Upper GI endoscopy quiz

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Upper GI endoscopy quizAnthony Morris

ramasamy saravanan

Questions

Case 1Figures 1a and 1b are endoscopic photographs of patients with chronic dyspepsia.1 What is the underlying condition?2 What is the recommended management of such patients?3 Which of these would you be most concerned about?4 What further investigations or techniques should be considered?

Anthony Morris MSc FRCP is Professor and Director of the National

Endoscopy Training Centre in Liverpool, UK, and President of the

British Society of Gastroenterology. He trained in Manchester, London,

UK, and Pittsburgh, USA, before moving to Liverpool as Senior

Lecturer in Medicine (Gastroenterology). His interests are mainly now

in therapeutic endoscopy and endoscopy training. Competing interests:

none declared.

Ramasamy Saravanan MRCP is a final year Specialist Registrar in

Gastroenterology in the Merseyside Deanery, UK. He is undertaking an

Advanced Therapeutic Endoscopy Fellowship in Canada. Competing

interests: none declared.

Figure 1

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Case 2This endoscopic picture was taken during the extubation phase of an otherwise normal endoscopy undertaken for dyspepsia. This lesion was in the uppermost part of the oesophagus1 What is the lesion?2 Could it be the cause of the patients symptoms?3 Can this lesion cause any problems with respect to the patient’s health?

Case 3These patients presented with mild dysphagia and non-specific dyspeptic symptoms.1 What is the likely diagnosis?2 What is the cause thought to be?3 What treatment would you try?

Figure 2

Figure 3

1 © 2007 Elsevier Ltd. All rights reserved.

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Case 4These patients were being investigated for iron deficiency anae-mia (IDA).1 What is the lesion shown in the figures?2 In a 60-year-old patient with IDA and this condition, should further investigation be undertaken?3 What treatment is available?

Figure 4

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Case 5These patients were being investigated for dyspepsia.1 What is the differential diagnosis of the lesions shown?2 How do they usually present?3 What further investigation should be undertaken?4 Is treatment indicated, and if so with what?

Figure 5


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Case 6This 26-year-old patient was referred for endoscopy with failure of medical therapy for dyspepsia.1 What are the possible causes of the abnormalities shown?2 What investigation is appropriate?3 How would you treat this patient?

Case 7This patient complained of acute onset odynophagia and dysphagia.1 What is the abnormality shown in the oesophagus?2 What are the common aetiological factors?3 What treatment should be given?

Figure 6

Figure 7

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Case 8This patient complained of dysphagia for a few months on a background of longstanding heartburn.1 What abnormalities are shown?2 What is the cause?3 What classifications are used in this condition?4 What treatment should be considered?

Figure 8

© 2007 Elsevier Ltd. All rights reserved.

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Case 9This patient presented with mild dysphagia and a cough on drinking. The views were taken from 23, 24 and 25 cm from the incisors.1 What does the endoscopy show?2 How would you investigate this patient?3 What is the correct form of treatment?

Figure 9

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Answers

Case 11 Barrett’s Oesophagus (Columnar lined oesophagus).2 Most specialist societies recommend quadrantic biopsies every 2cms of the Barrett’s mucosa at two to three yearly intervals in order to look for dysplasia. If low grade dysplasia is found then repeat endoscopy at 6–12 months. If high grade dysplasia then endoscopic ultrasound to look for underlying evidence of a cancer (in 50–60%) and then if repeat biopsy confirms high grade dysplasia then either local endoscopic resection or ablation or oesophageal resection. Full dose acid suppression is recom-mended on a long term basis, with little evidence to support its prophylactic abilities.3 In fig 1a there is an irregular area at 12 o’clock with some granular mucosa adjacent, biopsy of which showed high grade dysplasia.4 Dye spraying with Lugol’s iodine, narrow band imaging with blue light endoscopy with, or without magnification and auto-fluorescence are all techniques that can be used to help with in-vivo diagnosis of dysplasia.

Case 21 Herald patch or gastric heterotopia, a developmental condi-tion with an area of normal, but ectopic gastric mucosa.2 This is usually a coincidental finding, and is often missed by either too rapid intubation or extubation. The uncomplicated case does not cause major symptoms.3 It can rarely be the site of ulceration or malignancy.

Case 31 Concentric rings in the oesophagus said to be suggestive of eosinophilic oesophagitis.2 It is thought that this represents an allergy to an, as yet, un-known allergen. Its incidence is increasing and whereas it was predominantly a diagnosis made in paediatric practice it is now increasingly found in adults.3 Use of topical steroids is first line treatment, after confirmed diagnosis by biopsy.

