Gpat - Upper Gi

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Upper GI

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Ends with the stomach

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Esophagus

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Muscular tube that connects the nose and mouth with the stomach. Extension of the pharynx in the back of the oral cavity. It extends down the neck next to the trachea, through the thoracic cavity, and PENETRATES THE DIAPHRAGHM to connect with the stomach in the abdominal cavity

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Function of the esophagus

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Conveys boluses of food from the pharynx to the stomach. Food is passed through the esophagus by using the process of PERISTALSIS

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PERISTALSIS

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rhythmic contraction of smooth muscles to propel contents through the digestive tract.

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5 Types of esophageal disorders

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1) congenital, 2) Motor, 3) Hiatal hernia, 4) esophagitis, 5) neoplasms

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Types of congenital disorders

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1) tracheoesophageal fistulas, 2) rings, 3) webs, 4) esophageal diverticula

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Fistula

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abnormal connection or passageway between two epithelium-lined organs or vessels that normally do not connect (in this case between trachea and esophagus)

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tracheoesophageal fistulas

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Communication between the trachea and esophagus. Most common esophageal anomaly.

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Upper and lower boundaries of fistulas

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90% of fistulas upper portion of esophagus starts in a blind pouch (ATRESIA), and the lower end communicates with the trachea; Aspiration occurs immediately after birth as Upper blind sac fills with mucus

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Esophageal Artesia

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failure of the esophagus to develop as a continuous passage. Instead, it ends as a blind pouch. It occurs in approximately 1 in 4425 live births.

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5 Classifications of Tracheoesophageal Fistulas

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Types A, B, C, D, and H; see slide pic

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Type A fistula

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Proximal and distal esophageal bud—a normal esophagus with a missing mid-segment.

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Type B

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Proximal esophageal termination on the lower trachea with distal esophageal bud

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Type C

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Proximal esophageal ATRESIA (esophagus continuous with the mouth ending in a blind loop superior to the sternal angle) with a distal esophagus arising from the lower trachea or carina. (Most common, up to 90% of cases.)

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Type D

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Proximal esophageal termination on the lower trachea or carina with distal esophagus arising from the carina.

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H-Type

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A variant of type D: if the two segments of esophagus communicate; resembles the letter H

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Rings and webs

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Thin mucosal membranes that project into the esophagus lumen. Can block esophagus either partially or completely; Unknown cause; Generally asymptomatic. Pts may complain of dysphagia or difficult, painless swallowing of solid food. When pain occurs is referred to as odynophagia. Also, acid reflux symptoms may be present.

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Rings

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bands of normal esophageal tissue that form constrictions around the inside of the lower esophagus (i.e., Schatzki ring).

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Webs

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arise in the upper esophagus as thin layers of cells that grow across the inside of the esophagus.

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Plummer-Vinson Syndrome (sideropenic dysphagia)

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Esophageal webs with risk of developing oral cancer; Comes with iron deficiency (sideropenia)and difficulty swallowing;*90% of cases are in middle-aged women since hormonal factors may be involved and it is related to alcohol and tobacco use

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Symptoms of Plummer-Vinson Syndrome

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1) oropharyngeal mucosal lesions that cause burning mouth syndrome in tongue and oral mucosa; 2) Atrophy of lingual Padilla (dorsal tongue is shiny red and smooth) which causes Glossodynia (tongue pain) , 3) some risk of esophageal cancer but greater risk of oropharyngeal cancer

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diverticulum

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a sac or pouch arising from a tubular organ

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true diverticulum

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outpouching of a wall containing all layers of the esophagus

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False diverticulum or pseudodiverticulum

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outpouching of a wall that lacks a muscular layer

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Where do Esophageal Diverticula occur?

