Upper GI — 5-min cram sheet

Upper GI — 5-min cram sheet

_Built from the upper-gi disease index. Deck-faithful._

Buzzword → answer (the vignette reflex)

• Left supraclavicular node (Virchow's) = Troisier's sign → gastric adenocarcinoma
• Krukenberg tumour (ovarian met, transperitoneal spread) → gastric adenocarcinoma
• Sister Mary Joseph nodule (umbilical) / Blumer's shelf (rectal shelf) → gastric adenocarcinoma
• Free air under diaphragm on erect AXR + board-like rigidity → perforated peptic ulcer
• Succussion splash + projectile, non-bile-stained vomiting of old food → gastric outlet obstruction (pyloric stenosis)
• "Herald bleed" after AAA repair / aortic graft → aorto-enteric fistula
• Whipple's triad (hypoglycaemia sx + low glucose + relief on glucose) → insulinoma
• 4D — Diabetes + Dermatitis (necrolytic migratory erythema) + DVT + Depression → glucagonoma
• WDHA — Watery Diarrhoea despite fasting + Hypokalaemia + Achlorhydria → VIPoma (Verner-Morrison)
• Flushing + right-sided valvular heart fibrosis + wheeze → carcinoid syndrome
• Reheated/improperly cooked fried rice → Bacillus cereus (preformed emetic toxin, 1–6 h)
• Profuse rice-water stool → cholera (Vibrio)
• Reversal of hot/cold sensation after reef fish (grouper, barracuda, red snapper) → ciguatera
• Flushing + urticaria minutes after tuna / mackerel → scombroid (histamine)
• Ground beef → bloody diarrhoea in the absence of fever → HUS → Shiga-toxin E. coli (STEC/EHEC O157:H7)
• Home-canned food + descending paralysis + visual disturbance → botulism

Endoscopy / histology / imaging → diagnosis

Criteria / staging / scores at a glance

Oesophagus

• LA classification (reflux oesophagitis): A = break ≤5 mm; B = break >5 mm; C = continuous between ≥2 folds, <75% circumference; D = ≥75% circumference (Grade B most prevalent).
• Corrosive CT grades (A–C): A homogenous enhancement → resolves; B-I wall oedema + mediastinal stranding → stricture 20%; B-II external enhancement + internal necrotic mucosa → stricture 80%; C absent post-contrast enhancement → perforation.
• Phases of lye injury: acute necrotic 1–4 days → ulceration-granulation from 3–5 days (lasts 10–12 days, oesophagus weakest) → cicatrization/scarring from 3rd week.
• Grade-based corrosive mgmt: A oral / first aid only; B TPN or tube + endoscopy after 3 wks ± dilatation → stent → surgery; B-II surgery; C jejunostomy + surgery.
• Perforation mortality: overall ~20%, Boerhaave (spontaneous) ~36%, instrumental ~18%, primary emergency repair ~12% (cervical lowest, thoracic highest; delay >24 h ↑ mortality).
• Perforation surgery by site: cervical → left neck; upper/mid-thoracic → right thoracotomy; lower/distal → left thoracotomy (7th ICS) or transhiatal; <24 h primary anastomosis, >24 h diversion (spit fistula + staple stomach).
• Oesophagus regions from incisor: cervical 15–18 cm, upper thoracic 18–24, midthoracic 24–32, lower thoracic 32–40 cm.
• AJCC TNM (oesophageal ca): Tis = HGD; T1 muscularis mucosa (a) / submucosa (b); T2 muscularis propria; T3 adventitia; T4a resectable / T4b unresectable; N1/N2/N3 = 1–2 / 3–6 / ≥7 nodes; M1 = distant met. (SCC stage groupings add grade + location; Stage IV = any M1.)

Stomach / gastritis / PUD

• Updated Sydney system (2001): classifies gastritis by aetiology, topography, morphology.
• H. pylori eradication (regimen titles): bismuth quadruple = current first line; clarithromycin- & levofloxacin-based dropped (resistance); salvage; high-dose dual therapy (HDDT).
• Test-and-treat H. pylori (ACG 2017): active/past PUD, MALT lymphoma, post-EMR early gastric ca, dyspepsia <55 without alarm features, long-term low-dose aspirin, chronic NSAIDs, unexplained IDA, ITP.
• Bleeding severity in PU: microscopic → mild (granulation tissue) → moderate (small vessel) → severe (gastroduodenal artery — usually fatal).
• Stages of perforated PU: pathology = perforation → chemical peritonitis → septic peritonitis; clinical = shock → lucid interval (obliterated liver dullness) → septic peritonitis.
• Forrest (PU rebleed risk): Ia jet arterial 90%; Ib oozing 50%; IIa visible vessel 25–30%; IIb adherent clot 10–20%; IIc black spot 7–10%; III clean base 3–5%.

Gastric cancer

• Bormann gross (I–IV): I polypoid, II fungating, III ulcerated, IV infiltrating (linitis plastica); III & IV incurable.
• Depth: Early = mucosa/submucosa ± LN (T1; 5-yr ~90%) vs Advanced = into muscularis (has 4 Bormann types).
• TNM (gastric): T1 lamina propria/submucosa; T2 muscularis propria/subserosa; T3 penetrates serosa; T4 adjacent structures; N1 perigastric, N2 left gastric artery, N3 common hepatic/splenic/coeliac; M1 distant.
• LN dissection: D1 perigastric (N1); D2 = D1+N2 (standard curative); D3 = D2+N3.
• Stage vs 5-yr survival: T1N0M0 95+%; T1N1M0 70–80%; T2N1M0 45–50%; T3N2M0 15–25%; M1 0–10% (key prognostic factors = depth of invasion + LN involvement).
• IGCLC CDH1 testing: ≥2 diffuse gastric ca in 1st/2nd-degree relatives with ≥1 before age 50, OR ≥3 relatives at any age.

