Gastroenterology: Oesophagus and Stomach

• Oesophagus: Approach to Dysphagia | GORD and Hiatus Hernia | Barrett's Oesophagus | Eosinophilic Oesophagitis | Achalasia and Motility Disorders | Oesophageal Cancer | Other Oesophageal Problems
• Stomach and duodenum: Dyspepsia | Helicobacter pylori | Peptic Ulcer Disease | NSAIDs, PPIs and Gastroprotection | Gastric Cancer | Other Gastric Conditions
• Nausea and motility: Gastroparesis and Functional Dyspepsia | Chronic Nausea and Vomiting | After Gastric and Bariatric Surgery
• Revision: Drug Reference Table | Spot the Diagnosis | Exam-style Scenarios | Key Points | Guidelines and Further Reading

🍽️ The oesophagus and stomach cause some of the commonest symptoms in medicine - heartburn, indigestion and difficulty swallowing. Most causes are benign, but oesophageal and gastric cancers often present late, so the skill is knowing which patients need an urgent camera test.
Your four questions for every patient: Are there red flags (dysphagia, weight loss, anaemia, vomiting, age 55 or over)? Is H. pylori or an NSAID involved? Is this structural, motility-related or functional? Does the patient need endoscopy now, or a trial of treatment first?

Approach to Dysphagia

What it is: Difficulty swallowing. New dysphagia at any age needs urgent endoscopy (NICE NG12) to exclude cancer.

Two main types:

• Oropharyngeal dysphagia - trouble starting a swallow:
  • Coughing, choking, nasal regurgitation, food sticking in the throat.
  • Causes: stroke, Parkinson's, motor neurone disease, myasthenia, dementia, pharyngeal pouch, head and neck cancer.
  • Assess with a speech and language therapist and videofluoroscopy.
• Oesophageal dysphagia - food sticks in the chest after swallowing:
  • Solids only, getting worse - a mechanical blockage: cancer, peptic stricture, rings, eosinophilic oesophagitis.
  • Solids and liquids from the start - a motility problem: achalasia, oesophageal spasm, systemic sclerosis.
  • Intermittent food sticking in a young man with atopy - eosinophilic oesophagitis.

Tests:

• Gastroscopy (OGD) first - it allows biopsy and dilatation.
• Barium swallow - useful for pouches, rings and motility.
• High-resolution manometry - for suspected motility disorders when OGD is normal.
• CT for cancer staging.

⚠️ Safety Pearl: Progressive dysphagia with weight loss is oesophageal cancer until proven otherwise. Never put it down to "reflux" without an endoscopy.

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GORD and Hiatus Hernia

What it is: Gastro-oesophageal reflux disease - stomach acid flows back into the oesophagus and causes symptoms or damage. It is very common (about 1 in 5 adults have regular symptoms).

Risk factors:

• Obesity.
• Hiatus hernia.
• Pregnancy.
• Smoking and alcohol.
• Large or late meals.
• Drugs that relax the lower oesophageal sphincter - calcium channel blockers, nitrates, anticholinergics, theophylline.
• Systemic sclerosis.

Symptoms:

• Heartburn (burning behind the breastbone, worse after meals or lying down) and acid regurgitation.
• Outside the oesophagus: Chronic cough, hoarseness, worse asthma, dental erosion.

Management (NICE CG184):

• Lifestyle: Lose weight, stop smoking, cut down alcohol, avoid late meals, raise the head of the bed.
• Full-dose PPI for 4–8 weeks (e.g. omeprazole 20 mg once daily, lansoprazole 30 mg once daily) - take 30–60 minutes before breakfast.
• Severe oesophagitis (LA grade C or D): Full-dose PPI for 8 weeks, then long-term full-dose maintenance.
• Long term: Use the lowest dose that controls symptoms, or "on demand".
• If PPIs fail: Check that they are being taken properly; double the dose or switch PPI; add an H2 blocker at night (famotidine); arrange endoscopy and 24-hour pH-impedance monitoring to confirm reflux before surgery.
• Anti-reflux surgery (laparoscopic fundoplication): For confirmed reflux in people who don't want long-term PPIs or still regurgitate. Side effects include bloating and difficulty swallowing.
• Do not give H. pylori eradication for GORD alone.

