GIT system

GORD:Definition: Reflux of gastric contents to the oesophagus.

Pathogenesis:1- Decreased lower osephageal sphincter tone2- Defective oesophageal motility 3- Delayed oesophageal emptying4- Hiatus hernia.

Clinical features:1- Heartu burn, affected with position, and pain on drinking hot fluids, akcohol2- Regurgitation, nocturnal, and when lying down 3- Iron deficiency anaemia Lx:1- 24-Hour intraluminal PH monitoring2- Manometry3- Barium swallow 4- Esophagoscopy

Complications:1-Esophagitis2- Benign oesophageal stricture4- Barretts oesophagus5- Iron deficiency anaemia, and haematemesis 6- Aspiration pneumonia

TTT:A- General measures:Weight reductionStop smokingMeals in small volumes Avoid alcohol, caffeinated drinks, fatty food, chocolate, night meals, acidic drinks, anticholinergic drugs, ca-channel blockers.B-Medical treatment:1- Antacids, e.g; Magnisium trisilicate, aluminium, hydroxide 5-10 ml TID before meals and one at bed time.2-Proton-pump inhibitors: Omeprazole 20mg TID3-H2-receptor antagonist: Ranitidine 150mg BID, Famotidine 20mg BID5- Prokinetic drug: Metoclopramide 10 mg TID, Domparidone one tab TID

C- Eradication of helicobacter pylori:Amoxicillin (1g BID), Clarithromycin (250mg), Omeprazole

D- Surgical treatment:Fundoplication( wrapping the fundus to oesophagus)

Achalasia: Definition: This is a motility disorder.. impaired relaxation in LOS and aperistalsis in the lower 2/3 of the oesophagus. Results from degeneration of the inhibitory neurones in the myenteric (Auerbachs) plexus.

Pathogenesis:Hypertonic LOS which fails to relax, lower oesophagus. Failure of peristalsis due to degeneration of the ganglion cells in the myenteric nerve plexus in the sphincter and the body of the oesophagus.

Clinical features: 1-intermittent Dysphagia for both liquids and solids2-Regurgitation, particularly at night, of undigested food.3-Retrosternal chest pain, which is severe.4-increased the habit of drinking large amounts of liquids5-Nocturnal cough, and weight loss.

Lx:1-CXR; dilated oesophagus with multiple fluid level behind the heart, fundus gas not present.2- Barium swallow: Food collection in the LOS give the appearance of (Swan neck = Rat tail= birds beak).3-Endoscopy: to exclude carcinoma, and mechanical obstruction.4-CT: to exclude intramucosal carcinoma5-manometry: 1-it shows pressure in oesophagus grater than the stomach, due to fluid filled oesophagus.( increase in resting LOS pressure)2-Incomplete relaxation (50%)3-absence of peristalsis..

TTT:1-General measures: Chew food well, sleep with trunk elevated, avoid eating before sleep.2- Medical therapy:Antimuscarinic agents(Dicyclomine), sublingual nitroglycerin, and ca-channel blockers. Last 2 are useful in short term ttt.1-Endoscopic: pneumatic / hydrostatic/mechanical dilatation, botulinum toxin injection2-Surgical: modified Heller cardiomyotomy usually complicated with GORD so Fundiplication is done after this operation.

Note: Malignancy may mimic achalasia(psuedoachalasia). Mechanical obstruction.

Diffuse oesophageal spasm:

Definition:This is motility disorder in which normal peristalsis is interrupted by non-peristaltic contraction. Also known as nutcracker oesophagus (pressure> 200 mmHg).The sphincter is normal.

Clinical features:1-Noncardiac retrosternal chest pain, it may radiate to the Back, neck, arm. Thus mimicking angina.2-dysphagia precipitated by ingestion of hot or cold liquids; relived bynitroglycirn .

Lx:1-Upper GI barium swallow, itll show crockscrew2-Oesophgeal manometery is diagnostic, it shows multiple simultaneous contractions after swallow, and sphincter response is normal.

TTT:1-Medical treatment:Nitrates and ca-channel blockers. Tricyclic antidepressant Oesophagotomy only used when the patient is incapacitated by symptoms.

Cancer of the oesophagus:

Definition: in the upper 1/3 it is rare 15%. In ht middle 1/3 is squamous carcinoma. In the lower 1/3 is adenocarcinoma.Five year survival rate 5%-15%, has poor prognosis.

