested us Gasset gastroesophageal reflux disease their ass. It leaks into the esophagus on that cause the symptoms and damage of the lining of the esophagus on disses duty, a dysfunction of the lower esophageal sphincter and there was factors are increasing age so drawn A 68. Um, he's at higher risk. It's developing good compared. Teo is younger counterparts, um, obesity malady and a high alcohol intake smoking, caffeine and spicy foods and some of the symptoms or, um, the classical symptoms going to be the burning reclast and or sensation. Sometimes this card describe this chest thing. So this is why we we called the heart then because it's the chest pain around the heart region, which also feels like burning. Um, patient's my complaint off increased belching and ordered aphagia. So you pay no swelling and chronic nocturnal cough because the symptoms are worse in the patients lying time at night. The assets were travel after the esophagus, and that's going to irritate the, um, irritate the the throat and the patient. My cough it night. But this also might happen during the day. Right? Um embarrasses offer guess as you have right. The identified um, is usually caused by, um is usually seen in patients who do have gastroesophageal reflux disease. Um, and it is a metaplasia off the esophageal. Oh, epithelial lining metaplasia means a transformation off. One different shapes is the one What's your cell into a different cell. So in this case, um, you can have a look in here at the bottom. Right? You can see on the left side off this picture, there is a stratified squamous epithelium, which is a normal epithelium seen in the esophagus. On on the right hand side, you can see this, um simple, calamine ear's like column like epithelium with blondes in here, which is seen in the intestines and in the in the stomach. So embarrassed esophagus, this lining of the esophagus. So the start if I squamous epithelium iss transformed to disinter Stangel lining to be able to deal with this to damage erosions in and acidic environment better. Um, it is a reversible reversible change. So one's there, and then the problem is removed. So if we can stop in control their the acid reflux, it is a reversible condition. So the Barrett's esophagus can reverse back Teo back to normal mucosa. Um, a Z I said it's caused by chronic acid reflux, which damages the the lining and then triggers this transformation. Teo aligning That's more resilient and acidic environment. And at the time when people with cord seek medical attention, 10% of people already have developed on Barrett's esophagus. The way we diagnose it is with endoscopy in biopsy, and it's a histological diagnosis. So when you do the endoscopy, you can see this characteristic appearance seen in here and on the previous light on. But then you take biopsies. And if on the biopsy from the esophagus, you can see this simple columnar, um, epithelium with glance, then you have the diagnosis off barges off a guess. Symptoms are very similar to Guster. So for your reflux disease, on goes as I, as I mentioned, usually overlap. The risk factors are being Caucasian being a male being, um, older than 50 smoking obesity and having a high dose hernia. Um, and it's, um, there is a risk that Bart itself against my progress. T my progress to cancer. Um, and this is why we have to Teo keep an eye on the patients with Bart yourself against by doing your regular regular checks with with, um, upper jaw and osteo bi. Um, and if at any point during the surveillance, high grade dysplasia is find, um, that means that there is a higher risk of progression. Two concepts I would have to intensify, then just copied surveillance. And sometimes, um, parts of the lining might have to be resected, all right. And so I kind of gave it away a little bit. But if John just have, um if he does have back to self against, then what we're going to do for him? What do you think? So he did mention that surveillance endoscopy. But are there any medications that we can give to him? Order any? Is there any other advice to you can give to him or anything else you can think about it and again, just give you, uh, minute or so. Perfect. All right. Thank you very much for your answering on that. We just try and some Where is that? So the management, um, for drunk would be starting from simple measures, Less advice. So as you work, you did say we're going to Teo advised to avoid alcohol as much as possible or at least try to reduce it. Try to avoid, um, tricky. It's so coffee or fatty foods with strongly encourage him to stop smoking. And we're referring to your smoking cessation service, if necessary, and for patients with gastroesophageal reflux disease. And we're going to see we're going to give them a proton pump inhibitor medication. So, for example, in that Brazil, but it's most likely going to require to lifelong, um, later on. If if this lifestyle advice and the pertinent pump inhibitor is not helping after a couple of weeks, a couple of months, um, then the patient can consider surgery. Um, so the options are available. Are innocents fundoplications? Would you conceal in here on the top, right, So you have a loose, lower esophageal. Think that. Then you pull up the food funders of the stomach and then your rapid around Teo tighten it essentially on be. Newer techniques include radiofrequency so endoscopically you deliver a radiofrequency to thicken the sphincter. Or we can surgically inserts