Hiatus hernia:

• Sliding (about 80%) - the junction slides up into the chest; causes reflux.
• Rolling (para-oesophageal) - part of the stomach rolls up beside the oesophagus. It can twist (gastric volvulus) and strangulate, so large symptomatic ones are often repaired.

Complications of GORD: Oesophagitis, peptic stricture, Barrett's oesophagus, adenocarcinoma.

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Barrett's Oesophagus

What it is: Long-term reflux makes the normal squamous lining of the lower oesophagus change into columnar (glandular) lining, usually with intestinal metaplasia. It is the main precursor of oesophageal adenocarcinoma, although most people with Barrett's never get cancer (risk about 0.3% per year without dysplasia).

Risk factors:

• Long-standing GORD.
• White men over 50.
• Central obesity.
• Smoking.
• Family history.

Diagnosis: Endoscopy with biopsies, measured using the Prague C&M criteria (C = circumferential length, M = maximum length).

Surveillance (BSG - check the latest update):

• Under 3 cm with intestinal metaplasia: Endoscopy every 3–5 years.
• 3 cm or more: Every 2–3 years.
• Under 3 cm without intestinal metaplasia: Repeat biopsies once; if there is still no metaplasia, consider stopping surveillance.
• Surveillance is only worthwhile if the patient is fit enough for treatment.

Dysplasia:

• Indefinite: Optimise the PPI and repeat endoscopy in 6 months.
• Low-grade dysplasia (confirmed by 2 pathologists): Repeat endoscopy at 6 months; endoscopic ablation (radiofrequency ablation) is often offered.
• High-grade dysplasia or early (intramucosal) cancer: Endoscopic resection of visible lesions, then ablation of the remaining Barrett's. This has largely replaced oesophagectomy.

Treatment:

• A PPI for reflux symptoms (long-term).
• Aspirin for chemoprevention is not routine (AspECT trial showed a modest benefit with high-dose PPI and aspirin).
• Capsule sponge (a swallowed sponge on a string) is being rolled out in parts of the UK to find Barrett's without endoscopy.

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Eosinophilic Oesophagitis

What it is: An allergic, immune-driven inflammation of the oesophagus, with eosinophils in the lining. It is now a common cause of dysphagia and food bolus impaction in young adults.

Who gets it:

• Young men.
• People with atopy (asthma, eczema, hay fever, food allergy).

Symptoms:

• Intermittent solid-food dysphagia; food getting stuck (often a presentation to ED).
• Heartburn that doesn't respond to PPIs.
• Children: feeding difficulty, vomiting, abdominal pain.

Diagnosis:

• Endoscopy can look normal, or show rings ("trachealisation"), linear furrows, white plaques or a narrow oesophagus.
• Biopsies - at least 6 from different levels; 15 or more eosinophils per high-power field.
• Always take biopsies in someone with a food bolus or unexplained dysphagia, even if the oesophagus looks normal.

Treatment (the "3 Ds" - drugs, diet, dilatation):

• High-dose PPI for 8 weeks (e.g. omeprazole 20–40 mg twice daily) - works in about half.
• Orodispersible budesonide (Jorveza 1 mg twice daily, NICE TA708) - a topical steroid that dissolves on the tongue. Avoid eating or drinking for 30 minutes afterwards. Oral thrush is a side effect.
• Elimination diets (with a dietitian) - e.g. removing milk, or milk and wheat, then reintroducing foods.
• Endoscopic dilatation for strictures.
• Dupilumab is licensed, but NICE's appraisal was terminated, so it is not routinely funded.
• Re-biopsy after treatment to check that eosinophils have gone. EoE is chronic - most people need maintenance treatment.

