Gastro

• Esophagitis


  Inflammation of the esophageal mucosa secondary to direct mucosal injury (e.g., gastroesophageal reflux or GERD, substance-induced esophagitis) or to an inflammatory process (e.g., eosinophilic esophagitis)
• Esophagitis


  • Can also occur secondary to local infection (e.g., esophageal candidiasis, HSV esophagitis, CMV esophagitis), especially in immunosuppressed individuals
  • Typical manifestation is retrosternal pain (heartburn)
  • Associated features such as regurgitation, odynophagia, or dysphagia may provide clues to the underlying etiology
  • Coronary artery disease (CAD) may mimic the retrosternal symptoms of esophagitis and should be ruled out if suspected
• Diagnosis and management of esophagitis

  1. Empiric pharmacotherapy with a trial of proton pump inhibitors (PPIs) is recommended in patients with typical features of GERD

  2. Inadequate response to empiric therapy or atypical features at presentation (e.g., significant dysphagia, odynophagia, fever), risk factors for esophageal cancer, or red flags for dyspepsia should prompt an esophagogastroduodenoscopy (EGD) to directly visualize the esophageal mucosa and obtain biopsies from areas of mucosal abnormalities

  3. Further diagnostics (e.g., esophageal pH monitoring, high-resolution esophageal manometry) should be considered if EGD is inconclusive

  4. Specific management depends on the underlying cause and includes PPIs for GERD, PPIs, dietary restriction and topical steroids for eosinophilic esophagitis, and systemic antifungal or antiviral therapy for infectious esophagitis
• Complications of prolonged or severe esophagitis include Barrett esophagus, esophageal strictures, hematemesis, and aspiration
• Achalasia


  A condition characterized by dysphagia to solids and liquids, which can be progressive or paradoxical, regurgitation, and retrosternal pain
• Achalasia


  • Esophageal barium swallow shows a bird-beak sign (dilation of the proximal esophagus with stenosis of the gastroesophageal junction) and delayed barium emptying
  • Upper endoscopy is usually normal, but if malignancy is suspected, biopsy and endoscopic ultrasound are indicated
  • Esophageal manometry is the confirmatory test of choice, showing absent or uncoordinated peristalsis in the lower two-thirds of the esophagus, incomplete or absent lower esophageal sphincter (LES) relaxation, and high LES resting pressure
  • Chest x-ray may show a widened mediastinum
• Treatment of achalasia


  1. For low surgical risk patients: Pneumatic dilation or Heller myotomy (surgical incision of the LES)

  2. For high surgical risk patients: Botulinum toxin injection in the LES or nitrates/calcium channel blockers
• Esophageal cancer (EC)


  The eighth most common type of cancer worldwide, affecting predominantly male individuals (3:1), with two main forms: esophageal adenocarcinoma and squamous cell carcinoma
• Esophageal cancer


  • Adenocarcinomas are considered the fastest-growing neoplasms in Western countries, while squamous cell carcinoma is still most common in resource-limited countries
  • Adenocarcinoma, which usually affects the lower third of the esophagus, may be preceded by gastroesophageal reflux disease and associated Barrett esophagus
  • Other risk factors for EC include smoking and obesity
  • Major known risk factors for squamous cell carcinoma include carcinogen exposure (e.g., in form of alcohol and tobacco) and a diet high in nitrosamines, but low in fruits and vegetables
  • Initially, EC is usually asymptomatic, so locally advanced disease is common at time of diagnosis
  • Weight loss and dyspepsia can precede the primary symptom progressive dysphagia
  • Late stages may be characterized by cervical adenopathy, hoarseness or persistent cough, and signs of upper gastrointestinal bleeding, such as hematemesis or melena
• Diagnosis and staging of esophageal cancer


  1. Esophagogastroduodenoscopy is used for direct visualization and allows biopsy of the lesion for histopathological confirmation

  2. Staging of the tumor includes transesophageal endoscopic ultrasound, CT scans of chest and abdomen, and bronchoscopy
• Treatment of esophageal cancer

  1. Curative surgical resection may be considered for locally invasive cancers, but in about 60% of patients EC is already unresectable at time of diagnosis

  2. In those cases, treatment options includes chemotherapy, radiation, and palliative stenting
• Prognosis for esophageal cancer is generally poor due to the aggressive nature of EC and oftentimes late diagnosis
• Esophageal diverticula


  Abnormal pouches that arise from the wall of the esophagus, most commonly occurring in middle-aged and older men
• Esophageal diverticula


  • In early stages, they are often asymptomatic or may manifest with swallowing difficulties or retrosternal discomfort
  • In advanced stages, they can cause weight loss, progressive dysphagia (from solids to liquids) with possible odynophagia, retrosternal chest or back pain, cervical adenopathy, hoarseness and/or persistent cough, and signs of upper gastrointestinal bleeding such as hematemesis or melena
• Clinical features of esophageal diverticula include dysphagia, regurgitation of undigested food, halitosis, aspiration, coughing after food intake, retrosternal pressure sensation and pain, weight loss, and neck mass
• Diagnosis of esophageal diverticula

