16. Gastroenterology I: Dysphagia, oesophagus & peptic ulceration Flashcards
symptoms of gastrointestinal disease
- abdominal pain
- dysphagia
- heartburn
- dyspepsia
- flatulence
- vomiting
- constipation
- diarrhoea
- steatorrhoea
what is dysphagia?
- difficulty is swallowing
what is heartburn?
- retrosternal discomfort, spreads up towards throat
- common system of heartburn
what is dyspepsia?
- discomfort in upper GI tract
- used to describe range of symptoms EG.
~ nausea
~ heartburn
~ acidity - patients usu call it indigestion
what is steatorrhoea?
- passage of pale bulky stools that contain fat
- often indicative of pancratic + billiary disease
upper digestive tract passage
- lips
- oral cavity
- oropharynx
- pharynx
- oesophagus
- stomach
- first part of duodenum
OESOPHAGUS
- what is the oesophagus?
- what do it’s symptoms include?
1
- Musculotendinous tube connecting
pharynx to the stomach
2
– Dysphagia
– Pain
– Cough or vomiting
OESOPHAGUS
important diseases to consider?
– Pharyngeal pouch
– Achalasia (difficulty swallowing)
– Oesophageal spasm
– Oesophageal web
– Peptic ulcer disease/reflux
– Carcinoma
ANATOMY OF OESOPHAGUS
- what is it/ what does it connect?
- what does it pass through?
- where does it lie?
1
- 25cm musculotendinous tube connecting
pharynx to the stomach
2
- passes through the chest via the mediastinum
3
- lies posterior to the trachea
ANATOMY OF OESOPHAGUS
what constrictor muscles does the pharynx overlap
- pharynx has 3 overlapping constrictor muscles to consider
- superior
- middle
- inferior
(each inside each other)
ANATOMY OF OESOPHAGUS?
- potential weakness?
- killian’s dehiscence = meeting point of 2 parts of inferior constrictor
- thyropharyngeus
- cricopharyngeus
- this is a point where the weakness can be exploited and outpouching can be created = zenekers diverticulum
- zenekers diverticulum passes through killian’s dehiscence
- during swallowing thyropharyngeus is populsive and cricopharyngeus is sphincteric
- if cricopharyngeus fails to relax, a posterior mucosal herniation may take place via Killian’s dehiscence
ANATOMY OF OESOPHAGUS?
- outer muscle
- inner muscle
- upper and lower oesophagus muscle type (striated, non-striated)
- motor and sensory nerves?
- where do the nerves lie?
1
outer longitudinal muscle coat
2
inner circular muscle coat
3
- upper 2/3 oesophagus = striated muscle
- lower 2/3 oesophagus = non striated muscle
- middle 1/3 = mixed
4
come from X (vagus) —> oesophageal plexus
5
- nerve plexi lie between outer longitudinal and inner circular muscle planes & also submucosally
6
- lining mucosal = stratified squamous non keratinising epithelium
BUT
- lower part CAN be lined by ectopic gastric (columnar) muscle
PHYSIOLOGY OF THE OESOPHAGUS
symptoms of oesophageal disorders?
(what they are, what may be the result?
- DYSPHAGIA
- sensation of difficulty in swallowing
- true dysphagia should cause weight loss if persistent - PAIN
- may result from acid reflux or spasm
- cardiac pain may be impossible to distinguish clinically (ECG & cardiac enzymes) - COUGH OR VOMIT
- if food or liquids do not pass normally to the stomach they may reflux back to the pharynx
- overflow into the lungs may present as a cough - BLEEDING - haematemesis
= NB anti emetic for stopping nausea/ vomiting
possible causes of dysphagia
- intrinsic lesion
- neuromuscular disorders
- motility disorders
- extrinsic pressure
Main diseases to consider?
- pharyngeal pouch
- achalasia
- oesophageal spasm
- oesophageal web
- peptic ulcer disease reflux
- carcinoma
PHARYNGEAL POUCH
1. what is pharyngeal pouch?
2. possible symptoms?
- herniation of mucosa through weakness in pharyngeal constrictor muscles (killian’s dehiscence passing through zenker’s diverticulum)
- undigested food can get stuck in this pouch
-
what is oesophagitis?
- inflammation of oesophagus
- many causes - most common = refluxed acid coming up
candida oesophagitis
- oesophagitis can also be infective
- infected by candida (can also be infected by diff bacteria)
why may a person be infected??