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close to upper and lower esophageal sphincters, and in midportion of esophagus

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Complications of Esophageal Diverticula (4)

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1) regurgitation of undigested food, 2) halitosis, 3) cough, and even 4) aspiration pneumonia

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Zenkers diverticulum

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upper portion of esophagus

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Traction diverticulum

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midportion of esophagus

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Epiphrenic diverticulum

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Lower portion of esophagus, close to diaphragm; *Diverticula are congenital

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Motor disorders

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Affect peristalsis

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2 Types of motor disorders

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Achalasia and Scleroderma

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Achalasia

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Rare motor disorder where there is Failure of the lower esophageal sphincter (a muscular ring at the junction of the esophagus and stomach) to relax during swallowing and there is No peristalsis in the body of the esophagus. Result: Food is retained within esophagus, leading to Esophageal HYPERTROPHY, Dysphagia and regurgitation

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Cause of Achalasia

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associated with loss or absence of ganglion cells in the mesenteric plexus; Common in Chagas disease (parasitic infection with protozoa Trypanosoma Cruzi where ganglion cells are affected)

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Esophageal tissue in Achalasia

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Redundant, hyperplastic esophageal squamous epithelium (Looks stretched out instead of narrow and thin)

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Scleroderma (progressive systemic sclerosis)

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a group of diseases that causes abnormal growth of CONNECTIVE TISSUE. FIBROTIC SMOOTH MUSCLE mainly affecting lower esophageal sphincter and impairs peristalsis. This occurs most often in the esophagus, but may also be seen elsewhere in the GI tract. Cause unknown. Mainly women.

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The 2 types of scleroderma

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1) Localized scleroderma: affects only the skin. 2) Systemic scleroderma: affects blood vessels and internal organs, as well as skin.

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Complications of scleroderma

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dysphagia; heartburn caused by peptic esophagitis due to acid reflux from the stomach

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Hiatal hernia

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Portion of upper stomach bulges through an enlarged esophageal hiatus in the diaphragm.

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Two types of Hiatal hernia

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1) Sliding Hernia: Common, mostly asymptomatic. Cap of gastric mucosa moves upward above the diaphragm. 2) Paraesophageal Hernia: Uncommon. Herniation of part of gastric fundus alongside the esophagus.

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Complications of Hiatal hernia

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Large hiatal hernia can allow food and acid to back up into esophagus (gastroesophageal reflux, regurgitation), leading to heartburn and chest pain. Dysphagia, odynophagia.

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Esophagitis

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Any inflammation, irritation, or swelling of the esophagus

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What is the Main barrier to gastroesophageal reflux (GER)

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lower esophageal sphincter (LES)

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Reflux esophagitis

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Most common type of esophagitis; Frequently caused by the backflow of acid-containing fluid and pepsin from the stomach due to decreased pressure of LES

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What can cause decreased pressure in LES?

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Alcohol, cigarette smoking, fatty foods, chocolate, pregnancy, estrogen tx, certain meds.

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Complications of reflux esophagitis

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1) Superficial mucosal erosions and ulcers with Vertical line streaks. 2) Reactive proliferation of the lamina propria papillae into basal squamous epithelium which is thickened, 3) Hyperemia; dilated capillary vessels. Increased inflammatory cells in submucosa. 4) Chronic esophagitis may result in esophageal stricture/stenosis where fibrosis can narrow lumen

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Barrett esophagus

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Metaplastic changes to “specialized epithelium” secondary to chronic gastroesophageal reflux: Esophageal squamous epithelium is replaced by columnar epithelium; Commonly in lower third of esophagus

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Causes of Barrett esophagus

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Alcohol and tobacco

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Complication of Barrett esophagus

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Metaplastic epithelium of a Barrett esophagus carries a risk of malignant transformation to an adenocarcinoma (dysphagia occurs and then adenocarcinoma develops); *This disease is considered a PRE-MALIGNANT CONDITION

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Symptoms of Candida esophagitis

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Dysphagia/odynophagia; Severe candidiasis may result in fibrosis (stricture)

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Populations most at risk for Candida esophagitis

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Immunosuppressed subjects:AIDS, Diabetes, On Meds for organ transplantation, Cancer chemotherapy, or Antibiotic therapy

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Herpetic Esophagitis

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due to HSV1 infection; occurs in otherwise healthy ppl

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Complications of herpetic esophagitis

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Associated with lymphomas and leukemia

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Statistics on esophageal carcinoma

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Uncommon in USA: Squamous cell carcinoma of esophagus represent 7% of G.I. cancers. Accounts for 2% of cancer deaths; In 2013, about 17,990 Americans were diagnosed with esophageal cancer and 15,210 deaths were estimated to occur in the same year from this type of cancer.

