GI SYMPTOMS

1
GI SYMPTOMS

• Dyspepsia

2
Nature of complaint

• pain or discomfort centered in the upper abdomen
• acute, chronic, or recurrent
• fullness, early satiety, burning, bloating,
  belching, nausea, retching, or vomiting
• 25 has got it

3
Heartburn

• Retrosternal burning
• Different from dyspepsia
• Due to GERD

4
Causes of Dyspepsia

• Simple self limiting
• overeating
• eating too quickly
• eating high-fat foods
• eating during stressful situations
• drinking too much alcohol/coffee drugs

5
Pathological dyspepsia(LUMINAL )

• Peptic ulcer (5-15)
• GERD (20)
• Cancer stomach (1) in 45
• Diabetics with GI motility issues
• Lacking lactase
• Malabsorption
• Parasites- giardia/threadworm

6
Helicobacter pylori
7
Other causes for dyspepsia

• Pancreatic cancer/pancreatitis
• Gall bladder related always dramatic
• DD heart attack/ hiatus hernia/ renal failure/
  thyroid/pregnancy

8
functional chronic dyspepsia

• 2/3 of patients have no identifiable cause
• Difficult to treat
• History may not always help!
• Check if associated with other serious complaints
• 25 of ulcers misdiagnosed as functional

9
Lab workup (45)

• CBC
• Electrolytes
• LFTs
• Calcium
• Thyroid tests
• Endosocpy- gold standard

10
?treat

• Under 45- (serology/fecal/breath ) tests for H
  pylori (USEFUL IF negative)
• Treat symptomatically
• If positive?- triple therapy

11
? Functional dyspepsia

• If mild- reassure/change the life style, Keep
  food journal
• 30 have placebo response
• Antacids/ H2 blockers/ Purple pill (helps 10-15)
• ?antidepressants
• Increase gut motility
• CAMS Psycho/hypno therapy/
• Peppermint/caraway- no SIDE EFFECTS!

12
GI SYMPTOMS

• Nausea and Vomiting

13
Description

• Nausea vague, intensely disagreeable sensation
  of sickness or "queasiness"
• NOT ANOREXIA/ REGURGITATION
• Vomiting center
• H1 receptors/ muscarinic receptors

14
Vomiting center (Medulla)

• Afferent inputs
• (1) Afferent vagal and splanchnic fibers
  serotonin 5-HT3 receptors
• (2) Fibers of the vestibular system, which have
  high concentrations of histamine H1 and
  muscarinic cholinergic receptors
• (3) Higher central nervous system centers
• (4) The chemoreceptor trigger zone (CTZ)

15
The chemoreceptor trigger zone (CTZ) (MEDULLA)

• outside the blood-brain barrier
• rich in opioid, serotonin 5-HT3, neurokinin 1
  (NK1) and dopamine D2 receptors
• stimulated by drugs and chemotherapeutic agents,
  toxins, hypoxia, uremia, acidosis, and radiation
  therapy

16
Complications

• Dehydration
• Hypokalemia
• metabolic alkalosis
• Aspiration
• rupture of the esophagus (Boerhaave's syndrome),
  and
• bleeding secondary to a mucosal tear at the
  gastroesophageal junction
• (Mallory-Weiss syndrome)

17
Red flags associated with vomiting

• WITH PAIN-
• peritonitis
• Intestinal obstruction
• Pancreatitis
• Cholecystitis
• CNS causes- headache/stiff neck/ vertigo/ focal
  paresthesias or weakness.

18
Red flags associated with vomiting (TIMING)

• morning before breakfast
• pregnancy/ uremia/ alcohol intake, and increased
  intracranial pressure
• immediately after meals -bulimia or psychogenic
  causes
• one to several hours after meals
  gastroparesis/obstruction (succusion splash)

19
Lab workup in serious cases

• Electrolytes- hypokalemia / uremia/ alkalosis
• LFTs/ Amylase
• If in pain- plain axr-
• Endosocpy
• CT/MRI abdomen

20
Antiemetic Medications

• Serotonin (5-HT3)Antagonists- Ondansetron
  (Zofran)
• Granisetron (Kytril)
• Dolasetron (Anzemet)
• Palonosetron (Aloxi)
• Indicated in- chemotherapy- and
  radiation-induced emesis (pre treatment)

