The upper GI tract and Pancreas (the foregut)

Question 1

lower esophageal sphincter (LES)

Answer 1

not a muscular ring but prevents reflux of stomach content through several mechanisms including tonic contraction of several centimeters of muscle, a sharp angulation, change in mucosal lining, and the crus of the diaphragm.

Question 2

Gastroesophageal Reflux Disease GERD

Answer 2

the passage of material from the stomach backward into the esophagus.
Heartburn
Regurgitation “acid brash”

Question 3

Hiatal Hernia

Answer 3

the upper aspect of the stomach is pulled up into the chest, which weakens the lower esophageal sphincter, a valve designed to prevent reflux into the esophagus.

Question 4

Heartburn

Answer 4

when acid from the stomach, combined with the stomach enzyme pepsin and bile, refluxes into the esophagus it will cause pain and inflammation.

Question 5

Spectrum of GERD manifestations

Answer 5

Typical GERD symptoms: erosive, non-erosive (*NERD)
Atypical: asthma, cough, laryngitis, chest pain, globus (feeling of something stuck there)
Complications: Ulceration, stricture, Barrett’s, Cancer

Question 6

Long term complications of GERD

1. strictures

Answer 6

scarring of the esophagus inhibits its motor function and eventually causes significant narrowing. ==> dysphagia (difficulty swallowing) for solid foods and then liquids.

Question 7

2. Barrett’s esophagus (intestinal metaplasia)

Answer 7

change of esophageal mucosal lining from squamous cell to columnar epithelium with goblet cell metaplasia.
can lead to esophageal adenocarcinoma.
barrett esophagus itself does not cause symptoms.

Question 8

dysphagia

Answer 8

hard to swallow

Question 9

Esophageal adenocarcinoma

Answer 9

almost all adenocarcinoma of the esophagus occurs in the setting of Barrett changes. The frequency of this cancer is on the rise. it typically presents with dysphagia. long term survival is low (20% at 5 years) because the tumor is large before presenting symptoms.

Question 10

the road to esophageal adenocarcinoma

Answer 10

chronic reflux ==> intestinal metaplasia (Barrett’s) ==> low grade dysplasia ==> high grade dysplasia ==> esophageal adenocarcinoma

Question 11

squamous cell cancer of the esophagus

Answer 11

the most common esophageal cancer worldwide, but low incidence in the US. most common in Asia.
RISK FACTORS: smoking, alcohol, nitrosamines in the diet, and lye strictures.
most common symptom = dysphagia. 5 year survival 10%

Question 12

Alarm Symptoms of esophagus cancer

Answer 12

dysphagia
odynophagia
GI bleeding and anemia
weight loss
chest pain
choking
recurrent pneumonia
age > 45

Question 13

Achalasia

Answer 13

the LES loss its ability to relax as a bolus of food travels down the esophagus. Eventually peristalsis above the LES is lost and the esophagus bags out and is filled with food and liquid. Gravity and hydrostatic pressure allow the esophageal contents to slowly drain into the stomach.
difficulty belching
unknown cause, can see clear loss of nerve body cells in the myentenric nerve plexus of the esophagus.
in this Latin America infection with trypanosome cruzii is common and causes chagas disease.
loss of ganglion cells in the myenteric plexus is one complication of this parasitic infection.

Question 14

peptic ulcer disease

Answer 14

a break in the mucosa of the stomach or duodenum. One in 10 people will develop an uncle some time in their life.

Question 15

Two main causes of peptic ulcer disease

Answer 15

1. Non-steroidal anti-inflammatory drugs such as ibuprofen (NSAIDs)
2. Helicobacter pylori

other causes: smoking, STRESS

Question 16

Symptoms and complications of peptic ulcer disease

Answer 16

pain
bleeding
   hematemesis
   melena, hematochezia
Perforation
pancreatitis
gastric outlet obstruction

Question 17

Helicobacter pylori

Answer 17

gram negative rod
microaerophilic
flagellated
urease producing "cloud"
lives beneath mucus layer
clearly associated with active gastritis and duodenal ulcers.

Question 18

erosive (acute) gastritis

Answer 18

aspirin and other NSAID medications are currently the most common cause of this problem
stress from trauma, critical illness, or incapacitation are also causative.
presentation: vague abdominal pain, severe life threatening hemorrhage, or chronic insidious bleeding leading to iron deficiency anemia

Question 19

non-erosive (chronic) gastritis

Answer 19

autoimmune gastritis is diffuse inflammation in the body and fungus of the stomach. it is associated with pernicious (B12) anemia and severe achlorhydria. chronic gastritis can also lead to intestinal metaplasia, a precursor to gastric cancer.

Question 20

Gastric adenocarcinoma

Answer 20

4th most common malignancy in the world
60% in developing countries
H. pylori infection doubles the risk

Question 21

risk factors for gastric adenocarcinoma

Answer 21

tabacco
H. pylori
pickled and smoked foods
low socioeconomic status
increasing age

Question 22

Malignant Lymphoma

Answer 22

this tumor mimics gastric adenocarcinoma. the stomach is the most common extra-nodal non-Hodgkin lymphoma. It accounts for about 5% of all gastric tumors.

Question 23

MALToma (mucosa associate lymphoid tissue)

Answer 23

a lymphoma of the stomach that is associated with H. pylori infection. For early tumors just eradicating the Hp can cure the MALToma.

Question 24

exocrine pancreas

Answer 24

contains acing cells which produce digestive enzymes and bicarbonate

Question 25

endocrine pancrease

Answer 25

refers to islet cells which produce hormones including insulin and glucagon.

Question 26

acute pancreatitis

Answer 26

1. obstructive – gallstones (45%)
2. alcohol (35%)

injury to the pancreas causes the zymogen granules become activated and cause autodigestion, inflammation, and cell necrosis ensues.

complications:
inflammation of the pancreas causes fluid to collect in and around the gland. phlegmon, over time the fluid may organize into a collection called a pseudocyst.
if necrosis occur, it has a potential of life threatening infection pancreatic abscess

Question 27

chronic pancreatitis

Answer 27

the leading cause of chronic pancreatitis.
chronic inflammation in the pancreas eventually leads to scar tissue formation (fibrosis), loss of functional pancreatic cells, and deformities of the ducts.
the process can be unnoticed by the patient.
hard to detect early changes.

other causes: cystic fibrosis, inheritance, hypertriglyceridemia, idiopathic.

Question 28

presentations of chronic pancreatitis

Answer 28

pain (85%)
mid-epigastric to back, worse with food
malabsorption
weight loss, mild steatorrhea, it deficiencies
diabetes
loss of endocrine function
when

Question 29

adenocarcinoma of the pancreas – a QUIET skiller

Answer 29

SMOKING
4th leading cancer in men and 5th in women.
PAINLESS JAUNDICE
vague mid-epigastric pain with possible radiation to the back. weight loss. metastasize to liver, lung or peritoneum.

therapy: whipple.