um, magnetic beads, so it's good in links method, and those are titanium taking beads ago. Brand just let us think Onda strengthened as well in patients who have Barrett's esophagus. So in John's case, they will need regular endoscopy and biopsies plus minus a resection. So again, depending on what is fine doing the endoscopy and on the biopsies you might have, Teo, I didn't, um, intensify the surveillance. And in patients of Barrett's esophagus ain't high dose birth and pump inhibitor. Unless the advice is the same as for, um, gold. All right, so we have Ah, we have given all this advice to John, and he was on high dose spread to pump inhibitors on. We have, uh we have followed him up with routine endoscopic. Um, surveillance on do symptoms were initially uncontrolled. However, five years later, he no presents to you again. Hey, just have ongoing acid reflex. Hey, has had his developed this new difficult in swallowing for last seven days. Complains of epigastric pain on down further questioning. He tells you he's lost about 10 kg over the last 23 months, and I don't know, he feels weak and has lost his appetite. Um, on the right hand side, you can see the latest endoscopy that John had performed. So this is the view of his esophagus. Um, and what do you What do you think diagnosis is not Yes, so far, majority of people said, but then the carcinoma of yourself against if one vote in fibrosis cream s sell one more vote. Squamous cell esophageal cancer. Okay, so you have rightly identified that. No, it's not simply got a super jewelry for disease or Barretts. There's something sinister going on. So not only does don't have red Fox symptoms, but he also does have a visible tumor on his endoscopy. So then we just go back so you can see that he's in here. All of this, um, is a tumor on its needy, um near whether it suffocates joins with the stomach. So the lower fed All right, so the very well done, um, he has developed esophageal cancer and and your righty have answered, That's it. It's more likely to be an adenocarcinoma. Say it's about your cancer is there are two main types that we see. The squamous cell carcinoma, um, usually affect the upper and middle part, um, upper middle thirds of the esophagus. And the risk factors are mainly smoking alcohol, excess chalasia, low vitamin A and low iron. Um, and then at dinner classes over issue usually seen in the lower fed, um, of the esophagus. And so you have seen on the previous slide, and you can see it in here is Well, um, so in this case, you can see the progression so you could see the Barretts, the classical burns of Barrett's, and you can see the other new costume on top of that. And so the, um, a dinner carcinoma happens in the lower, lower fat of yourself against, and there is this progression. So there is no more esophagus, and then back and progress. The Barrett's esophagus, which is a metaplasia. So I didn't say Is this reversible change and that and then progress Teo Neoplasia and the malignant changes of the adenocarcinoma. Um, and the risk factors for that are chronic gastroesophageal reflux disease, obesity and high fat intake, and then management of those patients and for screams that that's normal. We don't operate because it's it's very difficult to you before sagittal excision on off the tumors around, um around the appetite, the middle of the esophagus as those patients are given chemo, radiotherapy for a dental carcinoma and the patients will get chemo. Radiotherapy. I followed by a resection off the the lesion. Um, unfortunately, most cases at a time of presentation are too advanced for a for either surgical or even curative chemoradiotherapy. So majority of the cases require palliation with with either stents. Teo elevated the obstruction, nutritional support. Or sometimes, sir, just they'll just shrink the tumor, but not necessarily be curative. In the five year, survival is between 5 to 10%. The surgical options, um, include, I've a Louis east of injector me so just briefly and you have this right circle to me laparotomy. And then you exercise the this part of the esophagus you exercise on top of the stomach and the lymph nodes, and then you pull it up, um, and creates a conduit. Mac, you in esophagectomy. Isn't that a merged e treatment of Democrats? Know, Ms. But now you're going to have incision on the right side of the chest. You could have a laparotomy, and you're also going to have in that condition. But essentially, the outcome is very similar to cream. Discrete is conduit by excising esophagus, the stomach and the she more in the surrounding lymph nights. All right. Just to briefly that drawn the gastric cancer. It's a relevant a zone important differential because the symptoms of gastric esophageal cancer tend to overlap. Um, so just briefly that gastric consists of in 90% of them are a dental carcinoma. So, um, so you can see in here at the top, you can see some pictures off the stomach cancer. So this one in here and then in here in disappearance of very widespread stomach comes up. Um, the risk factors include being male, having a Helicobacter pylori infection, increasing age, family history for initial anemia and the symptoms very similar to this video concert. Very similar to go to, um so dyspepsia dysphasia any society vomiting million and anorexia on the referral criteria on the nice guy. Let's for a fair criteria are the same. The symptoms are the same for a PSA for do on gastric cancer. So the, um, you