21
Antiemetic Medications

• Corticosteroids
• Dexamethasone (Decadron)
• Methylprednisolone (Medrol)

22
Antiemetic Medications

• Dopamine (Dopastat, Intropin) receptor
  antagonists 
• Metoclopramide (Reglan)
• Prochlorperazine (Compazine)
• Promethazine (Phenergan)
• Trimethobenzamide (Tigan)

23
Antiemetic Medications

• Sedatives
• Diazepam (Valium)
• Lorazepam (Ativan)

24
Cannabinoids

• Marijuana
• appetite stimulant and antiemetic
• tetrahydrocannabinol (THC) is the major active
  ingredient in marijuana and is available by
  prescription as dronabinol

25
HICCUPS

• GI SYMPTOMS

26
HICCUPS (SINGULTUS)

• benign and self-limited annoyance
• gastric distention
• carbonated beverages,
• air swallowing, overeating
• sudden temperature changes
• hot then cold liquids,
• hot then cold shower
• 3. alcohol ingestion, and
• 4. states of heightened emotion/excitement
  stress, laughing

27
recurrent or persistent hiccups

• a sign of serious underlying illness
• Central nervous system Neoplasms/ infections,
  cerebrovascular accident/ trauma.
• Metabolic
• Uremia, hypocapnia (decreased CO2 levels)
  (hyperventilation)

28
recurrent or persistent hiccups

• Irritation of the vagus or phrenic nerve
• Head, neck Foreign body in ear, goiter,
  neoplasms.
• Thorax Pneumonia, empyema, neoplasms, myocardial
  infarction, pericarditis, aneurysm, esophageal
  obstruction, reflux esophagitis.
• Abdomen Subphrenic abscess, hepatomegaly,
  hepatitis, cholecystitis, gastric distention,
  gastric neoplasm, pancreatitis, or pancreatic
  malignancy.
• (4) Psychogenic and idiopathic
• Surgical General anesthesia, postoperative.

29
Workup

• CNS exam
• Serum Creatinine
• LFTs
• CXR
• CT chest/abdomen
• Echocardiography/Bronchoscopy / Endoscopy

30
Treatment

• acute benign hiccups
• Irritation of the nasopharynx- by tongue
  traction, lifting the uvula with a spoon,
  catheter stimulation of the nasopharynx, or
  eating 1 tsp of dry granulated sugar.
• Interruption of the respiratory cycle by breath
  holding- Valsalva's maneuver, sneezing, gasping
  (fright stimulus), or rebreathing into a bag.
• Stimulation of the vagus, carotid massage.
• Irritation of the diaphragm by holding knees to
  chest
• Relief of gastric distention by belching

31
Treatment

• Chlorpromazine (Thorazine)
• Anticonvulsants-
• Phenytoin (Dilantin)
• Gabapentin (Neurontin)
• Carbamazepine (Tegretol)
• Benzodiazepines- lorazepam diazepam
• Others- Baclofen (Lioresal)
• metoclopramide,

32
CONSTIPATION
33
define constipation

• as infrequent stools (fewer than 3 in a week)
• hard stools
• excessive straining, or
• a sense of incomplete evacuation

34
Causes of Constipation
1 Most common 
  Inadequate fiber or fluid intake/ Poor bowel habits
2 Systemic disease 
  Endocrine hypothyroidism, hyperparathyroidism, diabetes mellitus
  Metabolic hypokalemia, hypercalcemia, uremia, porphyria
  Neurologic Parkinson's, multiple sclerosis, sacral nerve damage (prior pelvic surgery, tumor), paraplegia, autonomic neuropathy
35
Causes of Constipation

• 3 Medications 
•   Opioids/   Diuretics/ Calcium channel blockers/
   Anticholinergics/   Psychotropics/   Calcium
  and iron supplements/ NSAIDs/ Sucralfate/
  Cholestyramine/
• 4 Structural abnormalities 
•  Anorectal rectal prolapse, rectocoele, rectal
  intussusception, anorectal stricture, anal
  fissure, solitary rectal ulcer syndrome, Perineal
  descent, cancer colon, radiation
• 5 Slow colonic transit 
•   Idiopathic isolated to colon/  Psychogenic/
    Eating disorders/
• 6  Irritable bowel syndrome 

