Disorders of the Upper Gastrointestinal Tract

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Disorders of the Upper Gastrointestinal Tract

• Dr. Aric Storck
• November 7, 2002

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objectives

• Review diagnosis and management of common
  disorders of the esophagus, stomach and duodenum
• Will not discuss
• disorders of bowel
• GI bleed covered next week

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Esophagus anatomy

• 25-30 cm
• Relation to adjacent structures
• Prevertebral fascia posteriorly
• Trachea / L mainstem bronchus/ heart anteriorly
• Fixed at origin
• Mobile throughout mediastinum
• Two layers
• Inner layer circular
• Outer layer longitudinal
• NB No serosal layer

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• Proximal 1/3
• Striated muscle
• Allows voluntary initiation of swallowing
• innvervated by spinal accessory nerve
• Middle 1/3
• Striated and smooth muscle
• Dorsal motor nerve of vagus
• Distal 1/3
• Smooth muscle
• Dorsal motor nerve of vagus

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Normal Healthy Esophagus
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Esophageal Obstruction

• 4 areas of narrowing
• Cricopharyngeus (upper esophageal sphincter)
• Aortic arch
• Left mainstem bronchus
• Diaphragmatic hiatus
• Large foreign body in esophagus can obstruct
  airway

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Esophageal obstructionclinical presentation

• Complete
• Unable to swallow
• Drooling
• Violent retching
• Pain from neck to epigastrium
• Proximal
• Sudden cyanosis
• Compression of trachea by food in upper esophagus
  or oropharynx

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Esophageal obstructioncauses

• Foreign bodies
• Coins, food, batteries
• Anatomic anomalies
• Carcinoma
• Schiatzkis ring
• Peptic / chemical stricture
• Extrinsic compression
• Thyroid enlargement
• Zenkers diverticulum
• Aortic arch
• Anomalous right subclavian artery
• Bronchogenic carcinoma

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Esophageal obstructiondiagnostic strategies

• Endoscopy
• Gold standard for diagnosis and treatment
• Plain radiographs
• If foreign body suspected
• Not seeing it does not rule it out
• Contrast studies
• Gastrograffin vs barium
• NBradigraphs contrast studies
• False negatives lt20
• False positives lt1
• CT scan

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Esophageal obstructionforeign body management

• Oropharyngeal
• Retrieve with Kelly / McGill forceps
• Esophageal
• Endoscopic removal
• Foley catheter (controversial)
• Lower esophagus
• Often food impaction
• Glucagon 1mg iv (maximum 2mg)
• Relax sphincter enough to allow passage of food
  in 50 of patients
• Affects only smooth muscle, thus not useful for
  proximal obstructions

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Reflux esophagitis stricture
pizza

• Food impacted proximal to stricture
• Could attempt glucagon

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Esophageal Strictures

• Caustic stricture
• Narrowing of 2/3 of esophagus due to caustic
  ingestion years ago
• Accidental in children
• Suicide
• Radiation stricture
• Smooth midesophageal stricture

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Esophageal obstructionforeign body management

• Effervescent agents (pop )
• Sharp objects
• Urgent intervention
• Cause intestinal perforation in 15-35
• Batteries
• button batteries urgent removal
• Zn, Li, Hg leakage causes toxicity
• Did you know . There is a National Button
  Battery Ingestion Hotline [phone]

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Bell in esophagus
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Case
A patient has been drinking heavily. He presents
to the emergency room after several hours of
severe vomiting and retching. He is complaining
of severe epigastric pain radiating to the back.
He has not had significant hematemesis. Diagnosis?
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Esophageal perforation

• Potentially life-threatening
• Boerhaaves syndrome
• Vomiting
• Valsalva maneuver
• Cough
• Childbirth
• Cough
• Iatrogenic
• Endoscopy
• Foreign body ingestion
• Trauma

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Esophageal perforationclinical presentation

• Upper esophagus
• Neck / chest pain
• Dysphagia
• Respiratory distress
• Fever
• Lower esophagus
• Abdo pain / pain radiating to back
• Pneumothorax
• Pneumomediastinum
• Subcutaneous emphysema (Hammans Sign)

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Esophageal perforationDiagnosis