Staging:I- tumour invades lamina propria or submucosa, -ve LNII- a tumour invades muscularis propria or adventitia with ve LN IIb invades muscularis propria with +ve LNIII- tumour invades adventitia with +ve LN, or invades adjacent structures (+ve LN)IV- distant metastasis.( lung, liver, bone)

Clinical features:1- Progressive dysphagia first for solid then liquids.2- Weight loss3- Anorexia4- Odynophagia suggest mediastinal invasion.5- Haematemsis, hoarseness of the voice6- Aspiration pneumonia, coughing, pleural effusion(fistula between oesophagus and trachea)7- Chest pain( site of obstruction. Lx:1- Barium/ upper endoscopy required for definitive diagnosis.2- Transoesophageal ultrasound has 90% accuracy to assess the depth of the infiltration. 80% for LN staging.3- Full metastatic work up( CT/MRI chest, abdomen, CXR, bone scan).4- Poistron emission tomography (PET) high specificity for distant metastasis.TTT:1- Chemotherapy and radiation before suregery prolongs survival2- Oesophagotomy is curative for stage 0, 1 , or 2A3- Palliative is the goal in most patient.(using expanding metal stent, photocoagulation, alcohol injection, 4- photodynamic to reduce the tumours bulk).Notes:- Oesophageal cancer metastasise early due to lace of serosa.SCC associated with tobacco& alcohol.-GORD mimic cough-variant asthma.PT with GORD should -avoid coffee, chocolate, garlic, onions, and nicotine.

Hiatal hernia:

Definition: there are 2 types of hiatal hernia, sliding type1, paraoesophageal type 2.

Sliding hernia type 1: accounts for 90% of cases. Gastroesophgeal junction above the diaphragm. This is a benign finding associated with GORD.-Paraoesophageal hiatal hernia: accounts for 5% the stomach herniates into the thorax but the gastroesophageal junction remains below the diaphragm, very serious one and can be strangulated and should be surgically repaired.

Clinical features:Majority are asymptomatic.Heartuburn, chest pain, and dysphagia.

Complications:Type1: GORDm reflux oesophagitis, aspiration pneumoniaType2: life threatening and include obstruction, haemorrhage, incarceration, and strangulation.

LX: barium amd upper GI endoscopy.

TTT:Type 1: life style modification ( small meals, elevation of the head after meals, and antacids) 15% require surgery ( Nissens fundoplication) if there is no response to medical therapy.Type2: elective surgery( gastroplexy) attachement of the stomach to the rectus seath and closure of the hernia.

Mallory Weiss syndrome:

Definition:Mucosal tear results from sudden increase in intra-abdominal pressure, due to forceful vomiting, or retching. Associated with binge drinking of alcohol.

Clinical features: Haematemesis always present and variant. With positive hx

Lx: endoscopy is diagnostic

TTT:1- 90% stop bleeding without any intervention.2- ABCDE, and stabilise the patient.3- Oversewing the tear, angiographic embolization4- Acid suppression to promote the healing.

Plummer-vinson syndrome (Upper Esophageal web):Key features: all causes of dysphagia, iron deficiency anaemia, kiolonychia, atrophic oral mucosa.Ten percent>> SCC in oral cavity, hypopharynx, oesophagus.

TTT:Oesophageal dilatation; correct nutritional deficiency.

Schatzkis Ring( Distal oesophageal webs)

Defintion:Circumferential ring in the lower oesophagus that is always accompanied by sliding hernia. Clinical picture:Mild to moderate dysphagia

Complications:Ingestions of Alkali may lead to ulcerative necrosis and then full thickness necrosis.Stricture formation, oesophageal cancer.

TTT:Oesophgeal dilatation, or antireflux surgery.OesophagectomyGastric lavage to avoid vomiting.Steroids amd antibiotics

Esophgeal diverticula:Definition: It is caused by underlyging motility disorder.Types of diverticula:1- Zenkers diverticulum: common in the upper third of the oesophagus, is failure of the cricopharngeal muscle to relax. Presented as dysphagia, regurgitation, halitosis, weigh loss, and chronic cough.2- Traction diverticula: midpoint due to pulmonary TB it causes hilar node scarring which causes traction.3- Epiphrenic diverticula: found in the lower third of oesophagus, associated with spastic pes[hgeal dysmotility or achalasia. Lx: barium swallow is dagnosticTTT: cricopharngeal myotomy, then oesophageactomy, divertuclotomy. =====Oesophgeal perforation:

Defintion:

Causes: blunt trauma, medical tubes, and instruments, forceful vomiting (Boerhaaves syndrome).

Clinical features: chest pain, tachycardia, hypotension, tachypnoea, dyspnoea, fever, Hammans sigh(mediastinal crunch), pneumothorax, pleural effusion.

Lx:Contrast oesophgram is definitive diagnostic study.CXR air in the mediastinum.

TTT:Stabilise the patient; IVF, NPO, antibiotic, and H2 bockers if the perforation is large-surgery within 24 hours

Book notes:Mallory-weiss syndrome: mucosal tear at the gastroesophageal junction.

-Boerhaaves syndrome: transmural tear( causing oesophageal perforation).

Check page 153 ub step-up medicine.

Done.

Diseases of the stomach

Peptic ulcer disease:

Complications of PUD:1- perforation2- gastric outlet obstruction3- GI bleeding