36
Dietary review

• Add 10-20 grams of fiber per day
• Add 1-2 glasses of fluids per meal
• Elderly at risk

37
Structural issues

• Cancers
• Strictures
• RED FLAG symptoms or signs - hematochezia,
  weight loss, anemia, or positive fecal occult
  blood tests (FOBT)
• 45-50 having new onset

38
Medical Issues

• Neurological- strokes/ paraplegias/
• Myopathies
• Endocrinal
• Hyper calcemia or Hypokalemia

39
Treatment of Constipation

• Fiber laxatives Psyllium Methylcellulose
  (Citrucel) Polycarbophil (FiberCon)
• Guargum
• Stool surfactants -
• Docusate (Colace)
• Mineral Oil(Kondremul)

40
Treatment of Constipation

• Osmotic laxatives -
• Magnesium Hydroxide (milk of magnesia)
  Lactulose (Duphalac)
• Stimulant laxatives
• Bisacodyl (Dulcolax)
• Senna (Ex-Lax) Cascara
• Enemas Phosphate/Soapsuds/Tapwater

41
GAS

• Belching- Normally 25 mL of air swallowed every
  time
• distention, flatulence, and abdominal pain
• rapid eating, gum chewing, smoking, and the
  ingestion of carbonated beverages
• Chronic aerophagia
• Therapy-Behavior modification, medicines not much
  help

42
Flatus

• Colonic
• swallowed air and bacterial fermentation of
  undigested carbohydrate
• Nitrogen (500 ml) H2/CO2/Methane
• Fermenters- sucrose/lactose/fructose
  (mushrooms/legumes/cruciferous vegetables)
• ?fructose intolerance

43
Cruciferous Vegetables

• Arugula,
• Broccoli,
• Cauliflower,
• Brussel Sprouts,
• Cabbage,
• Watercress,
• Bok Choy,
• Turnip Greens,

• Mustard Greens, and Collard Greens,
• Rutabaga,
• Napa or Chinese Cabbage,
• Daikon, Radishes, Turnips,
• Kohlrabi, and Kale

44
Gas producing vegetables/Items

• Beans of all kinds
• Peas, lentils
• Brussels sprouts
• Cabbage
• Parsnips
• Leeks
• Onions
• Beer and coffee

45
Foul odor

• garlic,
• onion,
• eggplant,
• mushrooms, and
• certain herbs and spices

46
Gas Management

• Eliminate complex starches fiber- but highly
  unacceptable
• only rice flour is gas-free.
• Beano ( -d-galactosidase enzyme) reduces gas
  caused by foods containing raffinose and
  stachyose, (cruciferous vegetables, legumes,
  nuts, and some cereals)
• Activated charcoal

47
diarrhea
48
GI FLUID BALANCE

• 10 L of fluid enter the duodenum daily
• 8.5 l totally absorbed (small intestine)
• Colon absorbs 1.3 l
• 200 ml lost in feces
• DIARRHEA
• defined as a stool weight of more than 200300
  g/24 h

49
CLUES IN ACUTE DIARRHEA

• Preformed toxins in food
• Community outbreaks- viral/food
• Food poisoning- vomiting prominent
• Unpurified water
• SMALL BOWEL large volume
• Watery/non bloody/ cramps/ bloating/dehydration/
  hypokalemia/
• fecal test for WBC negative

50
CLUES IN ACUTE DIARRHEA

• Inflammatory (Usually colonic damage)
• Small volume /fever/ bloody/ LLQ cramp/
  urgency/painful/
• Fecal WBC test positive

51
Types of ACUTE diarrhea (less than 2 weeks )
Noninflammatory Diarrhea Inflammatory Diarrhea
Viral  Viral 
  Noroviruses   Cytomegalovirus
  Rotavirus
Protozoal  Protozoal 
  Giardia lamblia    Entamoeba histolytica 
  Cryptosporidium 
Cyclospora 
52
Non-Inflammatory Bacterial  InflammatoryBacterial 


   1. Cytotoxin production Enterohemorrhagic E coli O157H5 (EHEC) Vibrio parahaemolyticus Clostridium difficile
   1. Preformed enterotoxin production food poisoning Staphylococcus aureus Bacillus cereus Clostridium perfringens

