Upper GI Pathology

In this remastered video podcast we talk about the most important pathologies that affect the oesophagus and stomach.

 

Lecture by

Video Duration: 18 minutes

  • Peptic Ulcer
    Created by Iain Doig
    General
    Epidemiology

    A peptic ulcer is an ulcer found in the lower oesophagus, stomach or duodenum

    Common - affecting 10% of the population (DU's 2-3 times more common than GU's)

    Most commonly seen in male patients >40 yrs

    Pathology

    Ulceration of the duodenal mucosa due to excess gastric acid

    Peptic Ulcers appear as well-circumscribed punched-out mucosal defects with granulation at the tissue base

    Top three causes

    H. pylori Infection, Smoking, NSAID's

    Clinical Features
    Symptoms

    General - Nausea, Anorexia, Weight Loss

    Specific - Recurrent Burning Epigastric Pain (For DU's pain is worse at night or when hungry, in GU's pain is worse when eating)

    Signs

    Epigastric Tenderness

    Single Pointing Sign

    Investigations
    Cultures

    None

    Bloods

    FBC (anaemia), Serum IgG (IgG against H. pylori), U+E's (rarely shows Zollinger-Ellison syndrome)

    Imaging

    None

    Scopic/Biopsy

    Endoscopy (confirm ulcer by sight or for biopsy)

    Functional

    Stool Test (first line test for H. Pylori)

    Urea Breath Test (also tests for H. Pylori)

    Treatment
    Conservative

    Cease smoking, reduce stress and stop NSAID's

    Medical

    H. Pylori Eradication (1 PPI + 2 Antibiotics)

    Surgical

    None

  • GORD
    Created by Iain Doig
    General
    Epidemiology

    GORD affects roughly 30% of the population

    Defined as a condition causing epigastric pain due to the reflux of gastric contents into the oesophagus

    Pathology

    Occurs when anti reflex mechanisms fail and continual reflex of acidic gastric contents into the oesophagus causes inflammation, redness and sometimes ulceration.

    Top three causes

    Hiatus Hernia, Raised Intra-abdominal Pressure and Transient LOS Relaxation

    Clinical Features
    Symptoms

    Dyspepsia (worse with hot drinks, alcohol or eating)

    Regurgitation of food)

    Signs

    None

    Investigations
    Cultures

    None

    Bloods

    None

    Imaging

    None

    Scopic/Biopsy

    Endoscopy

    Functional

    Intraluminal Montioring (pH and Monometry)

    Treatment
    Conservative

    Weight Loss, Reduce Precipitating Factors (Smoking, Alcohol, Caffeine) and Raising the head of the bed at night

    Medical

    Anatacids or PPI's

    Surgical

    Nissen Fundoplication



  • Achalasia
    Created by Eimear McClenaghan
    General
    Epidemiology

    Dysmotility disorder of the oesophagus,

    Pathology
    • Immune mediated destruction/degeneration of myenteric/Auerbach's plexus.
    • Lower Oesophageal Sphincter (LES) fails to relax in response to swallowing.
    • Smooth Muscle (SM) wall of oesophagus fails to propagate peristaltic wave.
    • Hypertrophy of the oesophagus may occur which predisposes squamous cell carcinoma (SCC) - the major complication of achalasia.
    Top three causes

    Cause is unknown but the following are reported.

    1. Defective release of nitric oxide by inhibitory neurons in the lower oesophageal with degeneration of ganglion cells within the sphincter and the body of the oesophagus.
    2. Loss of the dorsal vagal nuclei within the brainstem can be demonstrated in later stages.
    3. Infection with Trypanosoma cruzi in Chagas' disease causes a syndrome that is clinically indistinguishable from achalasia.
    Clinical Features
    Symptoms

    Specific

    • Progressive Dysphagia to solids:liquids:own secretions.
      • Progression is slow and initially intermittent.
      • Worsened by solids, eased by drinking liquids.
      • As disease progresses nocturnal pulmonary aspiration occurs which may present as recurrent chest infections etc.
    • Heartburn does not occur as the LES is so hypertonic, but patients may experience retrosternal pain due to oesophageal spasm.

    General

    • Malaise
    • Weight loss.
    Signs

    None

    Investigations
    Cultures

    None

    Bloods

    None

    Imaging

    Barium Swallow

    • Shows tapered narrowing of the lower oesophagus and, in late disease, the oesophageal body is dilated, a-peristaltic and filled with fluid/food/ingested contents.
    Scopic/Biopsy

    Endoscopy

    • Should always be carried out as carcinoma of the cardia (stomach) can mimic the presentation and manometric (motor function) features of achalasia i,e. carcinoma of the cardia produces pseudo-achalasia.
    Functional

    Manometry

    • Confirms high-pressure, non-relaxing LES and poor contractility of the SM of the lower oesophagus.
    Treatment
    Conservative

    None

    Medical

    None

    Surgical

    Endoscopic

    • Forceful pneumatic dilatation of balloon.
    • Injection of botulinum toxin (botox) induces clinical remission but relapse is very common.

    Surgical

    • Surgical myotomy (Heller's operation) is effective but invasive. For both pneumatic dilation and myotomy gastro-oesophageal reflux is a common complication which can lead to severe oesophagitis because of poor oesophageal clearance. Because of the high prevalence of such complication in Heller's operation, a partial fundoplication anti-reflux procedure is also carried out. PPIs may also be administered post-procedure.
  • Oesophageal Carcinoma
    Created by Eimear McClenaghan
    General
    Epidemiology

    Malignant epithelial tumour arising from the epithelium of the oesophagus.

    Pathology

    Dysplasia:Cancer in Situ:Malignant

    Two types:

    • Squamous Cell Carcinoma (SCC) - can occur anywhere but most common in middle third of the oesophagus.
    • Adenocarcinoma (ADC) - associated with Barrett's oesophagus, and so most commonly occurs in the lower third of the oesophagus.
    Top three causes

    SCC: smoking, alcohol, achalasia

    ADC: Barrett's

    Clinical Features
    Symptoms

    General

    • Weight Loss

    Specific

    • Dysphagia
    • Odynophagia
    • Haematemesis
    • Cough
    • Chest Pain
    Signs
    • Weight Loss
    • Lymphadenopathy
    Investigations
    Cultures

    None

    Bloods

    None

    Imaging

    Barium Swallow

    • extent of stricture
    • size of tumour

    CT/PET

    • grade tumour

    Bone Scan

    • for metastases
    Scopic/Biopsy

    Gastroscopy

    • Visualise tumour
    Functional

    None

    Treatment
    Conservative

    Pain relief and palliative support

    Medical

    Adjunct chemotherapy/radiotherapy

    Surgical

    Oesophagectomy