Gastrointestinal Tract

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Gastrointestinal Tract
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• Gastrointestinal tract
• Esophagus
• Dysphagia (difficulty in swallowing)- diseases
  that narrow or obstruct the lumen
• Pain and Hematemesis- inflammation or ulceration
  of the esophageal mucosa
• Heartburn (retrosternal burning pain)-
  regurgitation of gastric contents
• Most frequent GI complaint - gas.
• Inflammation (acute or chronic itis) ulcers
  
• Sinuses blind tubes
• Fistulas tunnels
• Perforation hollow viscous open up into hollow
  cavity ( usually peritoneal cavity)
• Herniation can be internal or external
• Bleeding (MC anemia of GI bleeding -IDA)
• Tumors

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• Esophagus
• Structures
• UES (upper esophageal sphincter)
• made up of skeletal muscle Cricopharyngeus muscle
• Involved in scleroderma or systemic sclerosis
• LES (lower esophageal sphincter) opens into the
  stomach
• gastro-esophageal junction ( 3 cm ), if gt3cm is
  called as ?
• transitional zone which is columnar
• 1.Congenital anomalies produce choking on
  breast feeding
• Atresia (noncanalized segment)
• Fistulas (Connection/opening between esophagus
  and trachea)
• several types
• Webs (produce dysphagia to solids)
• Webs - Plummer-Vinson / Paterson-Kelly syndrome(
  post cricoid web, IDA, Glossitis, cheilosis in
  perimenopausal female, Risk of postcricoid
  Squamous cell carcinoma )

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Fistulae
Most life threatening cough, sputter and
suffocate
Most common type
associated with heart other GIT anomalies
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• Schatzkis rings
• At LES
• Cause narrowing (Stenosis)
• Stenosis
• MCC Gastro-esophageal reflux
• Most commonly acquired (corrosives, radiation,
  Scleroderma CREST syndrome)
• Major symptom - Dysphagia
• 2. Lesions with motor dysfunction
• A) Achalasia cardia ("failure to relax." )
• Affect adults
• 1) Aperistalsis
• 2) Complete or partial relaxation of LES with
  swallowing
• 3) Increased resting tone of LES

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• 2. Lesions with motor dysfunction
• A) Achalasia cardia ("failure to relax." )
• Complications
• Aspiration pneumonia
• Candidal esophagitis ( due to stagnation of food)
• Diverticulae
• squamous cell carcinoma (2 to 5 of affected)
• Also Caused by
• Chagas disease (Trypanosoma cruzi)
• Diabetic autonomic neuropathy
• B) Hiatal Hernia
• Upward protrusion of part of stomach through the
  diaphragmatic esophageal foramen

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• 2. Lesions with motor dysfunction
• B) Hiatal Hernia
• Upward protrusion of part of stomach through the
  diaphragmatic esophageal foramen
• C) Diverticula (True)
• Out-pouching of the esophageal wall (contains all
  visceral layers) Z
• false Diverticulae out-pouching of mucosa and
  submucosa only
• A) Zenkers (pharyngeal) diverticulum T
• Seen as mass in neck of elderly pt. above UES
• Due to disordered cricopharyngeal motor
  dysfunction
• Produce Food regurgitation dysphagia E
• B) Traction Diverticulum
• Asymptomatic Located near midpoint of esophagus
• C) Epiphrenic Diverticulum
• Located just above the LES
• Caused by Dys -coordinated peristalsis and motor
  dysfunction of LES.
• cause regurgitation of food and aspiration
  pneumonia

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Hiatal Hernia

• Rolling
• (para-esophageal) hernia(lt10)
• Part of the stomach (fundus) herniates alongside
  esophagus into the thorax
• Vulnerable to serious strangulation

• Sliding
• (gt90)
• Shortened esophagus
• Dragging part of the stomach into the thoracic
  cavity
• (stomach continuous with esophagus)

prone to ulceration, bleeding, dysphasia.
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• 3. lacerations
• Mallory- Weiss Syndrome
• at the gastro-esophageal junction (GEJ)
• Caused by excessive vomiting in presence of
  spasm of LES
• Most common in alcoholics Pregnancy
• Irregular longitudinal tear in the GEJ involve
  only the mucosa
• Boerhaave syndrome -tear penetrates all layers
  of esophagus
• Clinically Mallory-Weiss cause severe
  hematemesis vomiting of blood ( Boerhaaves
  produce mediastinitis or peritonitis)
• 4. Esophageal Varices
• dilated tortuous submucosal veins
• Seen in long-standing cirrhosis with portal HTN
• 50 of cirrhotics bleed die of Varices (MCC of
  death)