• CXR / upright AXR
• Subcutaneous emphysema
• Pneumomediastinum
• Mediastinal widening
• Pleural effusion
• Contrast studies
• Gastrograffin/barium
• CT
• Mediastinal air
• Extraluminal contrast
• Fluid collections

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Boerhaaves Syndrome

• Esophageal rupture
• Contrast filling rounded area adjacent to distal
  esphagus
• Arrows rupture

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Esophageal PerforationTreatment

• Aggressive treatment
• Boerhaaves
• Unstable
• Contamination of mediastinum/pleura
• Tx with broad spectrum ABX
• Conservative treatment
• Stable, afebrile
• Endoscopic injury
• Delayed presentation

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Case

• A 42 year old woman comes to emergency
  complaining of trouble swallowing. The food seems
  to get stuck in her throat. This has been
  happening for several weeks. What has she got?

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Dysphagia

• From Greek dys difficult phagia eating
• sensation of food getting stuck
• /- pain
• indicates esophageal problem
• oropharyngeal
• esophageal
• 12 of patients in acute care hospital
• up to 50 of patients in chronic care

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Oropharyngeal dysphagia

• Inability to transfer food to esophagus
• food sticks immediately after swallowing
• neurological
• cortical - pseudobulbar palsy (UMN lesion) due to
  bilateral stroke
• bulbar - ischemia, tumour (LMN)
• peripheral - polio, ALS

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Oropharyngeal dysphagia

• Muscular
• muscular dystrophy
• cricopharyngeal incoordination
• failure of UES to relax with swallowing
• Zenkers diverticulum

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Esophageal Dysphagia
Solid food only
Solid or liquid food
Mechanical obstruction
Neuromuscular disorder
intermittent
progressive
intermittent
progressive
Reflux Sx
Respiratory symptoms
Lower esophageal ring/web
Agegt50
heartburn
DES
scleroderma
achalasia
Peptic stricture
carcinoma
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Achalasia

• Incomplete relaxation of LES (resting pressure
  gt30mm Hg)
• etiology
• idiopathic - most common
• Chagas disease - Latin America
• secondary to cancer (esophagus, stomach)

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Achalasia - Complications

• Respiratory
• aspiration
• bronchiectasis
• lung abscesses
• GI
• malnutrition
• increased risk of esophageal cancer

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Achalasia - Diagnosis

• CXR
• absent air in stomach
• dilated fluid filled esophagus
• barium esophagogram
• prominent esophagus with birds beak
• esophageal motility study
• required for definitive diagnosis

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Achalasia - Treatment

• Nitrates, CCBs
• balloon dilatation of LES
• 50 successful
• 5 perforation
• Surgery
• Heller myotomy

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Barium esophagogram. The dilated esophagus ends
in a "bird's beak" that represents the
nonrelaxing loweresophageal sphincter.
Fluoroscopy during the swallow revealed no
meaningful peristalsis in the esophageal body.
Achalasia
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AchalasiaManometry

• Failure of LES relaxation
• Failure of peristaltic conduction to LES

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Diffuse Esophageal Spasm

• Normal peristalsis interspersed with abnormal
  high pressure waves
• unknown etiology
• diagnosis
• barium esophagogram - corkscrew pattern
• manometry
• treatment
• medical - nitrates, CCB, anticholinergics
• surgery - long myotomy

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DES

• Nutcracker esophagus
• note pseudodiverticula caused by spasm

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CASE

• A 51 year old woman presents with trouble
  swallowing. You also note generally tight skin,
  particularly around the fingers. She says she has
  Reynauds phenomenon. What is the most likely
  diagnosis?

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Scleroderma

• Microvascular disease and intramural neuronal
  dysfunction
• aperistalsis loss of LES tone
• reflux
• stricture
• dysphagia

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Scleroderma - Treatment

• GERD prophylaxis
• anti-reflux surgery - last resort

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Scleroderma

• Distal esophageal stricture

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CASE

• A teenager presents to the emergency department
  with a 2 day history of severe pain while
  swallowing. She has to spit out her saliva rather
  than swallow. She has acne and is taking
  tetracycline. Diagnosis?