can later have a look again when the symptoms warrant a two week referral or or no energy referral. But essentially, the symptoms are very similar for gastric, and it's video concept, um, signs. Invasions of gastric cancer. My include a palpable mass in epigastrium, and it tries a sign, which, as I did mention before, is this possible lymph node in the left supraclavicular forces that that's suggestive off malignant concert in the abdomen and most like gastric. Um, And again, the survival of those patients, unfortunately, is very poor and at the time of presentation, and the disease tends to be quite widespread. Um, uncurable, But the options available, um, it's perioperative chemo. So patients you to get free runs a chemo before three rounds of chemo after. If it's approximate cancer, we do a total hysterectomy. It was a distant cancer. We do a subtotaled Castro to me. And just to show you, um, her looks, um, total hysterectomy in this case, Um, so if the patient has a proximal tumor, we're going to take I did then touch of the stomach. And then you're going to do this end to end anastomoses between the esophagus and a small bowel and ah, um end teo site side anastomosis. I'm off the for end of the duodenum on, uh, more distal part of the small about and that gives the best, um, functional outcomes. So it's called a rule. And why reconstruction, Right. So just some rice um, gastroesophageal reflux disease and most commonly presented practice journals. Chest pain, which spending in nature that's really important to remember non gas or designer differentials? Um, you should always ask about it. But like symptoms, because depending on what symptoms patient, half you might have to consider urgent or non urgent and oscopy to exclude cancer or to look for potential complications, off glasses, silver jewelry, fix disease and information is fine to have barged itself against. They need to regular surveillance endoscopy because there's a high risk of progression to adenocarcinoma of the esophagus. Um, unfortunately, the gastric and it's a video cancer still have your prognosis, but there are surgical, um, subsequent, um, adjunctive treatments available on. But if your patient does have symptoms, the red fact symptoms that warrant a referral have to make sure you do a two week wait, uh, referral for the patient. So just, uh, just a quick reminder that you can sign up to the webinar. So I haven't done so far on mind a bleep that com slash webinars Um And then there are some article. So we have already uploaded some of the some of the new articles on the top of that we have covered on previously. So apart from accessing the videos, you can also in I read the nights, which are available mindedly dot com slash surgery. All right, so if you have any questions, be supposed, um, here on, let me just go out quickly to pose the feedback link. In the meantime, all right, so it can access the feedback link on the face of paid already. So please, these different the feedback form. Because it's very important for for us because, as you can see, we do try to adjust our sessions Based on the feedback they they give us on, We find it very, very useful on we try Teo, take their the contents of the session. Um, your needs. So if you if you can think of anything, it'll they'll be beneficial for you will be happy to hear for me. Um, And also, if you do fill in the feedback form, you'll get the, um you get the access Teo, the video and director materials on. Do you also get a certificate for your portfolio just really important, cause the sooner you start building your sciatica before year, that better and easier. It's going to be for you later on. So do you have any questions? Oh, feedback. Like it's not working. That is very important. Um, okay, just give me one seconds. That's awful. Um, can you try scanning the Q occurred? Well, actually, I think I know what. Um, just give me one second. Yeah. Uh huh. Okay. Okay. If you can try. And I This is the the new thing, okay? You can You can keep posting the questions. I would go back to them in a second. Let's just see if this is working. Oh, dear. I'm very sorry. That's my contacts in the feet buckling. I I can see you can keep posting the questions. Just give me one second to sort of sight. Um, allergies. Everyone. Okay. Okay. And the feedback link, which which does work, should know. Be up. Yeah. Apologize everyone, please PC's that that last one I did send and I'll give you a couple of minutes, Tonto feedback, and then I'll go through any other questions you might have. But please, please, from the feedback form, because it's really important for you, for you. And it's really important for us. and we do value bit and try to change according to your suggestions, Um, so give you just the minutes. Perfect. Um, let me see for any questions here. And so there are two questions. Um, the feedback thing should be working. I promise. Because I checked it myself. Um, so they're two questions in the in the chat. Uh, the first one is, um, how often you do the endoscopic surveillance for dictations? Um, who's very stuff against. So he didn't include that in the in the session because I thought that might be going to much details, essentially depending on the on the findings. So if there is, um, there is Barrett's, but there is no great, um, low grade dysplasia. And then I think it's something like 60 12 months. But let me let me double check. So I'm not lying. And