  1. Barium swallow (best confirmatory test) with dynamic continuous fluoroscopy to visualize the diverticula

  2. Endoscopy to rule out malignancy in the pouch
• Treatment of esophageal diverticula

  Surgical treatment, including endoscopic diverticulotomy and myotomy or open surgery, is indicated for symptomatic Zenker diverticula
• Complications of esophageal diverticula include aspiration pneumonia
• Gastroesophageal reflux disease (GERD)


  A chronic condition in which stomach contents flow back into the esophagus, causing irritation to the mucosa
• GERD


  • Reflux is primarily caused by an inappropriate, transient relaxation of the lower esophageal sphincter (LES)
  • Risk factors include obesity, stress, certain eating habits (e.g., heavy meals or lying down shortly after eating), and changes in the anatomy of the esophagogastric junction (e.g., hiatal hernia)
  • Typical symptoms are retrosternal burning pain (heartburn) and regurgitation, but the presentation is variable and may also include symptoms like chest pain and dysphagia
  • Most patients with suspected GERD should receive empirical treatment with proton pump inhibitors (PPIs)
  • Diagnostic studies, e.g., esophagogastroduodenoscopy (EGD) and/or 24-hour pH test, may be indicated to confirm the diagnosis or to rule out other causes of symptoms
• Management of GERD


  1. Involves lifestyle modifications, medication, and, in some cases, surgery

  2. Treating esophagitis is especially important because chronic mucosal damage can cause Barrett esophagus, a premalignant condition that can progress to adenocarcinoma
• Barrett esophagus


  Intestinal metaplasia of the esophageal mucosa induced by chronic reflux, characterized by columnar epithelium instead of the normal squamous epithelium
• Barrett esophagus


  • A premalignant condition
  • Risk factors include male sex, European descent, age ≥ 50 years, obesity, and symptoms ≥ 5 years
  • Pathophysiology involves reflux esophagitis leading to stomach acid damage of the distal esophageal mucosa, resulting in replacement of the normal epithelium by nonciliated columnar epithelium and goblet cells (intestinal metaplasia)
  • Complications include esophageal adenocarcinoma
• Management and surveillance of Barrett esophagus

  1. Endoscopy with four-quadrant biopsies at every 2 cm of the suspicious area (salmon-colored mucosa)

  2. If high-grade dysplasia is found, endoscopic treatment of mucosal irregularities is indicated
• Mallory-Weiss tear


  Acute upper gastrointestinal bleeding caused by mucous membrane lacerations at the gastroesophageal junction, often due to forceful vomiting in patients with gastric mucosal injury, usually related to heavy alcohol use
• Diagnosis of Mallory-Weiss tear

  Gold standard test is EGD, which typically shows a single longitudinal tear (but multiple tears are possible) in the mucosa at the gastroesophageal junction, limited to the mucosa and submucosa, with a clot or active bleeding may be evident
• Dyspepsia


  Indigestion or discomfort in the upper abdomen
• Red flag features of dyspepsia


  • Patients ≥ 60 years of age with or without red flag features should be referred for EGD to exclude neoplasia and tested for the presence of H. pylori
  • Patients < 60 years of age with red flags of dyspepsia present should be considered for EGD on a case-by-case basis, while those without red flags can undergo a urea breath test
• Helicobacter pylori testing


  1. Absolute indications for H. pylori testing include uninvestigated dyspepsia in patients < 60 years of age and no red flag features, and MALT lymphoma

  2. PPIs should be discontinued at least 2 weeks prior to most H. pylori testing modalities to minimize rates of false-negative results

  3. Noninvasive methods include urea breath test, H. pylori stool antigen test, and serum IgG antibodies

  4. Invasive methods requiring biopsies include rapid urease test and histology (gold standard)
• Nonpharmacological recommendations for dyspepsia

  1. Dietary recommendations include avoiding eating at least 3 hours before lying down

  2. Reduce or avoid triggers such as stress and medications that may worsen symptoms (e.g., NSAIDs)
• Helicobacter pylori eradication therapy

  All patients who test positive for H. pylori infection should receive H.pylori eradication therapy
• Stomach


  A hollow intraperitoneal organ in the left upper quadrant of the abdomen, between the esophagus and the duodenum in the gastrointestinal tract
• Gastritis


  Inflammation of the lining of the stomach, most often the result of infection with the same bacterium that causes most stomach ulcers or the regular use of certain medications
• Gastritis


  Inflammation of the lining of the stomach
• Causes of gastritis


  • Infection with the same bacterium that causes most stomach ulcers
  • Regular use of certain pain relievers
  • Drinking too much alcohol
• Investigations for gastritis


  • Bedside: basic observations, gastro exam
  • Bloods: FBC, CRP/ESR, LFT, U+E
  • Imaging: upper GI endoscopy (only if suspicious features)
  • Special tests: H. pylori breath test (should be performed after > 2 weeks off PPI)
• Management of H. pylori gastritis

  • Triple therapy 7 days (PPI, Clarithromycin, amoxicillin or if pen allergy metronidazole)
• Management of erosive gastritis


  • Stop erosive agent (NSAIDs or alcohol)
  • PPI
• Management of stress-induced gastritis

  • Proton pump inhibitor
  • H2 antagonist
• Lifestyle changes for gastritis

  • Eating smaller and more frequent meals
  • Avoid irritating food such as spicy, acidic, fried
  • Stop alcohol