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Esophagitis

• GERD (1 cause)
• Infectious esophagitis
• Pill esophagitis
• Caustic ingestion
• Radiation
• Sclerotherapy

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Infectious Esophagitis

• Rare in immunocompetent hosts
• Risk factors
• DM, EtOH, GCs, elderly
• Immunosuppressants, broad spectrum abx
• Candida albicans most common
• Viral HSV, CMV
• Bacterial uncommon
• Trypanosoma cruzi, cryptosporidium

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Infectious esophagitisclinical manifestations

• Odynophagia
• Dysphagia
• Solids liquids
• Fever (uncommon)
• Bleeding (uncommon)

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Esophagitis - diagnosis

• Endoscopy
• Infectious
• Candida white plaques
• Herpes vesicles
• Definitive dx via biopsy

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Candidal esophagitis

• Common in
• HIV
• Antibiotics
• Chemotherapy
• dysphagia
• Tx fluconazole

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HSV Esophagitis

• Common in
• Chemotherapy
• HIV
• Tx acyclovir

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Esophagitis

• Early Esophagitis
• Diffuse nodularity of mucosal surface
• Mod. Esophagitis
• Thickened folds and nodularity in distal
  esophagus
• Severe Esophagitis
• Diffuse ulcerations and stricture

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Infectious esophagitistreatment

• Candida
• Fluconazole 200mg po od x 3-4 weeks
• HSV
• Acyclovir 400mg po 5x/day x 2 weeks
• CMV
• Gancyclovir
• Foscarnet
• Antacids, topical anesthetics, sucralfate

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Pill esophagitis

• Pill fails to enter stomach and remains in
  esophagus
• Risk factors
• Age
• Decreased esophageal motility
• Compression
• Large pills

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Pill esophagitisclinical manifestations

• Sudden onset odynophagia
• /- dysphagia
• Hx of pill ingestion
• Could be hours previously
• /- sensation pill is stuck

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Pill esophagitistreatment

• Prevention
• 4oz liquid with any pill
• Medications taken in upright position
• Avoid use of pills if possible

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GERD

• Asymptomatic reflux in most people
• GERD reflux plus one of
• Histopathologic changes of esophageal epithelial
  lining
• Symptoms of reflux
• Symptomatic reflux in
• 7 daily
• 14 weekly
• 40 monthly

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GERD mechanisms

• Decreased LES pressure
• Anticholinergics
• Benzos
• caffeine,
• CCBs
• Ethanol
• Nicotine
• Nitrates
• progesterone

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GERD - mechanisms

• Decreased Esophageal Motility
• Achalasia
• DM
• Scleroderma
• Increased gastric emptying time
• Anticholinergics
• DM gastroparesis

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GERD - symptoms

• Heartburn
• Beware - mimics ischemic heart pain
• Regurgitation
• Dysphagia
• Odynophagia
• Asthma
• Aspiration
• activation of vagal reflex arc
• Oropharyngeal
• Laryngitis, dental erosions, etc.

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GERD complications

• Erosion, ulceration, scarring
• Esophagitis
• Stricture
• Columnar metaplasia
• Barretts esophagus
• Predisposes to adenocarcinoma

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GERD - diagnosis

• History and physical
• Relief with antacids
• pH monitoring
• Esophageal manometry
• endoscopy
• Must R/O ischemic heart disease!!

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GERD

• Erosions/ulcerations caused by acid reflux

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Barretts Esophagus

1. Barretts esophagus ulceration of
   posterolateral wall
2. Midesophageal stricture from healed Barretts
   ulcer
3. Adenocarcinoma secondary to Barretts esophagus

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GERD - treatment

• Lifestyle
• Sleep upright
• Avoid eating before bed
• Avoid agents that decrease LES tone
• Nicotine, etoh, anticholinergics
• Decrease acid production
• H2-blockers
• eg ranitidine 150mg po bid
• Improvement in 70-90 of patients
• PPI

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GERD - treatment

• Acid neutralization
• OTC antacids
• Protect mucosa
• sucralfate

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Gastritis

• Histologic diagnosis of inflammation of gastric
  mucosa
• etiology
• H.pylori (1)
• NSAIDs (2)
• Ethanol, potassium, iron
• often underlying cancer, ulcer, etc.
• other infectious organisms (viral, mycobacterial,
  etc.)
• Corrosive agents
• Bile
• Ingested acids/alkali

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Gastritis - clinical presentation