   2. Mucosal invasion Shigella Campylobacter jejuni Salmonella Enteroinvasive E coli (EIEC) Aeromonas Plesiomonas Yersinia enterocolitica Chlamydia Neisseria gonorrhoeae Listeria monocytogenes
   2. Enterotoxin production Enterotoxigenic Escherichia coli (ETEC) Vibrio cholerae
53
Management

• 90 mild need oral rehydration
• If persists more than 7 days needs further
  testing
• RED FLAGS
• High Fever
• Bloody Diarrhea
• More than 6 watery stools in 24 hrs
• dehydration
• frail older patient
• HIV/AIDS
• Nosocomial

54
Oral Rehydration

• ½ tsp salt (3.5 g)
• 1 tsp baking soda (2.5 g NaHCO3)
• 8 tsp sugar (40 g) and
• 8 oz orange juice (1.5 g KCl) diluted to one
  liter with water
• OR Pedialyte, Gatorade

55
Antidiarrheals

• Imrpoves comfort/ symptom relief
• But not to be used in RED FLAG cases
• Loperamide (Imodium)
• Bismuth Subsalicylate (Pepto-Bismol )
• Diphenoxylate (Lomotil)
• Antibiotics
• Ciprofloxacin (Cipro)/ Sulfa/ Doxycycline
  (Atridox )/ Rifaximin (Xifaxan)

56
Acute Diarrhea when to refer? Algorithm for RED
FLAGS
57
Acute Diarrhea when to refer? Algorithm for RED
FLAGS
58
Chronic Diarrhea
Osmotic diarrhea 
  CLUE Stool volume decreases with fasting
    1. Medications antacids, lactulose, sorbitol
    2. Disaccharidase deficiency lactose intolerance
    3. Factitious diarrhea magnesium (antacids, laxatives)

59
Chronic Diarrhea
Secretory diarrhea 
  CLUES Large volume (gt 1 L/d) little change with fasting
    1. Hormonally mediated VIPoma, carcinoid, medullary carcinoma of thyroid (calcitonin), Zollinger-Ellison syndrome (gastrin)
    2. Factitious diarrhea (laxative abuse) phenolphthalein, cascara, senna
    3. Villous adenoma
    4. Bile salt malabsorption (ileal resection Crohn's ileitis postcholecystectomy)
    5. Medications
60
Chronic Diarrhea
Inflammatory conditions 
CLUES Fever, hematochezia, abdominal pain
    1. Ulcerative colitis
    2. Crohn's disease
    3. Microscopic colitis
4. Malignancy lymphoma, adenocarcinoma (with obstruction and pseudodiarrhea)
    5. Radiation enteritis

61
Chronic Diarrhea
Malabsorption syndromes 
CLUES Weight loss, abnormal laboratory values fecal fat gt 10 g/24h
1. Small bowel mucosal disorders celiac sprue, tropical sprue, small bowel resection (short bowelsyndrome), Crohn's disease
2. Lymphatic obstruction lymphoma, carcinoid, infectious (tuberculosis, Mycobacterium Avium Infection), Kaposi's sarcoma, sarcoidosis, retroperitoneal fibrosis
62
Malabsorption syndromes

• 3. Pancreatic disease chronic pancreatitis,
  pancreatic cancer
• 4. Bacterial overgrowth motility disorders
  (diabetes, vagotomy), scleroderma, fistulas,
  small intestinal diverticula

63
Chronic Diarrhea
Motility disorders 
CLUES Systemic disease or prior abdominal surgery
Postsurgical vagotomy, partial gastrectomy, blind loop with bacterial overgrowth
2.Systemic disorders scleroderma diabetes mellitus, hyperthyroidism
3.Irritable bowel syndrome
64
Chronic Diarrhea
Chronic infections 
Parasites Giardia lamblia, Entamoeba histolytica 
 2. AIDS-related
       ViralCytomegalovirus, HIV infection (?)
 Bacterial Clostridium difficile, Mycobacterium avium complex (MAC)
  Protozoal Microsporida (Enterocytozoon bieneusi), Cryptosporidium, Isospora belli 
65
LAB WORKUP

• FECAL FAT
• gt300g/24 hrs- diarrhea
• gt500g/24 hrs-excludes IBS
• gt0.3 (g/kg)/day Steatorrhea
• CBC/Albumin/Electrolytes

66
Causes of steatorrhea include

• Increased duodenal acid,
• Abnormal bile output,
• Pancreatic insufficiency,
• Intestinal mucosal impairment Whipple's disease,
  and various forms of enteritis, celiac disease
  and sprue.

