TUCOM
Internal Medicine: 4
th
Stage
Dr.Hassan
Page 1 of 7
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GASTROINTESTINAL TRACT
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DISEASES OF THE ESOPHAGUS:
Learning objectives:
1. Review the functional anatomy and physiology of esophagus.
2. Understand the concept of Gastro-esophageal reflux disease (GERD).
3. List the factors that associated with development of GERD.
4. Explain the clinical features of GERD.
5. List the important investigations and it’s indications in patients with GERD.
6. Review the treatment of GERD.
7. List the complications of GERD.
8. List other causes of esophagitis.
9. List the motility disorders of esophagus.
10. Describe the definition, pathogenesis, and clinical presentation of achalasia.
11. Outline the important investigations of achalasia.
12. review the treatment of achalasia.
13. List the types of esophageal carcinoma.
14. Recognized the epidemiology of esophageal carcinoma.
15. Understand the difference between squamous cell carcinoma and adenocarcinoma
of esophagus.
16. Known the clinical features of esophageal carcinoma.
17. List the important investigations of esophageal carcinoma.
18. Outline the treatment of esophageal carcinoma.
Esophagus:
• This muscular tube extends 25 cm from the cricoid cartilage to the cardiac orifice of the
stomach. It has an upper and a lower sphincter. It is lined by stratified squamous
epithelium. The muscle layers of the upper esophagus are striated skeletal muscle, while
the muscles of lower part are smooth.
• A peristaltic swallowing wave propels the food bolus into the stomach.
GASTRO-ESOPHAGEAL REFLUX DISEASE:
• Gastro-esophageal reflux disease (GERD) develops when the esophageal mucosa is
exposed to gastric contents for prolonged periods of time, resulting in symptoms and, in
a proportion of cases, esophagitis.
• Gastro-esophageal reflux resulting in heartburn affects approximately 30% of the general
population.
TUCOM
Internal Medicine: 4
th
Stage
Dr.Hassan
Page 2 of 7
Factors associated with the development of (GERD):
1. Obesity and dietary factors.
2. Defective oesophageal clearance.
3. Abnormal lower esophageal sphincter:
1. Reduced tone.
2. Inappropriate relaxation.
4. Hiatus hernia.
5. Delayed gastric emptying.
6. Increased intraabdominal pressure.
Hiatus hernia:
• Hiatus hernia: An anatomical abnormality in which part of the stomach protrudes up
through the diaphragm into the chest.
• Causes reflux because the pressure gradient between the abdominal and thoracic
cavities, which normally pinches the hiatus, is lost. In addition, the oblique angle between
the cardia and esophagus disappears. Many patients who have large hiatus hernias
develop reflux symptoms.
Types of hiatus hernia:
1. Sliding.
2. Rolling or paraesophageal.
Clinical features of GERD:
• Major symptoms; are heartburn and regurgitation, often provoked by bending, straining
or lying down.
• Waterbrash; which is salivation due to reflex salivary gland stimulation as acid enters the
gullet.
• Others develop odynophagia or dysphagia. A few present with atypical chest pain which
may be severe, can mimic angina and is probably due to reflux-induced esophageal
spasm.
Complications:
1. Esophagitis: A range of endoscopic findings, from mild redness to severe, bleeding
ulceration with stricture formation.
2. Barrett's esophagus: ('columnar lined oesophagus'-CLO) is a pre-malignant glandular
metaplasia of the lower esophagus, in which the normal squamous lining is replaced
by columnar mucosa of intestinal metaplasia. CLO is the major risk factor for
esophageal adenocarcinoma. Diagnosis of this condition requires multiple biopsies
from suspected area to detect intestinal metaplasia and/or dysplasia. Neither potent
acid suppression nor antireflux surgery will stop progression or induce regression of
CLO. Esophagectomy is widely recommended for those with high grade dysplasia.
TUCOM
Internal Medicine: 4
th
Stage
Dr.Hassan
Page 3 of 7
3. Anaemia; Iron deficiency anaemia occurs as a consequence of chronic, insidious
blood loss from long-standing esophagitis.
4. Benign esophageal stricture; Fibrous strictures develop as a consequence of long-
standing esophagitis.