but essentially, if somebody has a high grade dysplasia, then you intensify Teo every three months and then so on. But, um, I thought that was outside of a scope of the presentation, but since she's going to be between every three months to every six months every 12 months, depending if it's still low grade. Um, the greater hard great I'm finding if it's adenocarcinoma, but then you have to do with it straight away. If it's a high grade dysplasia, you might have to resect some of the A bit of the esophagus is well, and and somebody has asked, um well, let me posted again. Okay? They see if this was working, and I can put the QR code a zoo. Well, okay, let's try to keep our code. So does, if you have an access, is conexes is we'll move my face away. Um, not a question. Waas. Um well, you have your device a patient, Will you tell them before the endoscopy? And so you have to warn a patient is going to be uncomfortable. It is quite a big scope that goes into patients in life, and some patients find it very uncomfortable, especially because it triggers the gag reflex. And it's, um it's a fairly uncomfortable examination. We even advice the patient that they're going to have this numbing spray and they're going to be slightly sedated, so they shouldn't feed it and feel it as much. Um, but some patients find it very difficult to find it very, very difficult to tolerate. And my thing is all the by to managing expectations. And it's really important tol the patients. That's you know it's going to be uncomfortable and we try to do our best to to make this comfortable. It's possible. But the reason we are doing it because we're thinking that you might have cancer. So it's really very important that the patients are on both on aware of that. Um, okay. Perfect. Um, you can you have hopefully scans their feedback form. Please do. Very helpful. Um, let me go back to the question. Um, how do you differentiate between Hematemesis and Hemoptysis? Is him a tennis is is vomiting up blood. So it's blood in the vomit. Hemoptysis is bloodless, Putin and they kind of have Teo sometimes very difficult to differentiate. But sometimes it's really obvious on, you know, you can see the patient vomiting, bringing up gastric contents, and there is there is a blood in it. Um, and hemoptysis is again Just look at the quality and quantity of the blood off the fluid that comes comes in it. And sometimes patients might even describe that's they can see the blood well, is there after it, It coughed. So that's more like to be hemoptysis stomach hematemesis. Or they may tell you there I've vomited on. But then there was blood in it. Um, with patient. Sorry, I somebody asked why in this case, and the complications of the bars were know dealt with, Um, I kind of for the fast forwarded Teo to make the case more variable for you. But obviously, in, um, innovation, he's on the surveillance that we should be able, Teo, um, to catch the any high grade dysplasia at a very early stage and hopefully stop it from progression. Do it on a carcinoma. Um, however, doesn't always the case. Actually, some of the patients he even who are in surveillance, considered develop. I don't carcinomas, but because they're under surveillance, um, we're more likely to catch the the conservative much earlier stage, which means that the prognosis is going to be much better. And we can potentially try Teo surgically remove it. Um, how do you differentiate opposite red flags? Vessels warning symptoms. I think at this stage, and the important things would be to they're the red flags in mind. Include them in your history taking, and then this Class it with the senior to be able Teo Differentiate for sure. If this is a warning sign or this is ah, this is a red flag. Um, so I think it's really important to be aware of them and to be able to elicit that in the history. Um, but it's stage. Um, I think it might have to rely on the SR or support to be able to be 100% set. And if if you're managing the patient well and what to look for in the routine and Oscar getting Barrett's esophagus and what individually button? Yes, I think I've kind of covered the intervals. And then what we're looking for at the Junior Endoscopy is, um, we look at the appearance so we can see this velvety a change of the mucosa looking for a job. This microscopic tumor is also the patients who have biopsies taken. So during the routine surveillance, we take biopsies, and then we look at them under the microscope to see if there any changes there. No, just barrettes. But there are cancer. So there's going to be specific, um, appearance under the microscope that will tell us if this is a very small cancer, or is it still Bart's? D'oh Ah, I will sort of the certificate issues in just a second. And do you have any problems? But he's do get in touch with us, and we'll send the certificates told those people who couldn't access. Um, but in the meantime, order any other questions? Let me go back to compose him in the Facebook chance. Um, if not, um, please, please, going to drive us at Webinars Mind a bleep dot com or if i our Facebook page, if you have any questions or any issues at all, uh, the next section's going to be a peptic ulcer is an upper GI. I bleeds. And I hope you're joining us, um, for the talk next Monday and the same time. So if when I thank you very much, everyone, please make sure you, um you fit in the feedback forms on. But if you have any issues, just get the two of us