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Diseases of the upper GI tract,epigastric pain
Dr. Hajnal Székely
Esophagus
• 25 cm long
• tubular
• Propulsion of bolus into the stomach
• Interferes with acid content regurgitation
• Cervical, middle, supracardial part
• 3 physiological narowings
• Epiphrenic ampulle
• 2 sphincters
Symptoms of esophageal diseases
• Epigastric pyrosis, heartburn
• Regurgitation
• Dysphagia, odynophiagia
• Chest pain (non-cardiac)
Examination methods
• Laboratory parameters
• Barium swallow
• Upper GI endoscopy
• Examinations of motility - manometry
• Impedance
Congenital diseases
1/3000-4000 ; Genetical factors + intrauterin enviromental factors
50%-associated with other developmental alterations (spine, airways, kidneys)
Atresia
Tracheooesophageal fistula
Congenital stenosis
Doubled esophagus
Esophageal ring
Esophageal diverticula
• Aquired, occur predominantly in adulthood
• Classified according to: site of occurence:
• Hypopharyngeal – Zenker
• Epiphrenic
• Middle third
Esophageal diverticulaclassified according to mechanism of formation
According to wall thickness: true or false
Th.: esophagomyotomyPouch resection
Hiatal herniaInsufficiency of the LES +
Longitudinal contr. of the esoph.+
Increased intraabdominal pressure
Types: sliding - paraoesophageal-mixed
No sy. – dysphagia – NCCP
Imaging:
rtg/endoscopy
Th.: lifestyle
Surgical –laparosc.
GERD – Montreal classification
GERD – complex motility disorder
• main patogenetical factor: dysphunction of LES + decreased esophagealclearence + prolonged gastric emptying
• Agressive factors:
• Gastric acid + pepsin
• Duodenogastric reflux:
• Conj., deconj. bile acids, tripsin
GERD
GERD
GERD -symptomsHeartburn, acid regurgitation –
25% once / mo., 12% once /w., 5% daily sy.
NCCP –non cardiac chest pain
Dysphagia, odynophagia
Coughing, hoarsenedd, dypsnea
Extraoesophageal sy.:
persistent couhing, pharyngeal dysphagia,
throat pain, rec. pneumonia, asthma bronchiale, caries, otalgia, increased salivation, globus pharyngeus, sleep disturbance
Complications: stenosis, ulcer, bleeding
Barrett’s oesophagus,
adenocarcinoma
GERD
GERD - examinations
GERD – th.
Barrett esophagus
risk factors:long GERD historyage >50ymale gendercaucasioan rassobesitypositive family history
Barrett esophagus
BE - treatment
Esophagectomy:
• 3-10% mortality
• 45% morbidity
• Patients operative risk
• Focality of dyspl.
• Local endosc. +
• Surgical expertise
• EMR
• ESD
• RFA
Eosinophilic esophagitis - EE
• allergen-driven inflammation of the esophagus;
• P:30/100.000
• Young (21-31y)
• male patients (65-70%)
• 40-50% atopic diseases: asthma, food allergy,
• rhinitis all., rhinoconj., dermatitis
• Sy.: children – nausea, abd. pain, eating dist.
• Young – dysphagia, food impaction
• Elderly- + regurgitation, heartburn
Dg.based on histological examination of upper and lower esoph. biopsies (6) after initial treatment with PPPIs for 6–8 weeks.
Th.:Identification of the underlying food / airborne allergen –directs dietary advice.six-food elimination diet - can be tried if specific allergens cannot be identified.
Pharmacologic th: topical corticosteroids and leukotriene antagonistsEsophageal dilation - associated strictures, rings Safe- perforation rate of less than 1% effective - dysphagia improving for up to 1–2 years in over 90%
Motility disorders• Cricopharyngeal disorder
• Diffuse esophageal spasm
• Hypo /
• hypercontractile esophagus
(„nutcracker”)
Sy.: dysphagia, chest pain
Dg.: rtg., manometry
Th.:medication
surgery
• Inability of LES relaxation-
• dysphagia for both solids and liquids.
• difficulty belching, chest pain ,
• passive regurgitation of undigested food,
• aspiration, dyspepsia
• Dg.:rtg., manometry, endoscopy
• (CT, EUS)
Sec.- gastric tu. infiltr the esoph.
lymphoma, irradiation, Chagas’s., -kór, neuropathiás, idült in intestinal pseudoobstruction
Achalasia
AchalasiaISDN - ↓LES pressure-90 min. (66%)
Nifedipine – 30-40%, >60 min.