5. Gastric volvulus; Occasionally a massive intra-thoracic hiatus hernia may twist upon
itself.
Investigations:
• Young patients who present with typical symptoms of gastro-esophageal reflux, without
worrying features such as dysphagia, weight loss or anaemia, can be treated empirically
without investigation.
• Is advisable if patients over 55 year old, if symptoms are atypical or if a complication is
suspected or if there is no response to empirical treatment.
• Investigations include:
1. Endoscopy is the investigation of choice. This is performed to exclude other upper
gastrointestinal diseases which can mimic gastro-esophageal reflux, and to identify
complications.
2. Twenty-four-hour pH monitoring is indicated if, despite endoscopy, the diagnosis is
unclear or surgical intervention is under consideration.
1) A slim catheter with a terminal radiotelemetry pH-sensitive probe above the
gastro-esophageal junction.
2) episodes of pain are noted and related to pH. A pH of less than 4 for more than
6-7% of the study time is diagnostic of reflux disease.
Management:
1. Lifestyle advice; including weight loss, avoidance of dietary items which the patient
finds worsen symptoms, elevation of the bed head in those who experience nocturnal
symptoms, avoidance of late meals and giving up smoking.
2. Antacids and alginates; also provide symptomatic benefit.
3. H
2
-receptor antagonist drugs; also help symptoms without healing esophagitis.
4. Proton pump inhibitors; are the treatment of choice for severe symptoms and for
complicated reflux disease.
5. Anti-reflux surgery; Patients who fail to respond to medical therapy, those who are
unwilling to take long-term proton pump inhibitors and those whose major symptom is
severe regurgitation.
OTHER CAUSES OF ESOPHAGITIS:
1. Infection; Esophageal candidiasis, Herpes simplex virus, Cytomegalovirus (CMV)
,and HIV infection .
2. Corrosives; Strong household bleach or battery acid .
3. Drugs; Tetracyclines, potassium preparations, nonsteroidal anti-inflammatory drugs,
iron sulfate, and the bisphosphonate alendronate.
TUCOM
Internal Medicine: 4
th
Stage
Dr.Hassan
Page 4 of 7
• Candida esophagitis is often associated with oral thrush and tends to present with
dysphagia and only mild pain on swallowing. It has a characteristic appearance on
endoscopy, and esophageal brushings and biopsies demonstrate fungal hyphae.
Treatment with oral fluconazole is generally very effective.
• Herpes simplex virus causes multiple esophageal ulcers and presents clinically with severe
odynophagia. Acyclovir
is the treatment of choice for
herpes esophagitis.
• Cytomegalovirus (CMV) also
causes esophageal ulceration
and odynophagia. Endoscopy
usually demonstrates a single
l arge u l cer i n the d i s ta l
esophagus, and biopsies often
detect viral inclusions that
confirm the diagnosis. Both
ganciclovir and foscarnet are
effective treatments for CMV
esophagitis.
MOTILITY DISORDERS:
1. Pharyngeal pouch; Incoordination of swallowing within the pharynx leads to
herniation through the cricopharyngeus muscle and formation of a pouch.
2. Diffuse esophageal spasm.
3. Achalasia of the oesophagus.
4. Secondary causes; systemic sclerosis, Dermatomyositis, rheumatoid arthritis and
myasthenia gravis.
PHARYNGEAL POUCH:
• Most patients are elderly and have no symptoms, although regurgitation, halitosis and
dysphagia can occur. Some notice gurgling in the throat after swallowing. A barium
swallow demonstrates the pouch and reveals incoordination of swallowing, often with
pulmonary aspiration. Endoscopy may be hazardous since the instrument may enter and
perforate the pouch. Surgical myotomy and resection of the pouch are indicated in
symptomatic patients.
Diffuse esophageal spasm:
• Episodic chest pain which may mimic angina, but is sometimes accompanied by transient
dysphagia. Some cases occur in response to gastro-esophageal reflux.
• Treatment is based upon the use of proton pump inhibitor drugs when gastro- esophageal
reflux is present. Oral or sublingual nitrates or nifedipine may relieve attacks.
