GIT

Anatomy Physiology Clinical features Investigations Diseases of oesophagus

The esophagus is a muscular tube approximately 25 cm long. The musculature of the upper 5%, including the upper esophageal sphincter, is striated; the middle 40% has mixed striated and smooth muscle, the distal 55% is entirely smooth muscle.

Incisor teeth

Cricopharyngeal constriction
Aortic and Bronchial constriction
DiaphragmaticAnd “sphnicter”constriction 15
25
40


The parasympathetic nerve supply is mediated by the vagus. There are an upper and a lower esophageal sphincters.


The main function of the oesophagus is to transfer food from the mouth to the stomach. The initial movement of food from the mouth is voluntary.

The upper esophageal sphincter is normally closed at rest and serves as; * a protective mechanism against regurgitation of esophageal contents into the respiratory passages. * Also it serves to stop air entering the esophagus.



The lower esophageal sphincter(LOS) is a physiological sphincter, about 3-4 cm in length and has a pressure of 10-25 mmHg. The tone of it is influenced by many things including food, gastric distension, smoking, and GI hormones. Its main function is to prevent gastric and duodenal contents from refluxing into the lower esophagus.

Symptoms

Dysphagia is the term used to describe difficulty, but not necessarily pain, on swallowing. The type of dysphagia is important; it may be dysphagia for solids or fluids, intermittent or progressive.

Symptoms

Odynophagia It refers to pain on swallowing. Regurgitation and reflux Regurgitation strictly refer to the return of esophageal contents from above an obstruction in the esophagus. Reflux is the passive return of gastroduodenal contents to the mouth.

Symptoms

Chest pain Chest pain similar in character to angina pectoris may arise from an esophageal cause. Other symptoms of esophageal disorders include; loss of wt, anemia, cachaxia, change of voice, and cough.

Investigations

Radiography Plain X ray; may show opaque foreign bodies. Contrast radiography (Barium swallow) is a useful investigation for demonstrating narrowing, space-occupying lesions, anatomical distortion or abnormal motility.


Is the investigation of first choice for most oesophagial disorders. It is either for diagnostic or for therapeutic purposes. Diagnosis is by visual inspection of the inside of oseophagus and also by taking a biopsy or cytology specimen. For therapy, can be used for; Removal of FB Dilatation of strictures Oseophagial varices


Normal Endoscopic View of Oesophagus
Body of oesophagus
Lower oesophagus and cardia


There are two types; Rigid oesophagoscopy; which is now virtually obsolete. Disadvantages: Needs general anaesthesia, difficult to introduce, and carry high risk of perforation

Fibre-optic endoscopy

It has virtually supplanted the rigid instrument. It is done under local anaesthesia on an out-patient basis, easy to enter, and carry low risk of perforation.


Is widely used to diagnose oesophageal motility disorders. Recordings are usually made either by; Multilumen catheter Catheters with solid-state transducer


Prolonged measurement of oesophageal pH is now accepted as the most accurate method for the diagnosis of gastrooesophageal reflux.

Atresia and tracheo-oesophageal fistula Oesophageal stenosis Dysphagia lusoria

Foreign bodies in the oesophagus
A lot of things may become arrested in the oesophagus such as coins, pins, dentures. The commonest impacted material is food. Plain radiographs are the most useful examination. Endoscopy is good tool for the dx specially of non-opaque FB.

Foreign bodies in the oesophagus

Treatment: Flexible endoscopy is now the method of choice and the majority of objects can be extracted with suitable grasping forceps, a snare or a basket. An impacted food bolus will often break up and pass on if the patient is given fizzy drinks and confined to fluids for a short time

Perforation of the oesophagus

Perforation of the oesophagus is a serious condition that requires prompt diagnosis and treatment.Causes *Barotrauma _ Boerhaave’s syndrome So-called “spontaneous” perforation of the oesophagus is usually due to severe barotrauma when a person vomits against a closed glottis.

Boerhaave’s syndrome Usually at the lower third The clinical history is of severe pain in the chest or upper abdomen following a meal or a bout of drinking.

