Gastrointestinal tract – GIT

Esophagus
o Nonkeratinized stratified squamous epithelium
o musculature
 Skeletal mm. – striated : upper 1/3
 Smooth mm. – lower 1/3
 Mix of smooth and stiated in middle.
o Embryology
 Develops from foregut by week 10
 Upper esophagus : from branchial arches 4,5, and 6.
o Blood supply
 Branches of inferior thyroid aa. – upper
 Branches of aorta –middle and lower
 Branch of gastric aa. – lower and middle posteriorly
o Nerve supply
 Symphathetic =sympathetic trunk
 Parasympathetic = vagus
 Motor = vagus
• Esophageal disorders
o Dysphagia
 Difficulty swallowing
 Selective
• Solids worst than liquid
• Schatzki’s ring
o Intermittent and non progressive disphagia
 Usually in lower part of esophagus
• Peptic stricutures
o Progressive w/ chronic heart burn
• Esophageal cancers
o Progressive dysphagia
o Age >50 YOA
 Non selective
• Both solids and liquids
• Achalasia
o Progressive, chronic
o Lower esophageal sphincter (LES) fails to relax
 Loss of Myenteric plexus
 Dialated esophagus on barium swallow
• “Bird beak” appearance
nd
 2 due to Chagas disease
 • Cardiomyopathy + Megacolon
o Increased risk of esophageal carcinoma
o Scleroderma: CREST syndrome – E: esophageal dysmotility due to ↓
pressure proximal to LES.
o Clinically
 Dysphagia – solid + liquid
 Regurgitation of food at night
 Weight loss
o Tx
 Injection of botulinum toxin – endoscopy
 Pneumatic dilatation of LES – w/ a balloon
 Surgery: Modified Heller’s myotomy
• Diffuse esophageal spasm
o Intermittent – comes and goes
• Scleroderma
o Chronic heart burn
o CREST syndrome
o Odynophagia
 Sharp substernal pain on swallowing
 Usually severe erosive disease
• Mostly due to infection
o Candidiasis, Herpes virus
nd
• 2 to corrosive injury
o Caustic ingestion – poison, acid, bleach, etc.
o Pill induced
o Heart burn
 Substernal burning pain radiating to neck
 Acid reflux to esophagus
• Highly specific to GERD
o Dx tools
 Esophagoscopy
 Barium esophagraphy
 Esophageal manometry
 Esophageal pH recording
o Esophagitis
 Etiology
• Infectious
o Candida, CMV, Herpes virus, HIV, varicella
• Corrosive esophagitis
o 2nd to caustic substance ingestion
• Pill induced
o Alendronate, Doxycycline, ASA, iron sulfate, Quinidine
 Clinical symptoms
 • Heart burn, Odynophagia
 Dx
• Clinically monitoring the progress w/ antiviral and antifungal agents
• Endoscopy for resistant cases only
• Pill induced: prevent by taking pills w/ water in upright position after a meal
o Barret’s Esophagus
 Premalignant condition
 Metaplasia
• Squamous epithelium replaced by columnar epithelium
• Sequel to chronic reflux d/o
 Sx
• Dysphagia
• Reflux sx: heart burn, regurgitation
 Dx
• Edoscopically diagnosed
o Circumferential or tongue like orange colored gastric mucosa running up
into distal tubular esophagus
o 3 types of mucosa
 Gastric cardiac
 Gastric fundic
 Intestinal metaplasia – ↑ risk of carcinoma w/ this type
o If unnoticed / not tx can lead to
 Stricture and bleeding
 Adenocarcinoma - rare
 Tx
• Proton pump inhibitors
• Surgery
o Endoscopic surveillance w/ biopsy every 2-3 yrs
o Endoscopic ablation
o Endoscopic mucosal resection – high grade dysplasias
o Resection of segment w/ metaplasia
o GastroEsophageal Reflux Disorder – GERD
 Risk factors
• Incompetent LES
• Hiatal hernia
• Irritable effect of refluxate
• Abnormal esophageal clearance
• Delayed gastric emptying
 Sx
• Heart burn – ↑ by recumbency, meals, bending
 Tx
• Mild GERD: lifestyle changes, Antaacids, H2 receptor blockers
• Moderate GERD: H2 receptor blockers, Proton pump inhibitors, promotility drugs
 • Severe GERD: unresponsive to PPI’s, surgical w/ Nissan’s fundoplication
o Diffuse esophageal spasm – DES
 Esophageal dysmotility syndrome of smooth mm.
 Spontaneous non peristaltic contractions
 Sx
• Dysphagia
• Non cardiac chest pain
 Manometery (ambulatory)
• Simultaneous un coordinated esophageal contactions
o CORK SCREW on barium swallow
 Tx
• Calcium channel blockers
• Nitrates
o Mallory-Weiss Syndrome
 Nonpenetrating mucosal tear at GastroEsophageal junction
 Sx
• Induced by: retching, lifting heavy objects, vomiting… in Hx
• Strong predisposition to alcohol
• Sudden hemetemesis
• NO MELENA
 Tx
• Fluid resuscitation + blood transfusion
• Endoscopic hemostatic therapy
• Angiographic arterial embolization
o Esophageal webs
 Thin, diaphragm like membranes of mucosa
 Congenital, Graft vs. host disease
 Pemphigus vulgaris, pemphigoid
 Plummer-Vinson Syndrome
• w/ iron deficiency anemia
o Esophageal rings
 Smooth circumferential thin structures
 Common in distal esophagus
 Seen in
• GERD, Haital hernia
 Sx: Dysphagia
 Dx: barium esophagogram
 Tx: Bougie dilatation
o Zenker’s diverticulum
 Mucosal protrusion through pharyngoesophageal junction
 b/w cricopharyngeus + inferior cricopharyngeus mm.
 due to loss of elasticity of upper esophageal sphincter
 Sx: dysphagia + regurgiatation of food
  Complication:
• Halistosis – bad breath
• Bronchiectasis, pneumonia, Lung abscess*
 Tx: diverticulotomy, esophago myotomy
o Esophageal carcinoma
 Epidemilogy
• Age: 50-70 YOA
• M>F - 3:1
• Squamous cell carcinoma common in Blacks
• Adenocarcinoma common in Whites
• Common site: distal 1/3 of esophagus
 Risk factors
• Squamous cell carcinoma
o Alcohol, tobacco
o Caustic induced esophageal strictures
o Achalasia
• Adenocarcinoma
o Barrett’s esophagus
 Sx
• Progressive dysphagia
• Malaise, weakness, weight loss
• Hoarseness of voice*
• Chest pain
• Cervical + Supraclavicula lymphadenopathy**
• Organ infiltration with metastasis
 Evaluation
• Non specific changes Anemia
• Abnormal liver function tests 2ndary metastasis
 Dx
• CXR: widened mediastinum -- 2nd adenopathy
• Barium swallow: polypoid or infiltrative or ulcerative lesion
• Endoscopy w/ biopsy = definite Dx**
 Tx
• Extensive local spread or metastasis = Palliative care
• Radiation, Laser (yag)
• Stents placement
• Photodynamic therapy
• Surgery
o For stage 1 and stage 2A -- esophagectomy
• Chemotherapy + radiotherapy
o Cisplatinum, Flurouracil