67
Protein Losing Enteropathy

• excessive loss of serum proteins into the
  gastrointestinal tract
• hypoalbuminemia and an elevated fecal
  a1-antitrypsin level.
• 1) mucosal disease with ulceration
• 2) lymphatic obstruction
• 3) idiopathic change in permeability of mucosal
  capillaries weeping

68
Mucosal disease with ulceration

• Chronic gastric ulcer  
• Gastric carcinoma  
• Lymphoma  
• Inflammatory bowel disease 
•  Idiopathic ulcerative jejunoileitis

69
Lymphatic obstruction 

• Primary
• intestinal lymphangiectasia  
• Secondary obstruction-    
• Cardiac disease constrictive pericarditis,
  congestive heart failure   
•  Infections tuberculosis, Whipple's disease    
• Neoplasms lymphoma, Kaposi's sarcoma        
• Sarcoidosis

70
Idiopathic mucosal transudation 

•   Acute viral gastroenteritis  
• Celiac sprue  
• Eosinophilic gastroenteritis  
• Allergic protein-losing enteropathy  
• Parasite infection giardiasis, hookworm  
• Amyloidosis  
• Common variable immunodeficiency  
• Systemic lupus erythematosus

71
Test

• gut alpha 1-antitrypsin clearance (24-hour
  volume of feces x stool concentration of alpha
  1-antitrypsin serum alpha 1-antitrypsin
  concentration). A clearance of more than 13 mL/24
  h is abnormal.

72
Labworkup

• serum protein electrophoresis, lymphocyte count,
  and serum cholesterol to look for evidence of
  lymphatic obstruction
• Fecal fat
• Giardiasis/ ova
• Serum albumin

73
Therapy

• OctreotideSandostatin LAR Sandostatin
• Print low-fat diets supplemented with
  medium-chain triglycerides

74
Treatment

• benefit from low-fat diets supplemented with
  medium-chain triglycerides
• Rich sources of MCTs include coconut oil and palm
  kernel oils and are also found in camphor tree
  drupes.

75
APPENDICITIS
76
Facts

• Most common abdominal emergency
• 10 population affected
• 10-30 age group
• Ax obstruction by fecolith

77
FEATURES

• Early periumbilical pain (12 hrs) later right
  lower quadrant pain and tenderness.
• Anorexia, nausea and vomiting, obstipation.
• Tenderness or localized rigidity at McBurney's
  point.
• Low-grade fever and leukocytosis.

78
Lab workup

• WBC- 10-20,000
• US or CT scan (94)
• 20 at operation have normal Ax
• DD gyn?/ectopic
• Danger- perforation

79
GI SIGNS

• Upper Gastro Intestinal BLEED

80
Acute Upper Gastrointestinal Bleeding

• Hematemesis
• (bright red blood or "coffee grounds").
• Melina (black stools) in most cases
  hematochezia (blood in stools) in massive upper
  gastrointestinal bleeds.
• Volume status to determine severity of blood
  loss
• Endoscopy diagnostic and may be therapeutic.

81
RED FLAG UGI Bleed

• 7-10 mortality
• 50 older than 60
• Peptic Ulcer Disease
• Portal Hypertension
• (50 rebleed)

82
Mallory-Weiss Tears
Lacerations of the gastroesophageal
junction History of heavy alcohol use or retching
Other causes Erosive gastritis Gastric cancer
83
ACID-Drug Therapy

• IV proton pump inhibitors stop bleeding-
• Omeprazole (Prilosec) Lansoprazole (Prevacid)
  Pantoprazole (Protonix)

84
Varicies- Therapy

• Vasopressin, ADH (Pitressin)
• terlipressin
• Transvenous intrahepatic portosystemic shunts
  (TIPS)

85
GI SIGNS

• Lower Gastro Intestinal BLEED

86
Acute Lower GI Bleeding

• Hematochezia usually present. (10 UGI)
• Evaluation with colonoscopy in stable patients.
• Massive active bleeding calls for evaluation with
  sigmoidoscopy, upper endoscopy, angiography, or
  nuclear bleeding scan.