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Where in the world are esophageal cancers more prevalent

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Asian “Esophageal Cancer Belt”: From Caspian Sea region of northern Iran and Central Asia to northern China......incidence 30-fold greater than USA; Northern China: mortality rate in men 70-fold greater that in USA

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6 risk factors for esophageal carcinoma

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1) Cigarette smoking: association with esophageal dysphagia, 2) Excessive alcohol consumption, 3) Plummer-Vinson syndrome; Achalasia, 4) Chronic esophagitis, 5) Webs, rings, and diverticula, 6) Diets low in fruits, vegetables, animal protein, trace metals; *Tobacco and alcohol also put people at risk for head and neck carcinomas

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Esophageal carcinoma

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50% of cases are squamous cell carcinomas in lower third of esophagus with PERSISTENT DYSPHAGIA as most common symptom; Metastasis to lung and liver are common; VERY POOR PROGNOSIS - Mostly unoperable. In those who undergo surgery: ~20% survive for 5 yrs.

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3 Types of esophageal carcinomas

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1) Ulcerating: possible bleeding, 2) Polypoid: early obstruction of lumen; 3) Infiltrating: gradually narrow lumen

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Statistics on Adenocarcinoma of esophagus

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Account for ~ 60% of the malignant esophageal tumors in USA

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Cause of adenocarcinoma

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All adenocarcinomas arise from Barrett epithelium; Thus, endoscopy surveillance is important

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Symptoms of adenocarcinoma

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Similar to squamous cell carcinoma (SCC); 20% 5-year survival following radical surgery

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Stomach

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Muscular, sac-like organ that connects the esophagus and small intestine

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Function of stomach

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Breaking down food. Cells in the stomach lining secrete enzymes, hydrochloric acid, and other chemicals to continue the digestive process begun in the mouth.

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Muscles of the stomach (3)

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1) Longitudinal muscle layer, 2) Circular muscle layer, 3) Oblique muscle layer

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Pylorus

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most distal and narrow section of the stomach; Food passes through the pyloric canal into the small intestine

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3 Gastric Disorders

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1) Gastritis, 2) Peptic Ulcer Disease, 3) Neoplasms

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Acute Hemorrhagic Gastritis

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Gastric mucosa erosions that can lead to sharp punched-out ulcers and bleeding. Acute inflammatory response. Widespread petechial hemorrhages in any part of stomach (1-25 mm)

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Symptoms of Acute Hemorrhagic Gastritis

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vague abdominal discomfort to massive, life-threatening bleeding and mucosal perforation.

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Risk factors of Acute Hemorrhagic Gastritis (5)

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1) Nonsteroidal anti-inflammatory drug use (NSAIDs), 2) Heavy alcohol use, 3) Major surgery, 4) Severe stress: CURLING ULCERS (deep) in severely burned pxs. 5) CNS trauma: CUSHING ULCERS (deep); * Acute Hemorrhagic Gastritis is often associated with acute illness or trauma and all risk factors lead to breakdown of mucosal barrier, which permits acid-induced injury

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Helicobacter pylori Gastritis

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Most common type of chronic gastritis in the USA. H. pylori has only been found in association with gastric epithelium and/or areas with chronic gastritis. It is not present in other tissues. Prevalence of infection with H. pylori increases with age. By age 60, 50% people is seropositive. Two thirds will show histological evidence of mucosal gastritis; * Strong association with peptic ulcer disease

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Treatment of Helicobacter pylori Gastritis

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Gastritis is cured following treatment with bismuth or antibiotics; * Antibodies against H. pylori are commonly found in pts with chronic gastritis.

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Peptic Ulcer Disease

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Focal, chronic ulcers that occur in any portion of the gastrointestinal tract exposed to the aggressive action of gastric secretions (i.e., hydrochloric acid). Peptic ulcers are usually solitary lesions less than 4 cm in diameter. Not normally carcinogenic (less than 1% become cancer)

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Stats on peptic ulcer disease

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About 10% of population in Western industrialized countries may develop such ulcers at some point during their lifetime

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Most common sites of peptic ulcer disease (3 from most common to least common)

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1) Proximal duodenum: male preponderance; ~ 30-60 yrs of age, 2) Distal stomach: male = female; middle aged and elderly, 3) At the gastroesophageal junction, in the setting of gastroesophageal reflux or Barrett esophagus

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3 Environmental risk factors of peptic ulcer disease

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1) Diet: little evidence supports role of food, alcohol, coffee. 2) Cigarette smoking: a definite risk factor, especially for gastric ulcers. 3) Drugs: aspirin, other NSAIDs, and analgesics