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Achalasia and Motility Disorders

Achalasia:

• What it is: Loss of the nerve cells in the oesophageal wall. The lower oesophageal sphincter fails to relax, and the oesophagus stops squeezing food down.
• Who: Any age, usually 30–60. Chagas disease causes a similar picture (South America).
• Symptoms:
  • Dysphagia for solids and liquids from the start.
  • Regurgitation of undigested food, especially at night (risk of aspiration pneumonia).
  • Chest pain; slow weight loss.
• Tests:
  • OGD first - to exclude cancer at the junction ("pseudoachalasia", especially in older people with rapid weight loss).
  • Barium swallow - dilated oesophagus with a tapered "bird's beak".
  • High-resolution manometry - the gold standard; it classifies achalasia into types I–III (type II responds best to treatment).
• Treatment:
  • Pneumatic balloon dilatation (risk of perforation).
  • Laparoscopic Heller myotomy with partial fundoplication.
  • POEM (peroral endoscopic myotomy) - the muscle is cut from inside; reflux is common afterwards.
  • Botulinum toxin injection - for frail patients (wears off after months).
  • Nifedipine or nitrates - little benefit.
• Achalasia carries a small increased risk of squamous cell carcinoma.

Other motility disorders:

• Distal oesophageal spasm and hypercontractile ("jackhammer") oesophagus - chest pain that mimics angina, and intermittent dysphagia.
• Systemic sclerosis - weak oesophageal muscle and an open sphincter: severe reflux and strictures.
• Always exclude cardiac causes of chest pain first.

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Oesophageal Cancer

Two main types:

Symptoms:

• Progressive dysphagia (solids, then liquids).
• Weight loss.
• Odynophagia (painful swallowing).
• Regurgitation; iron deficiency anaemia.
• Hoarseness (recurrent laryngeal nerve).
• Cough on swallowing - a tracheo-oesophageal fistula.

Urgent referral (NICE NG12) - direct-access OGD within 2 weeks for:

• Dysphagia at any age.
• Age 55 or over with weight loss plus upper abdominal pain, reflux or dyspepsia.

Staging:

• CT chest, abdomen and pelvis.
• PET-CT (distant spread).
• Endoscopic ultrasound (depth and lymph nodes).
• Staging laparoscopy for junctional tumours.

Treatment (decided by the upper GI MDT):

• Very early cancer: Endoscopic resection.
• Operable adenocarcinoma: Peri-operative chemotherapy (FLOT) or pre-operative chemoradiotherapy (CROSS), then oesophagectomy. Adjuvant nivolumab if residual disease remains after chemoradiotherapy and surgery.
• SCC: Chemoradiotherapy then surgery, or definitive chemoradiotherapy without surgery.
• Advanced disease: Chemotherapy with immunotherapy (selected); HER2-targeted treatment for HER2-positive adenocarcinoma.
• Palliation of dysphagia: Self-expanding metal stent, radiotherapy, dietitian support.

Outlook: Poor overall - under 1 in 5 survive 5 years, because most present late.

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Other Oesophageal Problems

• Pharyngeal pouch (Zenker's diverticulum):
  • An outpouching at the back of the throat, usually in older men.
  • Regurgitation of old food, gurgling in the neck, halitosis, aspiration.
  • Diagnose with barium swallow (be careful at OGD - risk of perforation).
  • Treat with endoscopic stapling or surgery.
• Plummer–Vinson syndrome: Upper oesophageal web, iron deficiency anaemia and glossitis, usually in middle-aged women. Risk of SCC. Treat the iron deficiency; dilate the web.
• Schatzki ring: A thin ring at the junction - intermittent solid-food dysphagia ("steakhouse syndrome"). Treated with dilatation.
• Infective oesophagitis - painful swallowing:
  • Candida (inhaled steroids, diabetes, HIV, chemotherapy) - fluconazole.
  • Herpes simplex and CMV (immunosuppressed).
• Pill oesophagitis: Tablets stuck in the oesophagus cause ulcers - doxycycline, bisphosphonates, potassium, NSAIDs, iron. Take them upright with a full glass of water.
• Mallory–Weiss tear - a tear at the junction after repeated retching; see the Gastroenterology Emergencies chapter.
• Globus: A feeling of a lump in the throat between meals, with no true dysphagia - usually benign. Examine and consider ENT referral if persistent.

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Dyspepsia

What it is: Upper abdominal pain or discomfort, often with bloating, early fullness, belching, nausea or heartburn. Most people with dyspepsia have functional dyspepsia (no cause found), GORD or peptic ulcer disease. Cancer is rare.