• Variable non-specific
• asymptomatic
• abdominal pain
• nausea and vomiting
• GI bleed (rare)
• shock (rare)

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Gastritis

• Complications
• Perforation
• Gastric outlet obstruction
• Diagnosis
• Usually clinical
• Must rule out other potential causes of pain
• Endoscopy /- biopsy

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Gastritis - treatment

• H2 antagonists
• Consider H.pylori eradication
• refer to GI as outpatient if persistent

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Gastric Volvulus

• Rare (400 cases in literature)
• Caused by gt180 degree rotation of stomach upon
  itself
• Usually aged 40-50 y.o.
• 20 in children lt1
• Often have paraesophageal hernia
• Complications
• Gastric ischemia perforation
• Death (15-20)

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Gastric volvulus

• Clinical presentation
• Sudden, severe abdo pain
• May radiate to chest or back
• Vomiting
• Borchardts triad
• Epigastric pain distension, vomiting, inability
  to pass NG tube
• Diagnosis
• AXR large gas-filled loop of bowel
• Treatment
• Insertion of NG tube
• Decompresses and may reduce volvulus
• Surgery

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Peptic Ulcer Disease

• Erosion
• superficial to muscularis mucosa
• no scarring
• Ulcer
• penetrates muscularis mucosa
• scarring

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PUD - epidemiology

• 4 million in US
• 15 billion in US

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PUD - etiology
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PUD H. pylori

• Gram negative rod
• Lives in upper GI tract between epithelial
  surface and mucus
• fecal-oral transmission
• Increases risk of gastric cancer
• Almost all non-NSAID ulcers are due to H.pylori
  (95 duodenal, 84 gastric as per Rosen)
• Dx serology, biopsy, C14 breath test
• Not practical for emergency medicine

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PUD NSAIDs

• Direct effect
• Diffuse into mucosal cells
• Become trapped and directly damage cell
• Inhibition of prostaglandin secretion
• Reduced mucus production
• Reduced cell turnover
• Indirect effect
• Systemic inhibition of COX decreases production
  of protective prostaglandins

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PUD Hx and Px

• Abdominal pain (94)
• Generally epigastric
• Usually worst 2-4 hours after meal
• Often between 2-3AM (HCl secretion highest)
• Relieved with antacids
• Duodenal ulcer
• Pain worst before meal
• Relieved by meal

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PUD Diagnosis Workup

• History and clinical exam
• Endoscopy
• Upper GI series
• Labs CBC, lytes, LFT, lipase
• Imaging CXR / AXR if suspected perforation
• Cardiac workup if suspect MI/ACS

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Duodenal Ulcer (Huge!)

• Note fresh bleeding at edge
• gt90 H.pylori
• NSAIDS

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Gastric Ulcer

• Clean, well demarcated, benign looking
• All should be biopsied as high risk of cancer

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Stomach Ulcer

• Upper GI with barium contrast
• Arrow ulceration

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PUD - complications

• Upper GI bleed (15)
• Posterior surface (gastroduodenal art.)
• Tx resuscitation, endoscopy, PPI, surgery
• Perforation (7)
• Usually anterior duodenal ulcers
• Sudden generalized peritonitis
• Dx free air on CXR
• Tx surgery oversew ulcer and Graham patch,
  antrectomy vagotomy

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PUD - complications

• Gastric outlet obstruction (2)
• Nausea / Vomiting
• Caused by edema and scarring
• Tx surgery
• Penetration
• Posterior duodenal ulcers erode into pancreas
• Hx of epigastric pain that worsens and radiates
  to back. Becomes refractory to tx
• Lab elevated amylase

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PUD - treatment

• Lifestyle modifications
• Reduce caffeine, EtOH, spicy foods
• Smoking cessation
• Stop NSAIDs
• NSAID induced ulcer
• Stop NSAID
• PPI
• H2-blocker (less effective than PPI)

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PUD - treatment

• PUD in patient not taking NSAIDs
• Treat for H.pylori
• PPI
• H2-blocker

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H.pylori eradication

• Multiple regimes and commercially packaged
  products
• eg
• PrevPac x 14 days
• Lansoprazole 500 po bid, clarithromycin 500 po
  bid, amoxicillin 1g po bid x 14 days
• Many other acceptable cocktails