87

• Mild bleeding -Bright red blood that drips into
  the bowl after a bowel movement or is mixed with
  solid brown stool (anorectosigmoid source )
• LGI bleed serious in older men

88
Etiology

• lt50 years age infectious colitis, anorectal
  disease, and inflammatory bowel disease
• gt50 years age diverticulosis, vascular ectasias,
  malignancy, or ischemia / cause unknown (20)

89
diverticulosis, vascular ectasias, malignancy
90
Other causes for LGI BLEED

• Inflammatory Bowel Disease (IBD)- Ulcerative
  colitis
• Anorectal disease
• Ischemic colitis

91
Investigations for GI Bleed

• Anoscopy
• Sigmoidoscopy
• Colonoscopy
• Nuclear Bleeding Scans (Technetium-labeled RBC)
  and Angiography
• Small Intestine Video Capsule Imaging

92
Occult Obscure Gastrointestinal Bleeding

• FOBT (1 to 2.5 ) or
• iron deficiency anemia
• 5 of patients admitted cause not found

93
Review of causes of GI Bleed

• (1) neoplasms
• (2) vascular abnormalities (vascular ectasias,
  portal hypertensive gastropathy)
• (3) acid-peptic lesions (esophagitis, peptic
  ulcer disease, erosions in hiatal hernia)
• (4) infections (nematodes, especially hookworm
  tuberculosis)
• (5) medications (especially NSAIDs or aspirin)
  and
• (6) other causes such as inflammatory bowel
  disease.

94
Esophageal Disease
95
Primary Esophageal symptoms

• Heartburn,
• dysphagia, and
• odynophagia Erosions (corrosives/pills)/
  Infections (CMV/Herpes/Candidiasis)

96
Investigations

• Endosocpy
• Videoesophagography
• Barium studies
• Esophageal Manometry
• Esophageal pH Recording

97
GERD

• 20 affected
• Incompetent Lower Esophageal Sphincter

98
Hiatal hernia

• common and usually cause no symptoms
• leading to more severe esophagitis, especially
  Barrett's esophagus if gerd is present
• Heartburn an hour after meals and lying down
• Regurgitation
• Dysphagia

99
GERD

• Manage symptomatically for 4 weeks
• Then-Endosocpy- ?nerd
• Erosions present- Reflux esophagitis

100
(No Transcript)
101
Barretts esophagus intestinal metaplasia

• squamous epithelium of the esophagus is replaced
  by metaplastic columnar epithelium
• treated with long-term proton pump inhibitors
  /Surgery
• serious complication cancer esophagus/
  Stricture

102
Management of GERD

• lifelong disease that requires lifestyle
  modificationsavoid lying down within 3 hours
  after meals
• Elevating the head of the bed on 6-inch blocks or
  a foam wedge to reduce reflux and enhance
  esophageal clearance

103
Management of GERD

• avoid acidic foods (tomato products, citrus
  fruits, spicy foods, coffee)
• Avoid agents that relax the lower esophageal
  sphincter or delay gastric emptying (fatty foods,
  peppermint, chocolate, alcohol, and smoking)

104
Management of GERD

• Weight loss/ avoidance of bending after meals
  /and reduction of meal size
• Antacids - rapid relief of occasional heartburn
  (2 hrs of action) Gaviscon is an alginate-antacid
  combination that decreases reflux in the upright
  position
• H2 blockers
• ? Proton pump inhibitors

105
Barretts Esophagus
106
Chest Pain of Undetermined Origin (atypical
chest pain)

• 30 are non-cardiac
• Exclude cardiac causes first
• Chest Wall and Thoracic Spine Disease
• Gastroesophageal Reflux (50)
• Heightened Visceral Sensitivity
• Psychological Disorders
• Esophageal Dysmotility

107
Cancer of theEsophagus
108
Incidence and Mortalityin 2005

• Esophageal Cancer
• 14,520 new cases
• 13,570 deaths

• Gastric Cancer
• 21,860 new cases
• 11,550 deaths

U.S. 1,372,910 new cancer cases and 570,280
deaths
CA Cancer J Clin 2005 5510-30
109
Esophageal Cancer in the U.S.

• Esophageal Cancer
• 1 of all cancers diagnosed.
• Rapidly fatal.
• One of the most rapidly increasing cancers.

