Gastroenterology I:Dysphagia, Oesophagus & Peptic Ulceration

• What are some symptoms of gastrointestinal diseases?

  Abdominal pain

  Dysphagia

  Heartburn

  Dyspepsia

  Flatulence

  Vomiting

  Constipation

  Diarrhoea

  Steatorrhoea

  
• What is dysphagia?


  Difficulty swallowing
• What is heartburn?


  Retrosternal burning discomfort which spreads up towards the throat & is a common symptom of acid reflux

  Pain can sometimes be difficult to differentiate from IHD but a careful history will differentiate between the two
• What is dyspepsia?


  It describes a range of symptoms referable to the upper GI tract (e.g. nausea, heartburn, acidity, pain, distension) but patients are more likely to use the term 'indigestion' for these symptoms
• What is flatulence?


  Flatulence describes excessive wind, presenting as belching, abdominal distention & passage of flatus per rectum
• What is vomiting?


  Vomiting occurs as a result of stimulation of the vomiting centres in the lateral reticular formation of the medulla
• What might vomiting specifically result from?

  Stimulation of the chemoreceptor trigger zones in the floor of the fourth ventricle or from vagal afferents from the gut
• What is constipation?


  Infrequent passage of stool (<twice weekly) or difficult passage of hard stools
• What is diarrhoea?


  Passage of increased amounts of loose stool (stool weight> 250g/24hr)

  
  

  This must be differentiated from the frequent passage of small amounts of stool (which patients often refer to as diarrhoea), which is often seen in functional bowel disorders
• What is steatorrhoea?


  Passage of pale bulky stools that contain fat (>18mmol/24hr) & indicates fat malabsorptions a result of small bowel, pancreatic or biliary disease

  
  

  The stools often float because of increased air content & are difficult to flush away
• What does the upper digestive tract look like?

  Learn to redraw this

  
• What is the oesophagus?

  Musculotendinous tube connecting the pharynx to the stomach
• Where does the oesophagus pass through?

  Through the chest via the mediastinum & lies posterior to the trachea

  
• What are some symptoms of oesophageal problems and what are the important diseases to consider?

  Dysphagia, pain, cough or vomiting

  Important diseases to consider:

  Pharyngeal pouchAchalasia- muscles of the lower part of the oesophagus fail to relax.Oesophageal spasm -painful contractionsOesophageal web- Thin membranes that grow across the inside of the upper part of the esophagusPeptic ulcer disease/refluxCarcinoma
• How many overlapping constrictor muscles does the pharynx have and what are they called?

  3 overlapping constrictor muscles :

  
  

  superior, middle, inferior
• What is a potential weakness in the structure of the pharynx?

  Killian's dehiscence-the meeting point of 2 parts of inferior constrictor:

  thyropharyngeus & cricopharyngeus

  
• What is Zenker's diverticulum?

  Out pouching of the posterior hypopharynx that causes regurgitation of undigested food several hours after eating
• How might a posterior mucosal herniation take place?

  During swallowing, the thyropharyngeus is propulsive & the cricopharyngeus is sphincteric

  
  

  If the cricopharyngeus fails to relax at the right time, a posterior mucosal herniation may take place via Killian's dehiscence
• Describe the histology of the oesophagus.

  It has an outer longitudinal muscle coat & an inner circular muscle coat

  Upper2/3 of oesophagus = striated muscle

  Lower2/3 of oesophagus = non-striated muscle

  So the middle 1/3 is mixed
• Where does the motor & sensory nerve innervation come from for the oesophagus?

  It's derived from thevagus (X) nerveforming something called theoesophageal plexus

  (plexus of nerves within the muscle wall of the oesophagus, controlling its function & regulating its activity, & also coordinating peristalsis)
• Where does the nerve plexus lie in the oesophagus?

  Between outer longitudinal & inner circular muscle planes & also submucosally
• What is the mucosal lining of the oesophagus?

  Stratified squamous non-keratinising epitheliumbutthe lower partcanbe lined by ectopic gastric (columnar) mucosal
• Describe how swallowing happens.

  1. Initial phase of swallowing = voluntary

  
  

  2. Triggers peristaltic wave = pushes food bolus to the stomach.

  
  

  3. Wave progresses by reflex activity at 2-4 seconds.

  
  

  4. Stretching get causes depolarisation and action potential

  
  

  5. This propagates and creates waves of muscle relaxation and contraction = peristalsis

  
• What is the cardiac sphincter at the gastro-oesophageal junction?

  It's not a clearly defined anatomical structure (can't see it in endoscopy) so it's described as physiological but it prevents reflux of gastric contents into oesophagus
• Does the oesophagus have a temperature sense?

  Yes, it's perceived as a dull pain
• Is pain from the oesophagus well localised?

  No, it's poorly localised & may also be confused with pain from other mediastinal structures e.g. the heart
• What are some causes of dysphagia?

  - A sensation of difficulty in swallowing

  
• What is haematemesis?


  Vomiting blood
• What is haemoptysis?


  Coughing up blood
• What is a pharyngeal pouch?

  A herniation of mucosa through a weakness in the pharyngeal constrictor muscles

  
  

  The pouch hangs down due to gravity
• What will the patient complain about if they have a pharyngeal pouch?

  Dysphagia combined with swelling developing in the lower neck, usually left side
• What are some potential complications of a pharyngeal pouch?

  Undigested food may be regurgitated into the mouth hours after eating

  
  

  Overflow into lungs may cause respiratory symptoms
• What is the most common cause of oesophagitis?

  GORD
• What is candida oesophagitis?

  Candida infection in oesophagus

  
• What is achalasia (of the cardia)?

  This refers to a condition where there has been a loss of ganglia from the intramural plexus, and therefore a failure of relaxation of the gastro-oesophageal sphincter.

  
  

  This then leads to functional obstruction to oesophageal emptying with dysphagia for solids & liquids.

  
  

  Failure of peristalsis leads to progressive dilatation of the oesophagus and retained oesophageal contents may be regurgitated, causing respiratory problems

  
• What are possible treatments for achalasia?

  Drugs e.g:

  nifedipine (Ca channel blocker) to relax the sphincter

  Balloon dilatation

  Cardiomyotomy
• What is an oesophageal spasm?

  A descriptive term for spasm due to variety of causes leading to attacks of dysphagia & pain
• What are some potential causes of oesophageal spasm?

  Atypical achalasia

  Gastro-oesophageal reflux

  Motor disorders

  Symptomatic peristalsis

  Obstruction at the cardia

  Neuromuscular disorders
• What is a corkscrew oesophagus?

  A classic manifestation of an oesophageal spasm

  
  

  The pain can resemble reflux & heartburn and it should be managed with muscle relaxants

  
  

  It is diagnosed by radiological appearance

  
• What is an oesophageal web?

  It's classically seen in middle-aged women and consists of:

  glossitisiron deficiency anaemiadysphagiakoilonychia - spoon nails

  Although rare, it is important as it ispremalignant