Upper Gastrointestinal Diseases

1
Upper Gastrointestinal Diseases
2
Upper GI Diseases

• Esophagus
• Stomach
• Duodenum

3
Esophageal Diseases
4
Esophageal Diseases

• Esophageal Symptoms
• Esophageal Motility Disorders
• Gastroesophageal Reflux

5
Esophageal Swallowing Disorders

• Esophageal Symptoms
• Dysphagia difficulty swallowing
• oropharyngeal dysphagia difficulty initiating
  swallow or transferring food from mouth into
  esophagus. Can also experience nasopharyngeal
  regurgitation (comes out nose) or pulmonary
  aspiration.
• esophageal dysphagia food gets stuck in
  esophagus after swallowing

6
Esophageal Motility Disorders

• Achalasia (failure to relax)
• Diffuse Esophageal Spasm (DES)

7
Achalasia

• Most often results from post-ganglionic
  denervation of smooth muscle of esophagus absence
  of inhibitory neural input to LES ?? LES pressure
• Functional esophageal obstruction ? can lead to
  esophageal dilatation
• Similar disorder in Chagas disease (Trypanosoma
  cruzi causes injury to myenteric plexuses of
  esophagus)

8
Diffuse Esophageal Spasm (DES)

• periodic chest pain dysphagia high amplitude,
  simultaneous, repetitive SM contractions
• can be spontaneous or initiated by swallow
• barium swallow ? corkscrew appearance to
  esophagus
• pathogenesis unknown

9
Gastroesophageal Reflux (GER)

• A little bit of GER is normal in all of us
• Normally, thoraxic cavity has negative pressure
  during inspiration
• GER would occur continuously without antireflux
  mechanisms
• a portion of esophagus is below the diaphragm ?
  intra-abdominal pressure (5 mm Hg) can reinforce
  LES pressure (antireflux effect)
• Loss of subdiaphragmatic LES ? correlation
  between esophageal hernia and GERD

10
Gastroesophageal Reflux (GER)Mechanisms

• Incompetent anti-reflux mechanisms
• Ineffective esophageal clearance
• Decreased gastric emptying

11
Gastroesophageal Reflux (GER)Risk factors

• Obesity
• Pregnancy
• Smoking
• High-fat foods

• Theophylline
• Caffeine
• Coffee
• Chocolate
• High levels of estrogen/progesterone

12
Gastroesophageal Reflux (GER)

• Pyrosis
• Dyspepsia
• Regurgitation
• Dysphagia

13
Gastroesophageal Reflux (GER)

• Diagnosis of GER
• Best test pH probe
• checks for existence of acid reflux and
  association between esophageal acid and chest
  pain
• Other tests
• Barium swallow
• Esophagoscopy
• Esophagial biopsy

14
Gastroesophageal Reflux (GER)

• Complications of GERD
• Erosive esophagitis
• Esophageal ulcer
• Bleeding
• Esophageal stricture
• Intestinal metaplasia (Barretts)
• Adencarcinoma from Barretts
• Lung diseases

15
Gastritis and Ulcer Disease
16
Peptic Ulcer Disease Range of injury

• Ulcer
• A lesion on an epithelial surface (skin or
  mucous membrane) caused by superficial loss of
  tissue.
• Erosion
• A lesion on an epithelial surface (skin or
  mucous membrane) caused by superficial loss of
  tissue which is limited to the mucosa.

17
Peptic Ulcer Disease Location

• Stomach
• typically in antrum (distal stomach normally
  lined by columnar epithelium that does not
  secrete acid - more susceptible to peptic
  ulceration)
• parietal cells located in body/fundus (proximal
  stomach - ulcers not found as often here)

18
Peptic Ulcer Disease Location

• Duodenum
• within duodenal bulb
• can cause outlet obstruction
• usually single
• multiple/large/more distal ulcers
  (Zollinger-Ellison sdr.)

19
Gastric Mucosa Secretions

• The defensive forces
• Bicarbonate
• Mucus layer
• Mucosal blood flow
• Prostaglandins
• Growth factors
• The aggressive forces
• Helicobacter pylori
• HCl acid
• Pepsins
• NSAIDs
• Bile acids
• Ischemia and hypoxia
• Smoking and alcohol
• When the aggressive factors increase or the
  defensive factors decrease, mucosal damage will
  result, leading to erosions and ulcerations.

20
Gastritis
21
Causes of Acute Gastritis

• Alcohol
• NSAIDs
• Helicobacter
• Stress/ICU associated

22
Mechanisms of Acute Gastritis

• Drugs (non-steroidal anti-inflammatory drugs
  NSAID), alcohol cause acute erosion (loss of
  mucosa superficial to muscularis mucosae).Can
  result in severe haemorrhage
• Acute Helicobacter infection has a prominent
  neutrophil infiltrate

23
Chronic Gastritis

• A autoimmune
• B bacterial (helicobacter)
• C - chemical

24
Chronic Gastritis

• Type A - Autoimmune (associated with vitamin B12
  malabsorption (pernicious anaemia)
• Type B - Helicobacter pylori infection
• Type C - Chemical damage (bile reflux, drugs)

25
Helicobacter Pylori

• Adapted to live in association with surface
  epithelium beneath mucus barrier
• Causes cell damage and inflammatory cell
  infiltration
• In most countries the majority of adults are
  infected

26
Helicobacter Gastritis

• Acute inflammation mediated by complement and
  cytokines
• Polymorphisms infiltrate epithelium and may be
  partly responsible for its destruction
• An immune response is also initiated (antibodies
  may be detected in serum)

27
Consequences of Gastritis

• Peptic ulcer disease (Helicobacter)
• Adenocarcinoma (all types)

28
Definitions

• Peptic Ulcer
• An ulcer of the alimentary tract mucosa, usually
  in the stomach or duodenum, and rarely in the
  lower esophagus, where the mucosa is exposed to
  the acid gastric secretion.
• It has to be deep enough to penetrate the
  muscularis mucosa.

29
Etiology

• The two most common causes of PUD are
• Helicobacter pylori infection
• Non-steroidal anti-inflammatory drugs (NSAIDS)
• Other uncommon causes include
• Gastrinoma (Gastrin secreting tumor)
• Stress ulceration (trauma, burns, critical
  illness)
• Viral infections
• Vascular insufficiency

30
Etiology Helicobacter pylori
Helicobacter pylori
31
PUD Clinical Presentation

• Symptoms of PUD
• Pain
• Epigastric pain
• Hunger pain
• Nocturnal pain
• Other symptoms
• Waterbrash
• Heartburn
• Vomiting
• Asymptomatic
• 1 - 3 adults endoscopy volunteers
• 20 of complicated ulcers present without
  previous symptoms

32
Peptic Ulcer Disease - Diagnosis

• Diagnosis of ulcer
• Diagnosis of H. pylori

33
Diagnosis of H. pylori

• Tests for Helicobacter pylori
• Non-invasive
• C13 or C14 Urea Breath Test
• Stool antigen test
• H. pylori IgG titer (serology)
• Invasive
• Gastric mucosal biopsy
• Rapid Urease test

34
PUD Complications

• Complications of PUD
• Bleeding
• Perforation
• Gastric outlet or duodenal obstruction
• Chronic anemia