1. Upper GI quiz PBL 28

2. Helicobacter infection in the stomach is associated with: • Gastric carcinoma • Acute gastric ulceration • Chronic duodenal ulceration • Intestinal metaplasia • Gastric lymphoma

3. Regarding salivary gland tumours: • Malignant tumours arise most commonly in the parotid gland • Pleomorphic adenomas have a 20% risk of malignant transformation • Facial nerve impairment is an ominous sign • Adenoid cystic carcinoma has a good long-term prognosis • Enucleation of pleomorphic adenoma is appropriate treatment

4. Barrett’s oesophagus: • Is a dysplastic change • Confers an increased risk of oesophageal squamous carcinoma • Can contain small intestinal-type epithelium • Can be complicated by benign oesophageal stricture • Increases in frequency with increased duration of gastro-oesophageal reflux symptoms

5. Oral leucoplakia can be caused by: • Candida infection • Smoking • Epithelial dysplasia • Ill-fitting dentures • Invasive carcinoma

6. Concerning gastric cancer: • It is commoner in Australia than in Japan • Diffuse type (signet ring) adenocarcinoma is decreasing in incidence • Many cancers arise from pre-existing benign peptic ulcers • Overall 5 year survival is 25% • Histological type is the most important prognostic factor

7. Acute gastric ulcers: • Are often multiple • Are common in severely ill patients • Are usually >25 mm in diameter • Are confined to the antrum • Usually heal without scarring

8. Concerning chronic gastritis: • Autoantibodies to gastrin-producing cells are present in autoimmune gastritis • Squamousmetaplasia is often seen on biopsy • Chemical gastritis can be secondary to bile reflux • It confers a high risk of development of gastric cancer • It is frequently seen in patients taking long term steroids

9. Concerning squamous cell carcinoma of the mouth • The incidence is higher in the far east than the UK • Prognosis is best for anterior tumours • There is an association with sun exposure • The tumour rarely spreads beyond the oral cavity • Erythroplakia is a high-risk factor

10. A 63-year-old male presents to his GP with swallowing problems. He describes a gradually increasing difficulty with swallowing solid food, but no problems with liquids. The has recently lost 6 kg in weight and has a several-year history of “heartburn”.

11. What is your differential diagnosis based on this history? • Oesophageal obstruction most likely to be due to a benign inflammatory stricture or a malignancy • Hx of heartburn points to GORD • Achalasia (much less likely) • Benign strictures – physical or chemical injury (ingested caustic substances, irradiation, chemo), scleroderma

12. What changes may be present within oesophageal biopsies taken at endoscopy? • In benign strictures, oesophageal mucosal biopsies may show inflammatory changes with squamous epithelial hyperplasia. Ulceration may be present. The fibrosis causing a benign stricture may not be seen histologically as the scar tissue lies deeper within the wall of the oesophagus and may not be sampled in a superficial biopsy. • Inflammation and squamous hyperplasia would be seen in GORD. Identification of glandular epithelium within the anatomical oesophagus would signify Barrett’s metaplasia. • If malignant tumour is present, biopsy will confirm whether this is squamous cell carcinoma, adenocarcinoma, or a more unusual tumour type (such as sarcoma or melanoma). • Even if no mass is seen, in the presence of Barrett’s oesophagus there is an increased risk of malignancy and of premalignant (dysplastic) changes in the glandular epithelium. For this reason, patients known to have Barrett’s change may undergo regular endoscopies, although the effectiveness of this surveillance in identifying early-stage, potentially curable, oesophageal tumours is not yet clearly established.

13. A 78-year-old female is admitted to hospital as an emergency patient with abdominal pain and haematemesis. Urgent endoscopy is performed and a 15 mm ulcer is identified in the proximal duodenum as the source of the bleeding

14. What specific questions would you ask the patient to help establish the cause of the ulcer? • A careful drug history to exclude NSAIDs is essential. Many elderly patients suffer from osteoarthritis and buy medications over the counter. Smoking and alcoholic liver disease are associated with peptic ulceration and the relevant history of these habits should be obtained. Other relevant medical history would include chronic lung disease, chronic renal disease and hyperparathyroidism.

15. Why might the endoscopist take a biopsy from the stomach (rather than the duodenal lesion)? • H. pylori gastritis is frequently present in association with peptic duodenal ulceration. A rapid urease detection test for Helicobacter can be performed with the tissue sample in the endoscopy suite, of the biopsy material can be submitted for histopathological examination. Duodenal peptic ulcers do not undergo malignant transformation and can safely be assumed benign in nature without histological confirmation.