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Esophageal Varices
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• 4. Esophagitis
• Causes
• 1) Reflux of gastric contents (reflux
  esophagitis)
• MCC of esophagitis
• distal part of esophagus is affected
• Clinically Dysphagia, heartburn, regurgitation,
  develop Barretts esophagus in Long standing
  cases
• 2) Barretts Esophagus
• A complication of long-standing gastroesophageal
  reflux
• Columnar metaplasia of the distal esophagus
• 30 times more risk of cancer (Adenocarcinoma) in
  lower esophagus

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BARRETTS ESOPHAGUS

• The normal tan upper esophageal mucosa is at the
  far left
• The distal esophagus - Barrett mucosa (columnar
  metaplasia)
• a large ulcerating adenocarcinoma that extends
  into stomach (Adenocarcinomas can arise in
  Barrett esophagus)

BARRETTS
normal
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BARRETTS ESOPHAGUS

• Gastric-type mucosa above the gastroesophageal
  junction
• The metaplasia results from chronic
  gastroesophageal reflux disease (GERD
• Columnar epithelium to the left and the squamous
  epithelium at the right
• Typical" Barrett's mucosa, because there is
  intestinal metaplasia as well (note the goblet
  cells in the columnar mucosa).

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• EsophagusTumors
• 1. Leiomyoma
• MC benign tumor of esophagus arising from Smooth
  muscle cells
• 2. Squamous cell carcinoma
• Incidence common in China, Rare in US
  (Adenocarcinoma MC in USA) MgtF, age gt50 yr.
• Risk factors cigarette smoking, alcohol,
  nitrosamines in the preserved foods, fungus
  contaminated foods
• 50are in middle 1/3rd
• Early carcinoma upto submucosa ( 90- 5 year
  survival good prognoses even though lymph nodes
  are involved)
• Spreads locally into mediastinal structures to
  lymph nodes
• Clinically
• Insidious dysphagia, weight loss, hemorrhage,
  Esophago -tracheal fistula.
• Overall 5-year-survival is 5.

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• EsophagusTumors
• 3. Esophageal adenocarcinoma
• Incidence lt25 of esophageal cancers world wide
• up to half of all esophageal cancers reported in
  US
• Primary risk factor - Barretts esophagus
• Most arise in distal 1/3rd of the esophagus.
• Histology Mucin producing tubular (intestinal),
  or signet cell/ring (gastric/infiltrative)
  carcinoma, undifferentiated.
• present with dysphagia
• Overall 5-year survival - 15

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Esophagus Squamous cell carcinoma

• irregular reddish, ulcerated exophytic most
  common in mid-esophageal mass as seen on the
  mucosal surface (squamous cell carcinoma)

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Esophagus Squamous cell carcinoma

• neoplastic cells have abundant pink cytoplasm and
  distinct cell borders typical for squamous cell
  carcinoma
• Esophageal carcinomas are not usually detected
  early and, therefore, have a very poor prognosis
• in the lymphatics

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EsophagusMalignant Tumors
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Case - 1

• A 62-year-old man had a 2 month history of
  increasing difficulty swallowing. He found it
  more difficult to eat, and he had lost 5 kg
  during this time. He also had a history of both
  alcohol abuse and cigarette smoking. On upper GI
  endoscopy a mass lesion was seen . Surgery was
  performed. The mass is shown in the Esophagectomy
  specimen. It was 3 cm in diameter and appeared to
  extend through the muscular wall. On the surface
  it was ulcerated .

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1.1
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Case - 2

• This 55-year-old man had suffered from episodes
  of "heartburn" with sub-sternal chest pain from
  chronic reflux esophagitis for several decades
  (image 2.1). He then presented with dysphagia
  developing over the past month. On upper GI
  endoscopy a mass lesion was found in the lower
  esophagus, and biopsies were taken. Based upon
  the biopsy findings, a partial esophagectomy was
  performed. The mass lesion extended into the
  muscular wall and ulcerated the overlying surface
  mucosa . The predisposing lesion which developed
  from reflux is shown. The precursor lesion and
  the mass lesion are seen.

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2.1
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2.2
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2.3
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2.5
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2.6
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2.7