110
5 Year Survival ()

• Year of diagnosis
• Esophageal Gastric
• 1974 - 1976 5 15
• 1980 - 1982 7 18
• 1989 - 1996 12 21
• 2003 14 22

CA Cancer J Clin 5115-36 2001 cancer.gov 2003
111
Types of Esophageal Cancer
Squamous cell carcinoma (SCCA)
Adenocarcinoma of the distal esophagus Cancer of
the cardia Subcardial cancer
Non-cardia cancer
112
Esophageal Cancer
113
SEER Cancer Statistics Esophageal Cancer
114
Predisposing Factorsfor SCCA Esophagus

• Tobacco
• Alcohol
• Diet
• Chronic esophagitis

• Age
• Race
• Gender
• Role of HPV?

115
Other Risk Factors

• Previous head and neck or lung cancer (annual
  rate 3-7).
• Plummer-Vinson syndrome (Iron deficiency).
• Esophageal diverticulae.
• Lye strictures long latent period.
• Radiation injury (therapeutic, atomic bomb).
• Non-tropical sprue.

116
Adenocarcinomaof the Esophagus

• Incidence rates increased gt350 since the mid
  1970s.
• Increasing 20 per year in U.S.
• Even higher in U.K., Australia, Holland.
• Rates for gastric cardia adenocarcinoma also
  increased.

117
Adenocarcinomaof the Esophagus- Associated
Factors

• Obesity
• Reflux disease and Barrett's esophagus.
• Diet
• Smoking
• Scleroderma

118
Esophageal Adenocarcinomaand Obesity

• US study 4 x risk, highest quartile BMI compared
  to lowest.
• BMI gt30 vs BMI lt22, risk 16 fold.
• Similar trends in gastric cardia adenoca.

JNCI 90150-155, 1998
119
Esophageal Adenocarcinomaand Reflux Disease

• Swedish study Having reflux symptoms more than 3
  times a week associated with 17 fold increased
  risk.
• U.S. study daily GERD symptoms risk 5 times.

NEJM 340825-831, 1999 Cancer Causes Control
11231-238, 2000
120
Barrett's Esophagus

• Dysplastic changes in distal esophagus and
  gastroesophageal junction.
• 30-40 fold increase in adenocarcinoma of the
  esophagus.
• 10-15 of Barretts patients will develop
  adenocarcinoma.
• Risk of cancer is about 0.5 per year.

121
Malignant Transformationin Barrett's

• Long-standing gastroesophageal reflux.
• Field cancerization effect.
• Medical therapy does not reverse progression to
  malignancy.
• With ablation, new epithelium may grow over
  dysplastic clones.

122
Endoscopic Surveillance of Barretts Esophagus

• With high-grade dysplasia, 19-26 develop
  invasive cancer within 2 to 7.5 years.
• American College of Gastroenterology
• No dysplasia x 2 years q 2 years
• Low-grade dysplasia q 6 mo. x 2, then q year
• High-grade dysplasia surgery, ablation or EGD q
  3 mo.
• Am J Gastroenterol 1998 931028-1032

123
Presenting Symptoms

• Retrosternal discomfort or indigestion.
• Friction or burning when swallowing food.
• Dysphagia, odynophagia
• Weight loss.
• Hoarseness, cough
• Regurgitation, vomiting
• Hematemesis or melena (uncommon)

124
Poor Prognosis

• Significant dysphagia
• Occurs after 50-75 of the esophageal lumen is
  occluded.
• Extensive involvement of esophagus and
  surrounding structures in 90 of cases.
• Persistent substernal pain unrelated to
  swallowing
• May indicate mediastinal disease.

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Poor Prognosis

• Coughing after swallowing
• Indicates tracheoesophageal fistula is present.
• Hiccups
• Indicates involvement of diaphragm

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Diagnosis of Esophageal Ca.

• In the United States, most patients present with
  advanced stage disease.
• At least have 75 have locoregional extension or
  distant metastases that prevent surgical cure.

