Dr.

Ahmed Nassr
Teaching assistant , General Surgery Dep.

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1.Epigastric pain
2.Clinical evaluation
3.Causes
4.Indications for Upper G.I endoscopy
5.GERD
6. Barrett’s esophagus
7. Achalasia
8. Peptic ulcer disease
9. Sliding hiatus hernia
10. FD
11. Take-home message
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 Upper abdominal pain or discomfort is usually an
indicator of upper GIT problem.
 one of the most common presenting symptoms
in primary care.
 Has a very wide diversity of possible differential
diagnosis ranging from acute life threatening
conditions such as aortic dissection and
myocardial infarction, to relatively benign
conditions such as gastro-oesophageal reflux
disease (GORD) or functional dyspepsia .
 Commonly associated with symptoms like
heartburn, gastric reflux, nausea or vomiting ,
which are referred to as dyspepsia.
SOURCE: Rational investigation of
upper abdominal pain 3
 History Taking : - onset
- Duration
- relationship to food intake

- presence of alarm
symptoms

 Examination
 Non-invasive investigations

SOURCE: Rational investigation of

upper abdominal pain 4
 Esophageal
 Gastric
 Duodenal
 Biliary
 Pancreatic
 Bowel

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 Gastroesophageal reflux disease
 Peptic ulcer disease
 Hiatal hernias
 Gastritis/gastropathy
 Achalasia of the cardia
 Esophageal strictures
 FD (Functional dyspepsia)
 Chronic pancreatitis

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 Persistent symptoms despite appropriate
empirical therapy
 Warning signs such as intractable vomiting,

anaemia, weight loss, dysphagia or bleeding

 Part of the diagnostic work-up for patients

with anaemia, symptoms of malabsorption

and chronic diarrhoea
 surveillance of neoplasia development in

high-risk patient groups

SOURCE: NICE guidelines

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SOURCE: Rational investigation of
upper abdominal pain 9
 Upper gastrointestinal (GI) endoscopy is the
standard diagnostic method used to evaluate the
esophageal mucosa in patients with GERD

 Alarm symptoms

 the sensitivity of diagnosing GERD by

endoscopy is low,but the specificity has been
reported as high as 90 to 95%.

SOURCE: Gastroenterological
Endoscopy_3rd Edition-2018 10
 Definitive mucosal breaks (erosions)
 Ulceration
 peptic stricture
 Barrett’s esophagus

 Los Angeles classification of erosive

esophagitis

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 Prague classification was developed and
validated in 2006
 (C) circumferential extent
 (M) maximal extent of the Barrett’s segment .

 Endoscopic Surveillance for Barrett’s

Esophagus
 Endoscopic Ablation of Barrett’s Esophagus

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 The first step in diagnostic evaluation of a patient
with dysphagia

 Essential to rule out structural abnormalities such

as a stricture or malignancy.

 not diagnostic,and have a very low sensitivity and

specificity

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 Dilated atonic esophagus with retained fluid

 Pinpoint LES, which is difficult to pass

 In advanced disease,a tortuous esophagus with

thickened, friable, or even ulcerated mucosa can
be seen secondary to chronic stasis of food and
liquids.

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source: Ramchandani 2005 23
 The role of endoscopy is to provide a
diagnosis and exclude malignancy
 Advisable for new-onset dyspepsia in

patients older than age 50or those with alarm

features
 Routine biopsy is not recommended. When

endoscopic appearance of gastric ulcer does

suggest malignancy,multiple biopsies should
be taken from both the base and edges of
ulcer

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 Endoscopy is essential for management of
peptic ulcer bleeding

 Endoscopy allows the identification of the

bleeding focus, classification of risk of
rebleeding, and treatment to halt the
bleeding

source: Polito et al 2005 25

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Duodenal ulcer

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Active duodenal ulcer

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Duodenal ulcer
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Gastric ulcers
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 Antegrade upper endoscopy
• three landmarks are routinely obtained : the
squamocolumnar junction, the
gastroesophageal junction, and the
diaphragmatic crura
• The diagnosis of a hiatal hernia is made when
separation of the gastroesophageal junction
from the crura is visualized.
• a hiatal hernia is present when at least 2 cm of
the top of the rugal folds has migrated above
the pinch of the diaphragmatic crura

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 Retroflexion of the endoscope
• Assessment the competency of the
gastroesophageal barrier
• Hill grade evaluation of the gastrointestinal
junction
• Large hiatal hernias can be associated with
mucosal ulcerations from ischemia resulting
from friction between the gastric wall and the
diaphragmatic hiatus. These lesions are
called Cameron’s ulcers

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source: Thompson et al 1991 43
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 Upper GI endoscopy has an indispensable role
in diagnosis and management of upper GI
problms.
 Not every patient suffering from dyspepsia or
upper abdominal pain is candidate for
endoscopy.
 Endoscopy is an integral part of the evaluation
of a patient with a hiatal hernia, however,
relatively insensitive in the detection of small
type I hiatus hernias because the exams
trigger oesophageal shortening and
physiological herniation
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 Eradication of H.pylori is a key point step in
management of GERD & Peptic ulcer disease .

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