TUCOM
Internal Medicine: 4
th
Stage
Dr.Hassan
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ACHALASIA OF THE OESOPHAGUS:
Pathophysiology;
• Achalasia is characterised by:
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A hypertonic lower esophageal sphincter: which fails to relax in response to the
swallowing wave.
-
Failure of propagated esophageal contraction: leading to progressive dilatation of
the gullet.
Cause;
1. Is unknown.
2. Abnormal nitric oxide synthesis within the lower esophageal sphincter.
3. Degeneration of ganglion cells within the sphincter and the body of the esophagus
occurs.
4. Loss of the dorsal vagal nuclei within the brain stem.
5. Chagas disease.
Barium swallow findings: Tapered narrowing of the lower esophagus, esophageal body is
dilated, aperistaltic and food-filled.
Clinical features:
• Usually develops in middle life;
• Dysphagia develops slowly, and is initially intermittent, it is worse for solids and is eased
by drinking liquids, and by standing and moving around after eating.
• Episodes of severe chest pain due to esophageal spasm('vigorous achalasia').
• Nocturnal pulmonary aspiration develops.
• Predisposes to squamous carcinoma of the esophagus.
Investigations:
• Chest X-ray; widening of the mediastinum, aspiration pneumonia.
• A barium swallow; tapered narrowing of the lower esophagus, esophageal body is
dilated, aperistaltic and food-filled.
• Endoscopy; must always be carried out, carcinoma of the cardia can mimic the
presentation and radiological and manometric features of achalasia ('pseudo-
achalasia').
• Manometry; confirms the high-pressure, non-relaxing lower esophageal sphincter with
poor contractility of the esophageal body.
Management:
• Endoscopic Forceful pneumatic dilatation improves symptoms in 80% of patients. Some
patients require more than one dilatation, injection of botulinum toxin into the lower
esophageal sphincter.
TUCOM
Internal Medicine: 4
th
Stage
Dr.Hassan
Page 6 of 7
• Surgical myotomy ('Heller's operation') with anti-reflux procedure. Proton pump inhibitor
therapy is also often necessary. Because it may be complicated by gastro-esophageal
reflux.
OESOPHAGEAL STRICTURE:
CAUSES;
1. Gastro-esophageal reflux disease
2. Webs and rings
3. Carcinoma of the esophagus or cardia
4. Extrinsic compression from bronchial carcinoma
5. Corrosive ingestion
6. Post-operative scarring following esophageal resection
7. Post-radiotherapy
8. Following long-term nasogastric intubation
CARCINOMA OF THE ESOPHAGUS:
1. Squamous cell carcinoma; rare in Western, common in Iran, parts of Africa and
China, mostly in upper 2 third of the esophagus.
• Aetiological factors;
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Smoking.
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Alcohol excess.
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Chewing betel nuts or tobacco.
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Coeliac disease.
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Achalasia of the esophagus.
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Post-cricoid web.
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Post-caustic stricture.
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Tylosis (familial hyperkeratosis of palms and soles).
2. Adenocarcinoma; In Western populations, in the lower third of the esophagus, from
Barrett's esophagus or from the cardia of the stomach.
Clinical features:
• Progressive, painless dysphagia for solid foods.
• In late stages weight loss is often extreme.
• Chest pain or hoarseness suggests mediastinal invasion.
• Fistulation between the esophagus and the trachea or bronchial tree; pneumonia and
pleural effusion.
• Metastatic spread is common.
Investigations:
• Endoscopy; The investigation of choice, with cytology and biopsy.
• Barium swallow ; site and length of the stricture .
• Thoracic and abdominal CT
• Endoscopic ultrasound (EUS)
TUCOM
Internal Medicine: 4
th
Stage
Dr.Hassan
Page 7 of 7
Management:
1. Esophageal resection; overall 5-year survival rate is 6-9%. 70% of
patients have extensive disease at presentation.
2. Neoadjuvant (pre-operative) chemotherapy with agents such as cisplatin
and 5- fluorouracil.
3. Radiotherapy; squamous carcinomas are radiosensitive.
4. Palliative treatment;
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Relief of dysphagia and pain, laser therapy.
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Insertion of stents.
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Radiotherapy to shrink tumour size.
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Nutritional support.
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Analgesia.
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