Case 41 Gastric Antral Vascular Ectasia (GAVE). This vascular ecstatic condition can vary from small lesions to gross raised red folds. In the early or milder forms it is often mistaken for ‘gastritis’ by the inexperienced. Careful inspection shows normal mucosa immediately next to, and between the lesions.2 Although in its gross form this can cause anaemia, in patients over 50 years of age imaging of the colon should be undertaken before attributing the anaemia to GAVE, to exclude cancer.3 If it is found as a co-incidental finding no treatment is indicated. If it is thought that the GAVE has caused anaemia then argon beam coagulation, laser ablation or more recently cryo-ablation of the antral mucosa has been shown to work.


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Case 51 Both patients show a focal raised area of mucosa with either in case a and b an ulcerated centre or in case c a dimple. The overlying mucosa looks normal, and was confirmed as such on biopsy. The lesion is likely to be a GIST (Gastro Intestinal Stro-mal Cell Tumour) but the differential includes an extrinsic mass, lipoma, pancreatic rest or cystic lesion.2 In these cases the patients were being endoscoped for dyspep-sia, and the symptoms were unrelated. GIST lesions can present as GI bleeding or rarely due to a mass effect.3 Endoscopic ultrasound should be undertaken as this will de-lineate the site of origin of the lesion and can distinguish between a GIST, lipoma or an extrinsic mass. For large lesions a CT scan should be undertaken.4 If the lesion is observed over time to be growing, or is larger than 2cm at diagnosis it should be removed, usually surgically. In case of malignant GISTs, which are c-kit positive, imatinib (Glivec) therapy may be required for metastases.

Case 61 There are two ‘kissing’ ulcers in the body of the stomach. If the patient is Helicobacter negative (blood or stool test, biopsy or breath test) then detailed questioning about NSAID use should be undertaken. Rarely multiple ulcers are due to Zollinger Ellison syndrome.2 A slide based urease test at endoscopy if no other test of Helicobacter pylori status has been undertaken. If the patient is still on PPI therapy then more proximal gastric samples should be tested. A fasting gastrin level, off PPI therapy is required to initially ex-clude ZE syndrome. All gastric ulcers should be biopsied on di-agnosis and subsequently after treatment to ensure healing and to exclude malignancy.3 Eradicate H pylori if present, stop NSAID use and use high dose PPI therapy.

Case 71 Monilial (candida) oesophagitis.2 Inhaled steroid use, post antibiotic therapy, immuno- suppressed patients.3 In mild cases topical antifungals such as nystatin and am-photericin. For severe cases a course of fluconazole or similar systemic antifungal.

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Case 81 A stricture with discrete areas of radiating oesophagitis and some sacculation and pseudo-diverticulum formation indicating chronicity.2 Chronic gastro oesophageal reflux.3 Initially commonest classification was the Savary Classification, but this has been succeeded by the Los Angeles Classification. More recently the Montreal Classification system for describing gastro-oesophageal reflux and disease has been proposed, but is not currently widely accepted.4 Acid suppression, usually with full dose PPI therapy is the mainstay of therapy. In some cases where stricturing is mild this alone may relieve the dysphagia by healing the oesophagitis. Usually however where stricturing is prominent dilatation of the stricture with either bougies or through the scope balloons is necessary. This may need to be repeated on several, or many occasions.

Case 91 A tracheo-oesophageal fistula. Characteristically patients de-velop coughing when drinking fluids, although this can occur with other causes of high dysphagia.2 A biopsy should be taken to determine the cause. If spontane-ous it is usually the result of malignant infiltration either from a primary bronchial, or oesophageal cancer. It can occur as a result of radiotherapy for malignancies in this area, and of course congenital fistulation related to oesophageal atresia occurs in the newborn. Bronchoscopy should be undertaken with a view to stenting as discussed below. CT scanning although useful in de-lineating the size of tumour and its extent does not significantly help inplanning therapy.3 Before a decision on therapy is made it is important for the patient to have a bronchoscopy to assess the degree of tracheo-bronchial involvement, particularly in assessing the degree of lu-minal narrowing. The main risk in occluding the fistulous tract with a covered oesophageal stent is mass displacement leading to further reduction in airway size. This can be anticipated at bron-choscopy, permitting tracheo-bronchial stenting as a prelude to oesophageal stenting, by prevention of airway blockage. Stenting is the mainstay of managing this condition, with covered, ex-pandable stents of appropriate size (diameter and length). This patient had a small cell tumour causing the fistula.


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Upper GI endoscopy quiz