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Staging Primary Tumor (T)

• T1 Tumor invades lamina propria or submucosa
• T2 Tumor invades muscularis propria
• T3 Tumor invades adventitia
• T4 Tumor invades adjacent structures

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Staging

• Endoscopy
• Endoscopic ultrasound
• CT scans
• Mediastinoscopy or Laparoscopy
• (PET Scan)

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Endoscopic Esophageal Ultrasound

• Accurate in determining depth of tumor invasion
  in 60-90 of cases.
• Demonstrates transition between normal and
  pathologic esophagus.
• Can be used to identify lymph node metastases
  (accuracy 73-81).
• Limitation must be able to pass through
  malignant stenosis.

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Therapy Cancerof the Esophagus

• Complete resection is the goal.
• If complete resection not possible, no role for
  palliative resection.
• No survival benefit.
• Palliation of dysphagia with stents or combined
  chemoradiotherapy.

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Surgical Approaches for Esophageal Cancer
Ivor-Lewis Esophagectomy 3 Field Esophagectomy
Transhiatal Esophagectomy
The Oncologist 1999 495.
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Five Year Survival inResected Patients

• Tumor confined to esophagus 50
• Involvement of adjacent tissues 15
• Involvement of regional nodes 10
• Overall survival 20-25

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Comparison of Treatment Modalities Median
Survivals

• Surgery
• 16.5 months
• Radiotherapy and Chemotherapy
• 14.5 months
• Surgery, Radiotherapy, Chemotherapy
• 16-18.6 months

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Stents
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Gastric Diseases

• Peptic Ulcer

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Peptic Ulcer

• nonspecific epigastric pain (8090 ) related to
  meals
• characterized by rhythmicity and periodicity.
• 20 present with ulcer complications without
  prior symptoms

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Peptic Ulcer

• Of NSAID-induced ulcers, 3050 are asymptomatic.
  
• Upper endoscopy with antral biopsy for H pylori
  is the diagnostic procedure of choice in most
  patients.
• Gastric ulcer biopsy or documentation of complete
  healing necessary to exclude gastric malignancy.

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Peptic Ulcer

• 500,000 new cases per year of peptic ulcer and 4
  million ulcer recurrences
• Life time risk 10
• 95 duodenal MgtF
• DU 30-55 ages/ GU 55-70 ages
• More in smokers and NSAID users

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Peptic Ulcer Causes

• NSAIDs GU risk increases by 40
• chronic H pylori infection, and
• acid hypersecretion

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H pylori-Associated Ulcers

• one in six infected patients will develop
  duodenal ulcer
• Without antibiotics 85 ulcers will recur within
  1 year

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Peptic Ulcer

• Epigastric pain (dyspepsia) 80-90
• Can be silent
• Related to meals 50
• Nocturnal pain
• Periodic pain
• Nausea/vomiting
• Anemia

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Peptic Ulcer Diagnosis

• Endosocpy

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Testing for H pylori

• Biopsy
• noninvasive assessment for H pylori with fecal
  antigen assay or urea breath testing

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Peptic Ulcer Therapy

• (1) acid-antisecretory agents,
• Proton pump inhibitors
• rabeprazole 20 mg,
• lansoprazole 30 mg,
• esomeprazole or pantoprazole 40 mg
• (2) mucosal protective agents Misoprostol
  (Cytotec) a prostaglandin analog
• and
• (3) agents that promote healing through
  eradication of H pylori.

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H pylori Eradication Therapy

• Combination regimens that use two antibiotics
  with a proton pump inhibitor-
• Proton pump inhibitor twice daily1
• Clarithromycin (Biaxin )500 mg twice daily
• Amoxicillin (Amoxil ) 1 g twice daily
• Given for 7-14 days

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Cancer Stomach

• Dyspeptic symptoms with weight loss in age 40
• Iron deficiency anemia occult blood in stools.
• detected on endoscopy
• Declining in USA MgtF
• higher in Latinos, African-Americans, and
  Asian-Americans
• Chile, Colombia, Central America, and Japan have
  high rates
• H pylori gastritis a risk factor
• pernicious anemia and past gastric surgery

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Signs

• Epigastric mass 20
• Supraclavicular lymphnode
• Umbilical/Ovarian Metastases
• FOBT/ Anemia

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Therapy

• Surgery- if early
• Palliation- 30
• fluorouracil, 5-FU (Adrucil) ,
• Doxorubicin(Adriamycin) , and
• Cisplatin (Platinol) or
• mitomycin (Mutamycin)
• Prognosis- 15