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3 Genetic risk factors of peptic ulcer disease

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1) First-degree relatives of people with peptic ulcers: 3X risk, 2) Risk of duodenal ulcer is 30% higher in people with type O blood, 3) High circulating levels of pepsinogen I: 5X risk for duodenal ulcer

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Causes of peptic ulcer disease (3)

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1) Hydrochloric acid - Formation and persistence of peptic ulcers in the stomach and duodenum require HCl secretion, 2) Gastric ulcers almost invariably arise following mucosal injury by H. pylori or chemical gastritis. 3) About 75% pts with gastric ulcers harbor H. pylori

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2 Complications of peptic ulcer disease

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1) Hemorrhage (bleed into the stomach): Most common serious complication in up to 20% of pxs. May manifest as anemia or occult blood in stools. 2) Perforation (now blood leakage out of the stomach): Occurs in ~5% pts. Most common in duodenal ulcers. High mortality rate. * In one third there is no symptoms of peptic ulcer.

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4 Severe Diseases associated with peptic ulcer disease

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1) Cirrhosis: 10X risk than in normal subjects, 2) Chronic Renal Failure, 3) Hereditary Endocrine Syndromes (Multiple endocrine neoplasia syndrome, type I), 4) Chronic Pulmonary Disease

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2 Types of benign neoplasms

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Gastrintestinal stromal tumors (GIST) and Epithelial Polyps

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Cause of Gastrintestinal stromal tumors (GIST)

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Derived from pacemaker cells of Cajal in muscular tissue of the GI tract. Overexpression of c-kit oncogene encodes a tyrosine kinase that promotes cell proliferation. Nonagressive

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3 Types of Epithelial Polyps

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1) Hyperplastic: most common gastric polyps. Seen in pxs with chronic gastritis. No malignant potential. 2) Adenomatous: usually solitary. Glands lined with dysplastic epithelium. Potential for adenocarcinomas. 3) Fundic gland polyps: No malignant potential

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Stats on stomach cancer (malignant neoplasm)

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1) About 21,600 Americans were diagnosed with stomach cancer during 2013 and 10,990 deaths were estimated to occur in the same year from this type of cancer. 2) Average age at the time of diagnosis is 71. About two thirds of people with stomach cancer are older than 65. 3) Incidence of Gastric CA is very high in Japan and Chile: 7X-8X USA rates.

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3 Causes of stomach cancer

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1) Food, 2) Nitrosamines, 3) H. pylori (but cancer can also be found in pts without H. pylori; H. pylori ALONE neither sufficient nor necessary for gastric carcinogenesis)

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Food causing stomach cancer

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Starch, smoked fish and meat (carcinogen benzopyrene), pickled veggies

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Nitrosamines causing stomach cancer

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Secondary amines are converted to nitrosamines in the presence of nitrates or nitrites; High nitrate can be found in soil/water, Processed meat and veggies; Nitrosamine is present in cigarettes; However, a good diet of milk and fresh veggies rich in vitamin C can inhibit nitrosation of secondary amines.

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Adenocarcinomas of the stomach

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Adenocarcinomas greater than 95% of gastric CA; * Primary lymphoma of the stomach accounts for ~5% of all gastric CA

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4 Locations of Adenocarcinomas of the stomach

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1) Distal Stomach, 2) Lesser curvature of the antrum, 3) Prepyloric region, 4) Rare in the fundus (proximal stomach)

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Early gastric cancer

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Depth of invasion: limited to mucosa or submucosa (May exhibit an exophytic, flat or depressed, or excavated conformation); May have a more benign course, better prognosis; Metastasis to regional lymph nodes; Distant metastasis: the most common is to a supraclavicular node called Virchow node

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3 Types of Advanced gastric cancer

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1) Polypoid (fungating): 33% of adeno CA. Solid mass projects into lumen. 2) Ulcerating: 33% of adeno CA. Shallow ulcers with irregular, raised, firm margins and ragged base (in contrast to benign peptic ulcer). 3) Diffuse infiltrating: 10% of adeno CA. No true tumor mass is seen. Wall of stomach is thickened and firm (“leather-bottle-like” lesion). When all stomach is compromised is called linitis plastica.*Most gastric cancers are diagnosed at the advanced stage; Involves Mucosa, submucosa AND MUSCLE INVASION