First, look for red flags - refer for endoscopy (NICE NG12):

• Urgent (within 2 weeks):
  • Dysphagia.
  • Age 55 or over with weight loss and upper abdominal pain, reflux or dyspepsia.
  • An upper abdominal mass (refer urgently).
• Non-urgent:
  • Haematemesis (assess urgently if acute bleeding).
  • Age 55 or over with treatment-resistant dyspepsia.
  • Age 55 or over with upper abdominal pain and low haemoglobin.
  • Age 55 or over with raised platelets plus nausea, vomiting, weight loss, reflux, dyspepsia or upper abdominal pain.
  • Age 55 or over with nausea or vomiting plus weight loss, reflux, dyspepsia or upper abdominal pain.

No red flags - treat in primary care (NICE CG184):

• Review medicines (NSAIDs, aspirin, bisphosphonates, steroids, calcium channel blockers).
• Lifestyle advice; antacids for occasional symptoms.
• Either full-dose PPI for 4 weeks, or "test and treat" for H. pylori - then try the other if symptoms continue.
• If symptoms return, use the lowest PPI dose that controls them.

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Helicobacter pylori

What it is: A spiral bacterium that lives in the stomach lining. It is usually caught in childhood and is commoner in older people and people from areas of higher prevalence.

What it causes:

• Chronic gastritis.
• Duodenal ulcers (most) and gastric ulcers (many).
• Gastric cancer (adenocarcinoma).
• Gastric MALT lymphoma - often cured by eradication alone.
• Also linked to iron deficiency anaemia and ITP.

Testing:

• Urea breath test or stool antigen test (not antibody blood tests, which stay positive after cure).
• Stop PPIs for 2 weeks and antibiotics for 4 weeks before testing - they cause false negatives.
• At endoscopy: rapid urease (CLO) test or biopsy.

Eradication (NICE / UKHSA - 7 days, all twice daily):

• First line: PPI + amoxicillin 1 g + clarithromycin 500 mg or metronidazole 400 mg.
• Penicillin allergy: PPI + clarithromycin 250 mg + metronidazole 400 mg.
• Penicillin allergy and previous clarithromycin: PPI + bismuth + metronidazole 400 mg + tetracycline 500 mg (bismuth quadruple therapy).
• Second line: PPI + amoxicillin 1 g + whichever of clarithromycin or metronidazole was not used first. If both have been used - PPI + amoxicillin + tetracycline (or levofloxacin).
• Clarithromycin resistance is rising - avoid it if the patient has had it recently for any infection.
• If two courses fail, refer to gastroenterology (culture and sensitivity testing at endoscopy).

Re-testing after treatment:

• Not routine for uncomplicated dyspepsia.
• Do re-test (breath test, at least 4 weeks after antibiotics) after a peptic ulcer, MALT lymphoma, gastric cancer surgery, or if symptoms persist.

💡 Clinical Pearl: Adherence is the main reason eradication fails. Warn patients about a metallic taste (metronidazole), diarrhoea, and no alcohol with metronidazole.

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Peptic Ulcer Disease

What it is: A break in the lining of the stomach (gastric ulcer) or duodenum (duodenal ulcer - commoner).

Causes:

• H. pylori.
• NSAIDs and aspirin.
• Higher risk when combined with SSRIs, steroids or anticoagulants.
• Smoking.
• Severe illness (stress ulcers in ICU).
• Rare: Zollinger–Ellison syndrome (gastrin-secreting tumour - multiple or unusual ulcers with diarrhoea; part of MEN1), Crohn's disease, malignancy.

Symptoms:

• Upper abdominal (epigastric) pain, which may wake the patient at night.
• Classically, duodenal ulcer pain is eased by eating and gastric ulcer pain is worse with eating - but this is unreliable.
• Many ulcers (especially NSAID ulcers in older people) are painless until they bleed or perforate.

Diagnosis: OGD. Biopsy gastric ulcers (they can be cancers); test for H. pylori.