*Pathological perforation

Perforation of ulcers, such as a Barrett’s ulcer or tumours.*Penetrating ingury*Foreign bodies*Instrumental perforation

Diagnosis

Beware and beware of perforation Chest pain Subcutaneous emphysema in the neck Emphysema around the pericardium can be detected on auscultation as a mediastinal crunch Chest XR may show gas in the mediastinum

Diagnosis

Contrast swallow using barium suspension Treatment Prompt dx and treatment is essential for the best results There are two options: Operative Non-operative

Factors that favour Nonoperative Operative Small septic load Large septic load Minimal CV upset Septic shock Perforation confined to Pleura breached Mediastinum Endoscopic perforation Boerhaave syndrome Perforation of cervical Perforation of abdominal Oesophagus oesophagus
Management options in perforation of the oesophagus

Nonoperative management

AnalgesiaNil by mouthAntibioticsGeneral supportive care…IV fluidsWhen stable…enteral or paenteral nutritionNasogastric tube is not recommended

Operative management

It involves thoracotomy and repair of the perforation This is best done within a few hours of perforation

Corrosive injury Sodium hydroxide Sulphuric acid

Drug induced injury Antibiotic tab Potassium tab

Gastro-oesophageal reflux disease

Pathophysiology Competence of the gastro-oesophageal junction is dependent into: *Physiology of LOS; basal tone, length, intra-abdominal length *Anatomy of the cardia Diaphragmatic hiatus-Sliding hiatus hernia

Gastro-oesophageal reflux

Physiological reflux After meals Physiological reflux occurs during transient lower oesophageal sphincter relaxations(TLOSRs) Pathological reflux

Gastro-oesophageal reflux disease

Is by far the commonest condition affecting the upper GI tract. Its incidence increased during the last years; *Improvement of socioeconomic conditions H.pylori DU *Obesity


GORD
Reflux oesophagitis is a complication of GORD that occur in a minority of sufferers

Clinical features

Retrosternal burning pain( heartburn) Epigastric pain These are usually provoked by food, particularly fatty food. Unpleasant acidic taste In advanced cases there is a history of pain and reflux when lying flat or on stooping.

Clinical features

Odynophagia Less typical symptoms; Angina-like chest pain Pulmonary or laryngeal symptoms Dysphagia

Diagnosis of GORD

In the majority of cases the dx is assumed rather than proven and treatment is empiricalEndoscopy;To exclude serious pathologyReflux oesophagitisPeptic strictureBarrett’s oesophagus

Diagnosis of GORD

Oesophageal manometery 24-hours oesophageal pH recording Is the gold standard for the dx of GORD Barium swallow and meal; Gives the best appreciation of G-O anatomy but it is not important for the dx of GORD

Diffrential Dx

Achalasia and GORD are easily confused

Management of uncomplicated GORDNon-operative management

Medical management Simple medications; like Antacids, H2 receptor anagonists Simple measures; like Advice about wt loss, smoking, excessive consumption of alcohol, tea or coffee, and a modest degree of head up tilt of the bed

Non-operative management

Proton pump inhibitors; Omeprozole, Lansoprazole and pantoprazole are by far the most effective drug treatment for GORD

Operative managemnt

Indications: In uncomplicated GORD- Failure of medical therapy..PPI patient choice Disadvantages of surgery: 1- Mortality (0.1-0.5%) 2- Failed operation (5-10%) 3-Side effects; dysphagia, gas bloat(5-10%)

What operation

There are many antireflux operations for GORD;Total fundoplication …Nissen 360Disadvantage of Nissen: Overcompetent cardia….Dysphagia, gas bloat syndromePartial fundoplication …Belsy 240Disadvantage; high recurrence rateHill operation

Other antireflux procedures

Angelchik prosthesis Silastic prosthetic collar Partial gastrectomy with Roux-en Y reconstruction

What operative approach

AbdominalThoracicMinimal access surgery…Laparoscopic approach


Laparoscopic Fundoplication

Complications of GORD

Stricture …reflux induced stricture middle aged and elderly D.Dx from malignant strictureTreatment:DilatationLong-term PPI In younger and fit patients. Antireflux surgery

Complications Of GORD

Oesophageal shorteningReflux oesophagitis…longitudenal contraction…secondary hiatus herniaThe main problem is during antireflux operationCollis gastroplasty which produce neo-oesophagus around which a fundoplication can be done (Collis-Nissen operation)

