GM - gastro

• define odynophagia 


  pain on swallowing
• dysphagia


  difficulty on swallowing
• Dysphagia


  Difficulty swallowing
• Odynophagia


  Pain on swallowing
• Types of dysphagia


  • oropharyngeal dysphagia
  • oesophageal dysphagia
• Dysphagia characterized by difficulty initiating swallowingDifficulty "initiating" swallowing movement

  
• Causes of oropharyngeal dysphagia

  • Neurological: Bulbar palsy, Pseudobulbar palsy, Myasthenia gravis, Stroke
  • Structural: Oral cancer, Zenker's diverticulum

  
• Dysphagia characterized by sticking sensation of food after swallowing


  • Obstructive lesions cause dysphagia for solids more than liquids
  • Obstructive lesions diagnosed by endoscopy and biopsy
  • Motility disorders cause dysphagia for both solids and liquids
  • Motility disorders diagnosed by manometry and barium swallow

  
• Causes of esophageal dysphagia with odynophagia (esophagitis)


  • Obstruction: Strictures, esophageal webs, Schatzki rings, Esophageal carcinoma
  • Motility disorders: Achalasia, Diffuse esophageal spasm

  
• Define achalasia

  it is an esophageal motility disorder in which the LES fails to relax with swallowing, aperistalsisin the distal two-thirds of esophagus and an increased resting tone of LES

  
• Pathogenesis of achalasia


  • Results from degeneration of inhibitory neurons in the myenteric (Auerbach's) plexus
• Causes of achalasia


  • Idiopathic
  • Chagas disease
  • Diabetic autonomic neuropathy
  • Amyloidosis
  • Sarcoidosis
  • Pseudo-achalasia = achalasia like symptoms due to cancer of gastro-esophageal junction
• Clinical presentation of achalasia


  • Dysphagia for both solids and liquids
  • Age mostly < 50 years
  • Weight loss
  • Nocturnal cough, regurgitation
  • Heartburn does NOT occur because the closed esophageal sphincter prevents reflux

  
• Diagnosis of achalasia


  • Barium Swallow: Bird's beak appearance (esophageal dilatation with uniform tapering of distal esophagus)
  • Esophageal Manometry: Inc resting pressure in LES, dec peristalsis in esophagus

  
• Dysphagia caused by Scleroderma has decreased peristalsis and decreased resting LES pressure

  
• Complications of achalasia


  • Squamous cell carcinoma 5% (most serious)
  • Candida esophagitis
  • Diverticulitis
  • Aspiration pneumonia
  • Airway obstruction
• Clinical features of diffuse esophageal spasm


  • Episodic chest pain, mimicking an angina
  • Transient dysphagia

  
• Nutcracker esophagus


  Condition in which extremely forceful peristaltic activity leads to episodic chest pain and dysphagia

  
• Diagnosis of diffuse esophageal spasm and nutcracker esophagus

  • Barium swallow: "Corkscrew" appearance due to dyscoordinated diffuse contractions
  • Manometry: Repetitive high-amplitude contraction (400 - 500 mmHg) for diffuse esophageal spasm, Very strong peristaltic waves of > 180 mmHg for nutcracker esophagus

  
• Treatment of diffuse esophageal spasm and nutcracker esophagus


  • Calcium channel blockers
  • Nitrates
  • Pneumatic dilatation
  • Surgical myotomy

  
• Zenker diverticulum


  Also known as pharyngoesophageal diverticulum, it is the most common esophageal diverticulum defined as outpouching through the cricopharyngeus muscle, above the upper esophageal sphincter

  
• Zenker diverticulum

  • Protrudes through the natural weak point i.e. Killian's Dehiscence between inferior pharyngeal constrictor and cricopharyngeus muscle
  • When diverticulum is small = pharyngeal dysphagia, When diverticulum is large = esophageal dysphagia
• Clinical features of Zenker diverticulum


  • Dysphagia
  • Regurgitation
  • Mass in the neck
  • Halitosis - due to entrapped food
• Gastroesophageal reflux disease (GERD)


  Reflux of gastric contents into the lower esophagus, resulting in esophageal irritation and inflammation