Treatment:

• Stop NSAIDs if possible.
• Full-dose PPI for 4–8 weeks (8 weeks for gastric ulcers).
• Eradicate H. pylori if positive, and confirm cure.
• Gastric ulcer: Repeat endoscopy at 6–8 weeks to confirm healing and exclude cancer.
• If NSAIDs or aspirin must continue: long-term PPI.

Complications:

• Bleeding and perforation - see the Gastroenterology Emergencies chapter.
• Gastric outlet obstruction - vomiting of undigested food, a succussion splash, hypochloraemic hypokalaemic metabolic alkalosis.

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NSAIDs, PPIs and Gastroprotection

Who needs a PPI with an NSAID or aspirin?

• Age 65 or over.
• Previous peptic ulcer or GI bleed.
• Also taking anticoagulants, antiplatelets, SSRIs or steroids.
• Serious other illness (heart, kidney or liver disease).
• High-dose or long-term NSAID use.

Reducing NSAID risk:

• Use the lowest dose for the shortest time.
• Ibuprofen and naproxen have lower GI risk than others.
• Avoid NSAIDs altogether in heart failure and CKD.

PPIs - benefits and harms:

• PPIs are very effective but are overused. Review the indication regularly and step down where possible.
• Possible long-term harms:
  • Low magnesium (and resulting low calcium and potassium).
  • Low sodium.
  • C. difficile infection.
  • Fractures.
  • B12 deficiency.
  • Pneumonia.
  • Microscopic colitis (especially lansoprazole).
  • Rarely, interstitial nephritis and cutaneous lupus.
• Rebound acid after stopping - taper the dose and warn the patient.
• Clopidogrel: Omeprazole and esomeprazole reduce its activation - use lansoprazole or pantoprazole instead.

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Gastric Cancer

What it is: Almost all are adenocarcinomas. It is commoner in men, older people, and people from East Asia. Rates are falling in the UK as H. pylori becomes less common.

Risk factors:

• H. pylori.
• Atrophic gastritis and intestinal metaplasia.
• Pernicious anaemia.
• Smoking.
• Salty and smoked foods.
• Previous partial gastrectomy.
• Family history - hereditary diffuse gastric cancer (CDH1 gene; prophylactic gastrectomy is offered).
• Lynch syndrome.

Symptoms (often vague and late):

• Dyspepsia; weight loss; early fullness; vomiting.
• Iron deficiency anaemia.
• Upper abdominal mass.
• Signs of spread:
  • Virchow's node (left supraclavicular, Troisier's sign).
  • Sister Mary Joseph nodule (umbilicus).
  • Krukenberg tumour (ovary).
  • Ascites; liver metastases.
• Linitis plastica - diffuse infiltration giving a rigid "leather bottle" stomach.

Diagnosis and staging:

• OGD with biopsies.
• CT; staging laparoscopy (peritoneal spread); PET-CT in selected cases.
• HER2 and PD-L1 testing.

Treatment:

• Early cancer: Endoscopic resection (ESD).
• Operable: Peri-operative FLOT chemotherapy and gastrectomy (partial or total) with lymph node removal.
• Advanced: Chemotherapy, with nivolumab (selected); trastuzumab for HER2-positive tumours.
• Palliation: Stents for outlet obstruction; radiotherapy for bleeding.
• After total gastrectomy: Lifelong B12 injections.

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Other Gastric Conditions

• Autoimmune (atrophic) gastritis and pernicious anaemia:
  • Antibodies destroy the acid-producing parietal cells.
  • B12 deficiency (no intrinsic factor) and often iron deficiency.
  • Antibodies: anti-intrinsic factor (specific) and anti-parietal cell (sensitive). Gastrin is high.
  • Associated with other autoimmune disease (thyroid, type 1 diabetes, vitiligo).
  • Increased risk of gastric cancer and type 1 gastric NETs - consider endoscopic surveillance.
  • Lifelong B12 (hydroxocobalamin 1 mg IM every 3 months, after loading).
• Gastric MALT lymphoma: Linked to H. pylori. Low-grade disease often goes into remission after eradication alone.
• GIST (gastrointestinal stromal tumour):
  • A tumour under the lining, most often in the stomach.
  • May bleed or be found by chance.
  • KIT (CD117) positive.
  • Treated with surgery; imatinib for high-risk or advanced tumours.
• Gastric polyps:
  • Fundic gland polyps - common with long-term PPIs, benign (many in FAP).
  • Hyperplastic polyps - linked to H. pylori.
  • Adenomas - remove (risk of cancer).
• Zollinger–Ellison syndrome:
  • A gastrinoma (pancreas or duodenum) causes huge acid output.
  • Severe, multiple or recurrent ulcers, with diarrhoea.
  • Fasting gastrin is very high - stop the PPI first if safe to do so (specialist advice).
  • Screen for MEN1.
  • High-dose PPI; surgery if localised.
• Ménétrier's disease: Rare - giant gastric folds with protein loss (low albumin, oedema).