Botulinum toxin ˧ Ach release, 90%,
60% -1y., repeat
Dilation – 60-95%, 5y: 60%, perf.: 1-13%
Heller myotomy
POEM
Infective diseases of the esophagus
Candidiasis – present in healthy population
Causes oesophagitis:
Immunsuppr, states –
Tx, AIDS, haematological diseases, tumors, DM)
Sy.:asymptomatic, odynophagia-dysphagia, nausea / vomiting, haematemesis
Complications: stenosis, bleeding, perforation
Dg.: endoscopy
Th.: po. imidazol, amphotericin B journals.plos.org
Viral infections
HSV, CMV, VZV, EBV, HIV, HPV
Immunszuppressed patients
Odynophagia, chest pain, nausea, vomiting(haematemesis)
Dg.: endoscopy
Th.: antiviral th.
laccylovir, gancyclovir, foscarnet, fancyclovir
HSV
www.medscape.com
Infective diseases of the esophagus
Bacterial infections - Esophagitis caused by bacteria of physiological flora
Mycobacterium
Other : syphilis, diphteria, Nocardia
Parasitic infections -Chagas disease
Pill esophagitis
Infective diseases of the esophagus
Boerhaave-sy.
Esophageal tear
Chest pain – worsened by swalow, breathing
Subcutan emphysema, mediastinal crepitatio… shock
Chest X-ray, CT, Swallow with gastrographin
Th.:
Conservative - carentia, iv. fluid, AB
Surgery
radiopaedia.org
Mallory-Weiss sy
Consequence of retch, forced vomiting
Tear of the mucosa at the esophagogastric transition
Dg.: Endoscopy
Th.:
Conservative
Endoscopical
Surgicalwww.msdmanuals.com
www.statpearls.com
Functional diseases
Globus pharyngeus
Rumination
Functional heartburn
Functional chest pain
Functional dysphagia
Sy.- variable,
Long lasting
No alarm sy.
ROME criteria
Stomach
Gastritis
Inflammation of the gastric mucosa confirmed by histology
Time interval: acut / chronic
Histological signs: activity – atrophy – non-atrophic -metaplasia-specific forms
Anatomical localisation: antrum-corpus-multiple sites - pangastritis
Etiology: infetion – autoimmune – systemic diseases
Gastritis
Acut
H. pylori
Other bacteria
Viruses
Parasites
Fundal infections
Chronic
Autoimmune atrophic gastritis – type A
H. pylori gastritis - type B
Other types of chr. gastritis
Other infective agents
Granulomatosus gastritis
Lymphocytic gastritis
Collagenous gastritis
Eosinophil gastritis
Gastritis cystica profunda
GVH-gastritis
Allergic gastritis
Gastritis
Acut gastritis: asympt., sy.: epigastric pain, nausea, vomiting, fever
Chr. gastritis: asymp.
Type A (autoimmune gastritis, autoimmune metaplastic atrophic gastritis, diffusecorpus predominant atrophic gastritis):
Elderly women,
Antibodies against parietal cells
+other ai. diseases - anaemia perniciosa, 1DM, Hashimoto-thyreoiditis, hyperplastic + us adenomatosus polyps, endocrine tumors-carcinoma, praecancerosus állapot!
Type B - (H. pylori): non-atrophic
Acut gastritiswww.gastrointestinalatlas.com
medtube.netchr gastritis
erosiv gastritiswww.msdmanuals.com
atrophic gastritis
www.sciencephoto.com
Spiral, G-, in the mucus coating the mucosa / epithelium1983 –Marshall and WarrenMost prevalent GI tract bact.- 50%
Virulence of the Hp.cytotoxin assoc. gene A (CagA)vacuolating cytotoxin A (vacA)
Host geneticsEnviromental factors
Hp
Hp.1. Invasive – biopsy samples
*Histology - gold standard, sens: 90-95%, spec: 95-98%
*Culture - 4-7 d., sens: 90-95% (100%), spec: 80-90%, scientific puroses – AB resistance
*Urease test - Quick, simple, sens/spec: 85-95%, 95-100%, antrum biopsy –culture – bicarb., NH3 – change of colour
2. Non-invasive
*Serology – locally produced antibodies – IgA – sens: 60-80%, Syst. antibodies – sens., spec.: 95%
*PCR - gingiva, stool, gastric juice, biopsy forceps, sens.:100%, scientificpurposes
*UBT – controll of succes of erad., sens: 85-955, spec: 95-98%
*Hp. antigen examination – stool, Elisa, sens.:85-98%, spec:90-96%, multiple samples, -20 C
controll of succesfull erad. – 3-5 d after th.