Complications Of GORD

Barrett’s oesophagus (columnar-lined lower oesophagus)Barrett’s oesophagus is a metaplastic change in the lining mucosa of the oesophagus in response to chronic gastro-oesophageal refluxRisk of Barrett’s oesophagusBarrett’s ulcerDysplasia…Carcinoma

Diagnosis of Barrett’s OGD with biopsy

Long segment
Short segment
Dull red of the metaplastic columnar epithelium contrasts sharply with the pale glossy normal squamous lining

Treatment of Barrett’s oesophagus The primary aim is to prevent Barrett's oesophagus from turning into oesophageal cancer. Of the underlying GORD Ablation of abnormal mucosa by : Laser Photodynamic therapy Argon beam plasma coagulation Follow up: yearly OGD


Barrett’s ulcer Is an ulcer in the columnar-lined portion of a Barrett’s oesophagus.Barrett’s ulcers may be deep and prone to bleeding or, rarely, perforation


Paraoesophageal (rolling) hiatus hernia
Is a true hernia that is prone to complications True(pure) paraoesophageal hernia Mixed paraoesophageal hernia Sometimes the whole of the stomach lies in the chest and may undergo volvulus with perforation or gangrene.

Clinical features

Commonly occurs in the elderly, but it also may occur in young fit people The symptoms are Dysphagia Chest pain Symptoms of GORD Investigations: Plain X-ray of the chest Barium meal Endoscopy

Treatment

Rolling hernias always require surgical repair as they are potentially dangerous The principle of surgery is : Reduction of the hernia Gastropexy Some surgeons may perform a fundoplication

Neoplasms of the oesophagus

Benign tumours Are rare Leiomyoma is the commonest Oesophageal polyps
Squamus cell polyp

Malignant tumours Sarcoma are rare Leiomyosarcoma Rhabdomyosarcoma

Malignant melanoma
Is rare May be secondary Poor prognosis

Carcinoma of the oesophagus

Is the sixth most common cancer in the world. A disease of mid to late adulthood Carry a poor prognosis, 5-year survival is only 5-10%

Pathology

Histologic types: Squamous cell carcinoma (95%) World-wide is the commonest tumour Affect the upper 2/3rd Adenocarcinoma (4%) 70% from Barrett esophagus Is the commonest in westernised countries accounts for 60-75% of all oesophageal cancers. Affect the lower 1/3rd

Pathology

Radiological types polypoid/fungating form (most common) sessile/pedunculated tumor with lobulated surface "applecore" lesion ulcerating form infiltrating form gradual narrowing with smooth transition (DDx: benign stricture) varicoid form: superficial spreading carcinoma thickened nodular tortuous longitudinal folds (DDx: varices)

Pathology

The poor prognosis of oesophageal cancer is proof of its ability to spread This may be locoregional or systemic

Aetiology

EpidemiologySouth africaNorthren Iran and chinaThe cause in endemic areasFungal contamination of food….carcinogenic mycotoxinNutritional deficiences

Aetiology

In non-endemic areas Tobacco and alcohol are the major factors in the occurrence of squamous cancer.

High risk factors for oesophageal carcinoma

Alcohol and smokingBarrett’s oesophagusAchalasia cardiaStricture “ Corrosive,radiation”SclerodermaPlummer-Vinson syndromeHyperkeratosis(tylosis)

Clinical features

Patients with early disease may present with rather nonspecific dyspeptic symptoms or a vague feeling of “something that is not quite right” during swallowing. Features of advanced diseaseDysphagia, is the usual presenting feature Loss of weightHoarsenece of voiceHaematemesis or melaenaPalpable cervical lymphadenopathy

Diagnosis

Endoscopy; is the most important diagnostic tool and its widespread use is the major contributor to early diagnosis; when the disease at a relatively early stage when the chances of cure are greater. It should be emphasised that biopsies should be taken of all lesions no matter how trivial they appear.

Diagnosis

Contrast radiology “Barium swallow”;The tumour appears as a filling defect in the lumen of oesophagus.Not helpful for the diagnosis of early disease.Gives a good assessment of the length of the lesions.