Neuroendocrine tumours

• MEN-1: pancreatic (insulinoma/gastrinoma/VIPoma) + pituitary adenoma + parathyroid hyperplasia. MEN-2A/2B: medullary thyroid ca (100%) + phaeo (50%); MEN-2B adds marfanoid habitus (80%) + mucosal neuromata (>95%).
• Whipple's triad (insulinoma): hypoglycaemia symptoms + low glucose at symptom time + resolution on glucose.
• Glucagonoma 4D: Diabetes, Dermatitis (necrolytic migratory erythema), DVT, Depression.
• VIPoma WDHA: Watery Diarrhoea (despite fasting), Hypokalaemia, Achlorhydria.
• Somatostatinoma inhibitory pentad: diabetes, cholelithiasis/gallstones, weight loss, steatorrhoea, hypochlorhydria.
• Chromogranin A = general NET marker (positive = a NET somewhere).

UGI bleeding

• Causes by site: oesophageal = Mallory-Weiss, varices, oesophagitis, malignancy, AEF; gastric = PUD, varices, malignancy, gastritis, Dieulafoy; duodenal = PUD, ectopic varices, duodenitis, malignancy.
• Transfusion threshold: Hb 8.5 if ischaemic heart disease; 7.5 if otherwise well. Orthostatic drop = acute loss of ≥20% blood volume; shock signs = HR >100, SBP <90.

Functional / bowel

• Rome IV IBS: recurrent abdominal pain ≥1 day/week for 3 months (onset ≥6 months prior) + ≥2 of: related to defecation, change in stool frequency, change in stool form. (IBS-D = >25% Bristol 6–7 and <25% Bristol 1–2.)
• IBS subtypes (Bristol): IBS-C hard/lumpy ≥25% & loose <25%; IBS-D loose/watery ≥25% & hard <25%; mixed both ≥25%; unsubtyped.
• Constipation criteria: ≥2 of — <3 motions/week, incomplete evacuation, straining >25% of time, manual/digital evacuation. (Colon transit time normally 20–72 h.)
• Bristol stool chart: 1 hard lumps (severe constipation) → 3–4 normal → 7 liquid (severe diarrhoea).
• Chronic diarrhoea types: osmotic (improves fasting, stool osmotic gap >50 mOsm/L); malabsorption (weight loss + good appetite, high faecal fat); secretory (large watery, normal gap); inflammatory (fever, bloody, tenesmus); motility.
• BINDS (investigate acute diarrhoea): Bloody, Immunosuppressed, Nosocomial, Dehydration, Severe >10 days.
• Foodborne mechanisms: preformed enterotoxin (S. aureus, B. cereus — onset 1–6 h, vomiting); enterotoxin made in gut (C. perfringens, ETEC/STEC, cholera — >1 day, watery/bloody); bacterial invasion (Campylobacter, non-typhoidal Salmonella, Listeria).

Nutrition

• Malnutrition criteria: ≥2 of — low energy intake, weight loss, loss of muscle mass, loss of subcut fat, fluid accumulation, reduced hand-grip strength.
• NRS-2002: initial screen positive if BMI <20.5 / recent weight loss / reduced intake / severely ill; total ≥3 = at-risk; if age ≥70 add 1.
• Refeeding syndrome risk: high (≥1) — BMI <16, weight loss >15% in 3–6 mo, little/no intake >10 days, low K/PO₄/Mg; moderate (≥2) — BMI <18.5, weight loss >10% in 3–6 mo, no intake >5 days, alcohol/drug misuse. Onset usually within first 4 days of feeding; hypophosphataemia drives it.

Discriminators that decide questions

1. Gastric ulcer vs duodenal ulcer: GU pain provoked by food, blood group A, ~80% H. pylori, can be malignant → biopsy, recurs 40–60%/2 yr; DU pain relieved by food, blood group O, up to 95% H. pylori, almost always benign → no biopsy, recurs 95% (50% in 6–8 months). GU = 25%, DU = 75% (4× as common).
2. H. pylori vs autoimmune gastritis: H. pylori = antrum, neutrophils, normal/↑ acid, normal/↓ gastrin, anti-Hp Ab; autoimmune = body only (spares antrum), lymphocytes, ↓ acid (achlorhydria), ↑ gastrin, anti-parietal/intrinsic-factor Ab, neuroendocrine hyperplasia → carcinoid risk.
3. Oesophageal SCC vs adenocarcinoma: SCC = commonest worldwide, middle third, risks alcohol+tobacco / Plummer-Vinson / achalasia / caustic / HPV 16,18; adeno = commonest in US/West, lower third, risks Barrett's / GERD / hiatal hernia / Zollinger-Ellison / obesity.
4. Benign vs malignant gastric ulcer (endoscopic): benign = smooth, regular, rounded edge, flat smooth base, radiating folds; malignant = irregular overhanging margins, ulcerated mass into lumen, nodular/irregular folds.
5. Osmotic vs secretory diarrhoea: osmotic improves with fasting, stool osmotic gap >50 mOsm/L; secretory = large watery stool, normal osmotic gap (persists despite fasting).