  
• Pathogenesis of GERD


  • Transient LES relaxation, OR Incompetent LES
• Risk factors for GERD


  • Sliding hiatal hernia
  • Delayed gastric emptying
  • Reduction in reparative capacity of mucosa
  • Decreased LES tone due to: Hypothyroidism, CNS depressants, Pregnancy, Alcohol, Tobacco

  
• Clinical features of GERD


  • Esophageal: Heartburn and regurgitation, Dysphagia, "Water brash" - salivation due to reflex salivary gland stimulation as acid enters the gullet
  • Extra-esophageal: Atypical chest pain (mimicking angina), Chronic cough, asthma, Laryngitis, dental erosions, Recurrent chest infection

  
• Diagnosis of GERD


  • Based on history and empiric trial of proton pump inhibitors (PPI)
  • Endoscopy is the investigation of choice, especially when: Failure to respond to PPI, Alarm symptoms => 55 years, dysphagia, anemia, weight loss, positive fecal occult blood test
  • If diagnosis uncertain and endoscopy is normal, then: Manometry = decreased LES pressure, 24-hour pH monitoring is the most accurate investigation

  
• Treatment of GERD


  • Lifestyle Modifications: Avoid precipitants, lose weight, elevate the head of bed, Avoid large and late-night meals
  • Pharmacologic: Proton Pump Inhibitors (PPIs), H2-Receptor Antagonists
  • Surgery: Fundoplication
• Hiatal hernia


  Herniation of stomach upward into the chest through esophageal hiatus of diaphragm
• Types of hiatal hernia


  • Sliding Hernia (Axial): Herniation of proximal stomach through a widened diaphragmatic hiatus, The gastroesophageal junction is displaced above the diaphragm
  • Rolling Hernia (Non-axial): Also known as paraesophageal hernia, Herniation of portion of stomach (greater curvature) alongside the distal esophagus, The gastroesophageal junction remains at the level of diaphragm
• Clinical features of hiatal hernia


  • Often asymptomatic, Commonly an incidental finding on CXR, Heartburn and regurgitation can occur, Para-esophageal hernia can cause gastric volvulus
• Infectious esophagitis


  Usually occurs in immunocompromised individuals, Presents with odynophagia i.e. painful swallowing

  
• Causes of infectious esophagitis


  • Herpes Simplex Virus: Produces "punched-out" ulcers, Forms multi-nucleated giant cells with intra-nuclear inclusions
  • Cytomegalovirus: Produces "linear" ulcers, Forms both intra-nuclear and intra-cytoplasmic inclusions
  • Candida Albicans: Forms patchy gray-white pseudomembrane, Produces yeast and densely matted fungal hyphae
• Barrett esophagus


  Pre-malignant condition characterized by replacement of the normal squamous epithelium by the more resistant columnar epithelium containing areas of intestinal metaplasia, Occurs as a complication of long-standing GERD

  
• Types of Barrett esophagus

  • Short Segment Barrett: < 3 cm of columnar epithelium extending cephalad from GE-junction
  • Long Segment Barrett: ≥ 3 cm of columnar epithelium extending cephalad from GE-junction (aka Classic Barrett)

  
• Diagnosis of Barrett esophagus


  • Endoscopic biopsy - investigation of choice, Definitive diagnosis: when the columnar mucosa contains intestinal goblet cells, "intestinal metaplasia"

  
• Management of Barrett esophagus


  • Barrett Metaplasia without dysplasia = PPIs and endoscopy every 2 - 3 years
  • Low-grade dysplasia = PPIs and endoscopy every 6 - 12 months
  • High-grade dysplasia = Esophagectomy (surgical resection)

  
• Complications of Barrett esophagus


  • Ulceration with stricture formation (most common)
  • Adenocarcinoma: Short-segment = with unknown increased rate, Long-segment = 30 - 40 fold increased rate

  
• Esophageal carcinoma


  Squamous Cell Carcinoma: Most common type, Male-dominant, Occurs in upper and middle thirds of esophagus

  Adenocarcinoma: Malignant epithelial tumor with glandular differentiation, More prevalent in the West, Occurs in lower thirds of esophagus