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Gastroparesis and Functional Dyspepsia

Gastroparesis:

• What it is: Slow emptying of the stomach with no blockage.
• Causes:
  • Diabetes (autonomic neuropathy).
  • After surgery (vagal nerve damage).
  • Drugs - opioids, GLP-1 receptor agonists, anticholinergics.
  • Parkinson's disease; systemic sclerosis; amyloidosis.
  • Hypothyroidism.
  • Idiopathic (often after a viral infection).
• Symptoms:
  • Nausea; vomiting of food eaten hours earlier.
  • Early fullness; bloating.
  • Erratic glucose control in diabetes.
• Tests: OGD to exclude a blockage, then gastric emptying scintigraphy.
• Treatment:
  • Small, frequent, low-fat, low-fibre meals; liquids empty better than solids.
  • Improve glucose control; stop drugs that slow emptying.
  • Metoclopramide - MHRA advises up to 10 mg three times daily for a maximum of 5 days (risk of tardive dyskinesia), although specialists sometimes use it longer.
  • Domperidone - 10 mg up to three times daily, for the shortest time (QT prolongation; avoid in cardiac disease).
  • Erythromycin - short-term use (it stimulates emptying, but tolerance develops).
  • Specialist options: gastric electrical stimulation, G-POEM, feeding tube into the jejunum.

Functional dyspepsia:

• Persistent dyspeptic symptoms with a normal endoscopy - a disorder of gut–brain interaction, like IBS.
• Two patterns: Pain-predominant, or fullness after meals.
• Treatment:
  • Explanation and reassurance.
  • Test and treat H. pylori.
  • PPI trial.
  • Low-dose tricyclic antidepressant (e.g. amitriptyline 10 mg at night).
  • Psychological therapies.

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Chronic Nausea and Vomiting

Always look for a cause outside the gut too:

• Pregnancy - always check.
• Drugs - opioids, digoxin, chemotherapy, antibiotics, GLP-1 receptor agonists.
• Metabolic - hypercalcaemia, uraemia, Addison's disease, DKA, hyponatraemia.
• Raised intracranial pressure - morning vomiting with headache.
• Vestibular disorders.
• Eating disorders.

Specific syndromes:

• Cannabinoid hyperemesis syndrome:
  • Bouts of severe vomiting in heavy, long-term cannabis users.
  • Relieved by hot showers or baths.
  • The only cure is stopping cannabis.
  • Acute treatment: IV fluids, haloperidol, topical capsaicin cream on the abdomen. Standard antiemetics often fail.
• Cyclical vomiting syndrome: Stereotyped episodes of vomiting with normal health in between. Linked to migraine. Prevention with amitriptyline; acute treatment with antiemetics and sedation.
• Hyperemesis gravidarum - see obstetric guidance (thiamine, fluids, antiemetics such as cyclizine and ondansetron).

Check for complications of persistent vomiting:

• Low potassium.
• Metabolic alkalosis.
• Acute kidney injury.
• Thiamine deficiency (Wernicke's encephalopathy).
• Mallory–Weiss tear.

