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GASTRIC DISEASES and their treatment


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Gastric Diseases

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GASTRIC DISEASES and their treatment

  1. 1. By : Abdul Hameed ( Gastric Diseases and their treatment
  2. 2. By : Abdul Hameed ( GERD………..from Page (03-11)By Dr Shoaib Ansari PUD Esophagus Anatomy and Physiology…….. PAGE (13-81) Dr. Teresa Galdona PA-C Batter Treatment All PPI’s ;…………BY : ABDUL HAMEED
  3. 3. By : Abdul Hameed ( Courtesy : Dr Shoaib Ansari Associate professor Medical unit III Slide 8 to 16
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  13. 13. SURGERY Esophagus Dr. Teresa Galdona PA-C Courtesy by:
  14. 14. Esophagus  A) Function:  1)passaje for ingested food  2)emesis  3)conduit for endoscopic evaluation  4)evaluation of aorta and heart (TEE)  B) Anatomy:  Originates at cricoid cartilage  and pharynx in the neck By : Abdul Hameed (
  15. 15. Esophagus  B) Anatomy:  Posterior mediastinum behind aortic  and (L) mainstem bronchus.  Enters abd. cavity through esophageal  hiatus of diaphragm.  Mucosa and 2 muscular layers  mucosa is stratified squamous epithelium By : Abdul Hameed (
  16. 16.  B) Anatomy(cont)  2 muscular layers, inner layer is circular outer layer is longitudinal. There is not serosal layer  Musculature of upper 1/3 is skeletal and musculature of the lower 2/3 is smooth muscle.  2 sphincters: one is physiological one in the neck call upper esophageal sphincter, the other is located at the diaphragm called lower esophageal sphyncter Esophagus By : Abdul Hameed (
  17. 17. Esophagus  C) Physiology:  food is propelled down the esophagus by a peristaltic wave.  LES relaxes in anticipation of food, allows food enter stomach then returns to its high resting pressure, to prevent reflux.  Pathophysiology:  LES is to prevent reflux of gastric content. By : Abdul Hameed (
  18. 18. Esophagus  D) Pathophysiology:  1) Alteration of the mechanism of LES allows reflux of acid content, on an epithelial surface that is rich in sensory innervation  2) Failure of LES to relax, causes proximal dilation with contractile disorders By : Abdul Hameed (
  19. 19. Esophagus  E) S/S:  1) esophageal disorders per se  2) other organ manifestation disorders  like angina pectoris, asthma, Pneumonia.  3) signs of systemic Ds, like collagen Ds or neurological Ds, like scleroderma (systemic sclerosis, LES,smooth muscle) in CREST syndrome, or in stroke and other neurologic diseases. By : Abdul Hameed (
  20. 20. Esophagus  in CREST syndrome. Also in polymyositis/dermatomyositis, where ¼ of pts have dysphagia that involves UES (striated muscle) or in stroke and other neurologic diseases. By : Abdul Hameed (
  21. 21. Esophagus  F) Clinical presentation:  Dysphagia: difficulty with transition of ingested food  Odynophagia: painful swallowing  Globus ictericus: lump in the throat,evaluate carefully sensation b/c it may represent a mass lesionand no a psychological symptom  Pyrosis or water brash associated with GERD,achalasia and esophageal strictures  Regurgitation,vomiting By : Abdul Hameed (
  22. 22. Esophagus  Pyrosis or water brash associated with GERD,achalasia and esophageal strictures  Regurgitation: passive return of ingested food to oropharynx.  Vomiting: active return of stomach content By : Abdul Hameed (
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  24. 24. Esophagus  Recurrent episodes of bronchitis or pneumonia ( very young, elderly, may be sing of recurrent aspiration of esophageal or gastric content b/c of esophageal obstruction, congenital malformation, diverticula, or motility disorder).  By : Abdul Hameed (
  25. 25. Esophagus  Also,  Anemia (ulcerative esophagitis mcc of esophageal bleeding, occult blood in stools)  Hiccups or singultus (sign of diaphragmatic irritation and early sign of  stomach dilation, MI or diaphragmatic hernia) By : Abdul Hameed (
  26. 26. Esophagus  Esophageal diseases may mimic other process like angina pectoris. Must do cardiac and esophageal evaluation simultaneously b/c both processess are common diseases.  G) esophagus examination:  1) H/P By : Abdul Hameed (