Hp. eradication2x1 PPI+4x120mg bismuth-subsalicylate +3x500mg metronidazol+4x500mg tetracyclin
2x1 PPI+ clarithromycin (2x500 mg)+ amoxicillin (2x1 gr) / metronidazol (3x500 mg)
2x1PPI+2x250-500 mg levofloxacin2x1g amoxycillin
Sequential:2x1 PPI+2x1g amoxycillin 5 days,than2x1 PPI+2x500 mg clarithromycin+2x500 mg tinidazol 5 days
Gastropathy
Changes of gastric mucosa without inflammation
Reactive, chemical: drugs, NSAID, biliary reflux, alcohol consumption
Haemorrhagic: subepithelialis haemorrh., erosions, stress factors (phisical, termal, shock, sepsis, CNS injury)
Vascular: injury of vessels in the gastric mucosa
Gastric antral vascular ectasy (GAVE)
Portal hypertensive gastropathy
Hypertrophic:
Thickening of mucosal folds., giant folds
Menetrier disease
Zollinger-Ellison-sy.
Peptic ulcer disease
10% lifetime chance of ulcer form.
DU: 90%, GU:80% Hp. pos.
• Eradication-recurr. <5%/y.
Def.: ulcers caused by gastric acid activated pepsin- depth:musc. mucosaePatogenesis:
oGastric acid hypersecretionoNervous system dysphunction: cholinerg hypersen, parasympatic dominancy → gastric acid↑, pepsin↑
ohyperpepsinogenaemia: sign of H. pylori infection
oGenetic factors: O blood group, non-secretory state, HLA-B12 Ag, inherited hyperpepsinogenaemia
oEnviromental factors: (co-factors): osmoking, alcohol, eating habits, NSAID usage, oischaemia, stress (critically ill: severe burns, trauma, MOF)
DU> GU 5xDU: male: female – 3.5:1GU: 1:1GU: more common in elderlySy.: abd. pain, nausea, vomiting
1. H. pylori positive ulcers: 70-90% of DU, 30-60% of GU
PUD
PUD
PUD
PPI, eradication of Hp.Endos. th.Surgery - complications
Gastroparesis
Altered gastric emptying, > 3 mo., no mechanical obstruction
Female / male: 4:1
Causes:
Idiopathic
Diabetes mellitus
Connective tissue diseases: scleroderma, polymyositis/dermatomyositis, amyloidosis, SLE
Postoperative: gastrectomy, vagotomy, gastric resection, Nissen fundoplication
Diseases of the esophagus:GERD, achalasia
Endocrine diseases: hypo-hyperthyreosis, Addison’s
Metabolic causes: chr. Liver – kidney disorders
Neuromuscula diseases: Parkinson’s, head injury, stroke, brain tu.
Malignancies: paraneoplastic sy., leukaemia
Infections: HIV, Chagasdiseases
Anorexia nervosa
Radiation
Gastroparesis
Sy.: early satiety, nausea, vomiting, epigastric pain, dyscomphort, loss of weight
99mTc-scintigraphy
Th.:
Diet: small amounts of meal, diet containing less unsoluble starch
Medication: prokinetics, erythromycin, metoclopramid, antiemetic drugs
Electric stimulation of the stomach -pacemaker
Surgical - feeding jejunostomy, complete or partial gastric resection)
www.cureus.com
Rare organic diseases
Inherited – duplication, stenosis, obstruction
Chr. infections (syphilis, TBC, fungal infections, anthrax)
Besoar
Diverticuli
Eosinophil gastroenteritis
besoarwww.bing.co
m
diverticulagastrolab.net
Functional disordersCommon – prev.: may be as high as 25-50%
Patomechanism: multifactorial, complex – not fully understood
(altered motility, chemical effect, hypersensitivity of afferent sensory nerves, CNS perception alterations)
Functional dyspepsia
Eructation
Funct. vomiting, cyclic vomiting sy.
Rumination sy.
Rome IV criteria
Functional disorders
Physical exam., „rutin” lab data, abdominal US (gastroscopy)
Funct. disorder – probable if:
<45 y
Ongoing sy.without progression
Godd apetite, no loss of weight
Normal blood count (no anaemia)
No psysical signs with exam. (no palpable abd .mass)
Negative family history (no malignancies within the family)
NO ALARM symptoms
Th.: symptomatic
Gastric cancer
Gastric cancer – endoscopy, staging
Treatment options