Differentials
Oesophagitis
SIGNS / SYMPTOMS
Can occur concurrently with MWT. Suspect in a patient with a history of oesophageal reflux, systemic disease (e.g., telangiectasias, psoriasis), and recent intake of medications that can induce oesophagitis: for example, immunosuppression, corticosteroid, antibiotics (tetracycline, doxycycline), ferrous sulfate, and ascorbic acid.
Physical examination may include the skin, looking for evidence of immunosuppression or systemic disease (e.g., telangiectasias, psoriasis), and the oropharynx, looking for ulcers, thrush, and leukoplakia.
Although the patient may be asymptomatic, typical symptoms include odynophagia, dysphagia, retrosternal chest pain, and heartburn, together with 'coffee ground' emesis, anorexia, weight loss, cough, fever, and sepsis.
INVESTIGATIONS
FBC: may show anaemia.
HIV test: may be positive in high-risk patients.
Gastroscopy is the diagnostic test of choice because it allows mucosa visualisation, showing irritation/inflammation, brushing, and biopsy of the lesions.
Spontaneous oesophageal perforation (Boerhaave's syndrome)
SIGNS / SYMPTOMS
Classic presentation is an episode of retching or vomiting followed by severe retrosternal pain and/or epigastric pain.
History of alcohol intake in 40% of patients.
During physical evaluation, it is important to look for subcutaneous emphysema, which may be absent in 10% to 30% of patients.
Other common symptoms and signs include dyspnoea, tachypnoea, cyanosis, sepsis, and shock.
INVESTIGATIONS
Chest x-ray may reveal free mediastinal, peritoneal, or prevertebral air. Pleural effusion, with or without pneumothorax, widened mediastinum, and subcutaneous emphysema may be seen in late presentations.
Pleural fluid amylase measurement is indicative of oesophageal rupture.
Confirmatory tests include water-soluble contrast, which is helpful to localise the lesion.
CT scan may also be used as a confirmatory test; findings include oesophageal wall oedema, peri-oesophageal fluid with or without bubbles, and widened mediastinum.
Cameron erosions
SIGNS / SYMPTOMS
In an acute setting, there is no way to differentiate. However, patients with Cameron erosions may present with symptoms of persistent and recurrent iron deficiency anaemia (weakness, fatigue, dyspnoea). Manifestations of chronic iron-deficiency anaemia include angular cheilitis, glossitis, koilonychia (spoon nails), and pallor.
INVESTIGATIONS
FBC: may show anaemia.
Gastroscopy is the diagnostic test of choice because it allows mucosa visualisation and biopsy of the lesions. Endoscopic diagnosis of Cameron erosions or ulcers is made when linear erosions or ulcers are seen inside the sliding hiatal hernia.
Peptic ulcer disease
SIGNS / SYMPTOMS
Patients may present with upper gastrointestinal bleeding or melaena, without other symptoms. However, most patients describe a history of gnawing, burning, or hunger-like abdominal pain 40 to 60 minutes after eating, or, less often, before eating; patients also report nausea, vomiting, weight loss, and fatigue.
History of medication use such as aspirin and non-steroidal anti-inflammatory drugs.
Helicobacter pylori is involved in about 60% to 70% of patients with gastric ulcer disease.[45]
INVESTIGATIONS
Gastroscopy is the diagnostic test of choice because it allows mucosa visualisation, identification of the ulcer, and biopsy of the lesions.
Serology tests, urea breath test, H pylori stool antigen test (HpSA), and gastric biopsy may help in the diagnosis of H pylori infection.
Erosive gastropathy
SIGNS / SYMPTOMS
Patients may present with upper gastrointestinal bleeding or melaena and a chronic history of gnawing, burning, or hunger-like abdominal pain accompanied by nausea and vomiting.
History of smoking, alcohol intake, and/or medication use, such as aspirin or non-steroidal anti-inflammatory drugs.
INVESTIGATIONS
Gastroscopy is the diagnostic test of choice because it allows mucosa visualisation and biopsy of the lesions. Erosive gastropathy is characterised endoscopically by diffuse hyperaemic mucosa with multiple, small superficial areas of denudated mucosa called erosions.
Serology tests, urea breath test, Helicobacter pylori stool antigen test (HpSA), and gastric biopsy may help in the diagnosis of H pylori infection as a cause of gastritis.
Oesophageal or gastric neoplasms
SIGNS / SYMPTOMS
Patients may present with or without upper gastrointestinal bleeding (haematemesis, 'coffee ground' emesis, with or without melaena, and in rare cases, haematochezia); progressive dysphagia initially for solids and then also for liquids; weight loss; early satiety; unspecific abdominal discomfort; and symptoms of persistent and recurrent iron-deficiency anaemia.
INVESTIGATIONS
FBC: may show anaemia.
Liver function test: may detect liver metastasis.
Amylase: usually normal.
Lipase: usually normal, elevated in acute pancreatitis; however, lipase is not completely specific for pancreatitis. Lingual, gastric, intestinal, and hepatic isolipases have been isolated.
Radiological evaluation may include oesophagogram, upper gastrointestinal series, or CT scan, each demonstrating an oesophageal or gastric mass.
Gastroscopy is the diagnostic test of choice because it allows mucosa visualisation of the mass, brushing, and biopsy of the lesions.
Oesophageal varices
SIGNS / SYMPTOMS
Suspect in a patient with a history of heavy chronic alcohol misuse and/or a history of chronic liver disease who presents with upper gastrointestinal bleeding. Physical examination shows signs of liver failure or decompensated cirrhosis (i.e., jaundice, increasing ascites, hepatic encephalopathy), or chronic liver disease (i.e., splenomegaly, spider angioma, ascites).
INVESTIGATIONS
FBC: microcytic anaemia and/or thrombocytopoenia.
Liver function test: may be elevated in co-existing liver disease.
PT/INR: may be elevated in cirrhosis of the liver or liver failure.
Gastroscopy is the gold standard technique for the diagnosis and treatment of varices.[33][46][47][48][49][50][51][52]
Arteriovenous malformations
SIGNS / SYMPTOMS
Usually presents with massive bleeding. Suspect in a patient with a history of abdominal aneurysm or in those with a paraprosthetic-enteric fistula, who may have a history of a previous episode of mild 'coffee ground' haematemesis or melaena usually self-limited weeks or months earlier (called the initial herald or sentinel bleeding).
INVESTIGATIONS
FBC: may show anaemia.
Liver function test: may be deranged in patients with hereditary haemorrhagic telangiectasia of the liver.
PT/INR: abnormal value may indicate a less favourable course of the disease.
Consider gastroscopy to rule out other causes of upper gastrointestinal bleeding when the diagnosis of aortoenteric fistula is not clear. However, CT scan with contrast is probably the test of choice when aortoenteric fistula is highly suspected.
Exploratory laparotomy may allow definitive aortoenteric fistula repair.
Duodenitis
SIGNS / SYMPTOMS
Most patients report chronic, unspecific abdominal pain, which is described as a dull ache, throbbing, burning, or cramping pain that usually comes and goes. Symptoms can be partially relieved with antacids. Eating may help or may increase symptoms. Weight loss due to lack of appetite, nausea, and vomiting are common findings.
INVESTIGATIONS
Gastroscopy is the diagnostic test of choice because it allows mucosa visualisation, showing inflammation, and biopsy of the lesions.
Serology tests, urea breath test, Helicobacter pylori stool antigen test (HpSA), and gastric biopsy may help in the diagnosis of H pylori infection.
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