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After Gastric and Bariatric Surgery

• Dumping syndrome:
  • Early (within 30 minutes of eating): Food rushes into the small bowel and pulls in fluid - cramps, diarrhoea, palpitations, flushing, faintness.
  • Late (1–3 hours after eating): A surge of insulin causes hypoglycaemia - sweating, shaking, confusion.
  • Treatment: Small frequent meals, fewer simple sugars, fluids between (not with) meals. Specialist options include acarbose or octreotide.
• Nutritional deficiencies - lifelong supplements and blood monitoring:
  • B12 (needs injections after gastrectomy or bypass).
  • Iron.
  • Calcium and vitamin D - bone disease.
  • Folate; thiamine (especially with vomiting).
  • Copper and zinc.
• Other problems after bariatric surgery (see the Lipids and Obesity chapter):
  • Marginal ulcers at the join (smoking, NSAIDs).
  • Internal hernia after gastric bypass - intermittent colicky pain; can cause bowel ischaemia. Have a low threshold for CT and surgical review.
  • Gallstones; kidney stones (oxalate).
  • Altered absorption of drugs (avoid modified-release tablets).
  • Alcohol is absorbed faster - higher risk of alcohol problems.
• Bile reflux and afferent loop syndrome after older-style operations.

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Drug Reference Table

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Spot the Diagnosis

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Exam-style Scenarios

1. A 62-year-old man has 6 weeks of food sticking behind his sternum and has lost 5 kg.
Answer: Suspected oesophageal cancer - urgent direct-access OGD within 2 weeks.

• If cancer is confirmed: staging CT, PET-CT and EUS; upper GI MDT.
• Dietitian review; consider a stent for palliation if unresectable.

2. A 35-year-old woman has dyspepsia with no red flags. A 4-week PPI trial hasn't helped.
Answer: Test and treat for H. pylori.

• Stop the PPI for 2 weeks, then urea breath test or stool antigen test.
• If positive: PPI + amoxicillin 1 g + clarithromycin 500 mg (or metronidazole 400 mg) twice daily for 7 days.
• If negative and still symptomatic: functional dyspepsia - consider low-dose amitriptyline.

3. A 24-year-old man with asthma presents with a meat bolus. After clearance, the oesophagus has rings and furrows.
Answer: Eosinophilic oesophagitis (biopsies show 15 or more eosinophils per high-power field).

• High-dose PPI for 8 weeks, or orodispersible budesonide 1 mg twice daily.
• Consider dietary elimination with a dietitian; dilatation for strictures.
• Re-biopsy to confirm remission.

4. A 70-year-old on naproxen and sertraline has a gastric ulcer on OGD.
Answer: NSAID-related gastric ulcer, with higher risk from the SSRI.

• Stop naproxen; biopsy the ulcer; test for H. pylori.
• Full-dose PPI for 8 weeks.
• Repeat OGD at 6–8 weeks to confirm healing and exclude cancer.

5. A 55-year-old man with long-standing reflux has 4 cm of Barrett's oesophagus with no dysplasia.
Answer: Long-segment Barrett's.

• Long-term PPI for symptoms.
• Surveillance endoscopy every 2–3 years if he is fit for treatment.
• Advise weight loss and stopping smoking.

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Key Points

• New dysphagia at any age needs urgent OGD.
• Age 55 or over with weight loss and dyspepsia, reflux or upper abdominal pain needs urgent OGD.
• Solids only and getting worse: mechanical (cancer, stricture). Solids and liquids from the start: motility (achalasia).
• Dyspepsia without red flags: 4-week full-dose PPI, or test and treat for H. pylori.
• Stop PPIs for 2 weeks before H. pylori testing; use breath or stool tests, not serology.
• H. pylori first line: PPI + amoxicillin + clarithromycin or metronidazole, twice daily for 7 days.
• Gastric ulcers need biopsy and repeat endoscopy at 6–8 weeks.
• Give PPI protection to high-risk NSAID or aspirin users; use lansoprazole or pantoprazole with clopidogrel.
• Long-term PPIs: watch for low magnesium, C. difficile, fractures and B12 deficiency - review regularly.
• Barrett's is the precursor of adenocarcinoma; dysplasia is treated endoscopically.
• Eosinophilic oesophagitis: young atopic men with food bolus - biopsy even if the oesophagus looks normal.
• Metoclopramide has a 5-day MHRA limit; domperidone prolongs the QT interval.
• After gastrectomy or bypass: lifelong B12, iron, calcium and vitamin D.