Must consider why –
Immunocompromised –
transplant, chemotherapy HIV infection etc
ACHALASIA (of the cardia)
what is it?
treatment?
- ## if you can’t relax the sphincter, food tends to get stuck
how can the oesophagus dilate
oesophageal dialtion methods
OESOPHAGEAL SPASM
what?
causes?
what is corkscrew oesophagus?
how to manage?
- how is it diagnosed?
- Oesophageal spasm often leads to this odd shape
- Pain can resemble reflux and heartburn
- Manage with muscle relaxants
3
- by radiographical appearance
~ eg. barium swallow looks like a corkscrew
- oesophageal manometry
OESOPHAGEAL WEB (paterson-kelly syndrome)
- most common in M or F
- consists of?
- what happens
- treatment
- although rare it is important as it is premalignant
- Koilonychia = spoon shaped fingernail deformity
= bowl shaped
3
- mucosa becomes atrophic
- fibrous structure forms at the upper end of the oesophagus
- structure described as form ‘web’ on barium swallow
4
- dilation of structure + correction of iron deficiency
post cricoid web
Reflection 1
- Review Upper GI presentation
symptoms - Review anatomy of upper GI tract
– relate to BDS1 anatomy - Be aware that first part of the
duodenum is the regurgitation
limit –(bile can be vomited) – ie
defines the limits of haemoptysis - Reflect upon the conditions that
adversely affect the oesophagus
PEPTIC ULCER DISEASE (REFLUX)
- what is it and what may it cause?
- common aetiology?
- what may cause removal of mucous protection coat
- incidence, age, gender, geography, promoter factors
-
Peptic Ulcer Disease &
Oesophageal Reflux
(make q)
- Acid reflux into the oesophagus can
cause pain, ulceration and spasm - Peptic ulcers (oesophagus, stomach or
duodenum)
– Commonly due to mucosal inflammation
caused by acid and pepsin, with
Helicobacter pylori infection and stress - Dental relevance:
- avoid NSAIDs….
- Steroid complications?
acute vs chronic ulcer diff
ACUTE
- relatively small
- perhaps penetrated muscularis mucosae
- but submucosa and muscular wall of gut (peritoneum = intact)
CHRONIC
- larger
- further through it has penetrated = weaker wall becomes
- increases risk of rupturing and periotonitis
UPPER GI BLEEDING
ULCER
1. sites
2. microscopic sites
3. signs + symptoms
ULCER
- healing
- prognosis
- investigations
- treatment
Consequences of inflamed
stomach - gastritis
- Chronic inflammation / irritation risks
erosion, ulceration, bleeding & ultimately
malignant conversion - Inflammation reduces function – reduced
parietal cell function induces
– Reduced acid production (achlorhydria)
reduced potential ferric to ferrous
conversion of iron – only ferrous Fe can be
absorbed effectively. – risk iron deficiency –
eg glossitis & microcytic anaemia (also risk of
long term antacid therapies eg PPI –
omeprazole etc)
– Reduced Intrinsic factor production – cant bind
Vitamin B12 – therefore cant reabsorb the
complexed B12 in the terminal ileum
macrocytic anaemia & sore mouth etc.
Gastric parietal cell antibody production can
mimic this.
BARRETT’S OESOPHAGUS
what is it?
1
- condition where long-standing stomach acid reflux has caused change / inflammation in lower oesophageal lining (stratified squamous non keratinising epithelium)
- this is because if repeatedly exposed to acid it can metaplase (changes lining to a diff type)
- histologically looking normal BUT in the wrong place
- gastric metaplasia in lower oesophagus is a pre-malignant condition
- image = endoscopic view = redder more inflamed mucosa
CARCINOMA (CANCER) OF THE OESOPHAGUS
- incidence in uk
- age
- sex
- geography
- promoting
- macroscopic
- effects of local tumour spread
- what you see microscopically
- coeliac = malabsorption = low iron = can cause pharyngeal web
CARCINOMA (CANCER) OF THE OESOPHAGUS
- note
- what happens when the tumour spreads
CARCINOMA (CANCER) OF THE OESOPHAGUS
- survival
- how to diagnose
- cure or palliate (make comfortable for what time they have left)
- has late presentation
Oesophageal Carcinoma
2nd image = wire mesh stent
- screening x-ray
what is Pyloric stenosis
- manifests as Paediatric projectile vomiting
- can go into spasm