Staging

Once a diagnosis of oesophageal carcinoma is made, staging of the disease is necessary to establish the appropriate method of treatment. A careful search for metastatic disease Chest X-ray Ultrasonography CT scan of chest and abdomen MRI Endoscopic ultrasonography Bronchoscopy Laparoscopy

Staging system

TNM classification system T for tumour extent N for lymph nodes assessment M for distant metastases



Staging system

General assessment

Assessment for fitness Nutritional assessment

Treatment of oesophageal cancers

The treatment depends on: the staging of the disease the general condition of the patient.

The treatment options available are:

Surgerical excision Radiotherapy Chemotherapy Intubation Laser coagulation Combined modality treatment

Treatment of oesophageal cancers

The treatment is either Radical or Palliative Radical treatment; Indicated for potentially curable disease in fit patients Curative treatment involves; Radical surgery Radical radiotherapy

Radical Surgical Resection

Is the treatment of choice for tumours of the lower two-thirds of the oesophagus provided: 1-The patient is fit for major surgery 2-Preoperative staging tests indicate that the tumour is resectable and there is no metastatic disease.



The principle of surgical treatment
Resection of the tumour with safety margins. Restoration of the continuty, usually gastro-oesophageal anastomsis

Radical Radiotherapy

Radiotherapy may be a useful alternative to surgery especially in unfit patients. 5year survival 9-19%(average10%) while following surgical treatment 20-35% (20%)

Chemotherapy

Improved after the introduction of newer drugs like cis-platinum. Chemotherapy never cures the disease Best results are seen in SCC

Multimodality treatment

Adjuvant radiotherapy either pre- or post- operative Radiochemotherapy

Palliative Treatment

Simple procedures that will produce worthwhile relief of dysphagia with minimal disturbance to the patient Intubation Traction tubes Pulsion tubes

Traction tubes

Celestin

Pulsion tubes

Atkinson tube Metal stent


Endoscopic Laser Used to core a channel through the tumour Brachytherapy intraluminal radiation

Carcinoma of the oesophagus

Squamous cell usually affects the upper two-thirds;adenocarcinoma usually affects the lower third Common aetiological factors are tobacco and alcohol(squamous cell) and GORD (adenocarcinoma) The incidence of adenocarcinoma is increasing Lymph node involvement is a bad prognostic factor Dysphagia is the most common presenting symptom, butis a late feature Accurate pretreatment staging is essential in patientsthought to be fit to undergo ’curative’ treatment

Oesophageal Motility disorders

AchalasiaPathology:Loss of the inhibitory ganglion cells in Auerbach’s plexus.Aetiology:UnknownNeurotropic viruses, Varicella zosterTrypanosoma Cruzi cause Chagas disease

Achalasia

Incomplete or absent relaxation of the lower oesophageal sphincter and absent peristalsis in the body of oesophagus.It results in Retension of food in oesophagusDilatation….Megaoesophagus

Clinical features

Is commonest in middle lifeTypically presents with dysphagiaLong standing cases…overspill into the trachea at nightRetrosternal discomfort

Diagnosis

EndoscopyContrast radiology:Dilated oesophagusTapering stricture…bird’s beakAbsent gas bubble


Diagnosis
Oesophagial Manometry

Treatment

Forceful dilatation

Disadvantages:

Perforation Reflex Repeated sessions

Treatment

Heller’s cardiomyotomyOpen LaparotomyLaparoscopic

Treatment

Botulinum toxin Drugs Calcium channel antagonists

Other oesophageal motility disorders

Cricopharyngeal achalasia Diffuse oesophageal spasm Nutcracker oesophagus Eosinophilic oesophagitis

Oesophageal diverticula

Pulsion diverticula Traction diverticula


Zenker’s diverticulum(Pharyngeal pouch) it protrudes posteriorly above the cricopharyngeal sphincter through the natural weak point (the dehiscence of Killian) between the oblique and horizontal (cricopharyngeus) fibres of the inferior pharyngeal constrictor

Symptoms: Pharyngeal dysphagia Halitosis Oesophagial Dysphagia

Diagnosis: Endoscopy Barium swallow


Treatment: Endoscopic: stapler creating diverticulo-oesophagostomy Open surgery: Pouch excision Pouch suspension myotomy

المحاضرة الثالثة

Zenker’s diverticulum(Pharyngeal pouch)