  27. 27. Esophagus  2) stools (check for blood)  3) xray: PA and lateral to r/o thoracic pathologies  4) Barium swallow: esophageal anatomy and function. It is safe and highly cost-effective.  5) CT scan: relation to other anatomic structures and, mediastinum, esophgeal cancer.  6) MRI (no advantage over CT)  7) Esophagoscopy: allows direct visualization of lumen of esophagus, can get directed Bx and treat like esophageal varices (injecting sclerosing substances)  8) Manometry and fluoroscopy By : Abdul Hameed (
  28. 28. Esophagus  7) Esophagoscopy: allows direct visualization of lumen of esophagus, can get directed Bx and treat like esophageal varices (injecting sclerosing substances)  8) Manometry and fluoroscopy, mostly for Dx of esophgeal motility disorders. By : Abdul Hameed (
  29. 29. Esophagus  H) Pathologies:  1) Hiatal Hernia:  MCC in women who have been pregnant, and in both women and men when there is increased intraabdominal pressure, for example obesity, it predisposes to reflux of gastric acid into distal esophagus. It is important to know that GERD and HH are separated conditions. Although, 80% of pts with reflux have demostrable HH. By : Abdul Hameed (
  30. 30. Esophagus  type I: sliding hernia  Allows the GEJ and a portion of the stomach to slide into the mediastinum.  Only important when there is association with reflux of gastric acid into the lower esophagus. By : Abdul Hameed (
  31. 31.  Sliding Hiatal Hernia By : Abdul Hameed (
  32. 32. Esophagus  Type II: paraesophageal hernia.  GEJ is normal in position, reflux is uncommon.  Portion of the gastric fundus that herniates alonside esophagus is prone to herniation and incarceration.  Surgical repair is necessary to avoid strangulation or incarceration. By : Abdul Hameed (
  33. 33. Esophagus  Sliding and paraesophageal Hiatal hernia By : Abdul Hameed (
  34. 34. Hiatal Hernia  Figure 1 shows a normal connection between the esophagus in the chest cavity and the stomach in the abdomen. Figure 2 shows a small portion of the stomach pushing upward into the chest cavity from the abdomen, causing a hiatal hernia. By : Abdul Hameed (
  35. 35. Esophagus  Type III: combination of I and II.  It is a very large defect at esophageal hiatus.  Other abdominal organs may be found in the mediastinum like stomach.  Surgical repair is necessary.  I) Pathophysiology:  Loss of anatomic relationship between the diaphragmatic hiatus and esophagus By : Abdul Hameed (
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  37. 37. Esophagus  Reflux of gastric acid causes burn of esophageal mucosa.  Very important the degree of mucosal injury is due to duration of acid contact and not to excessive gastric acidity (normal acid in the wrong place).  Continue inflammation of distal esophagus may cause mucosal erosion, ulceration, scarring, stricture, chronic reflux, transformation of epithelium to columnar ( Barret’s esophagus), to Ca (adenocarcinoma) By : Abdul Hameed (
  38. 38. Esophagus By : Abdul Hameed (
  39. 39. Esophagus  J) Most commonly presentation is:  Reflux,(GERD) a burning epigastric or substernal pain or tightness. 10% of pts can be confused with MI.Becomes worse when supine or leaning over.  GERD symptoms are non specific and can mimic other processes for example:  a) angina of cardiac origin must be evaluated if pt has a sensation of substernal pressure that is not relieved by belching or antiacids. By : Abdul Hameed (
  40. 40. Esophagus  b) Occult blood in stools due to erosive esophagitis.  c) Schatzki ring is a variant of GERD, it is a muscular constriction of distal esophagus due to irritaton of circular muscle by refluxed acid. 10% becomes fibrotic and requires dilation and or excision.  d) Dysphagia is a symptom of oropharyngeal Ca or altered esophagial motility 2nd to achalasia or stroke. By : Abdul Hameed (
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  42. 42. Esophagus  f) DGER is bile and pancreatic enzimes reflux, this process can complicate GERD when both processes coexist.  Recurrent pneumonia may indicate advance GERD and distal esophageal stricture By : Abdul Hameed (
  43. 43. Esophagus  Immunocompromised pts with GERD may present with candida esophagitis, CMV or Herpes virus infection.  Gastric irritants and stimulants like chocolate, caffeine, alcohol, tobacco, ASA,  NSAID’s,can increase symptoms. By : Abdul Hameed (
  44. 44. Esophagus  Other way of presentation can be chronic aspiration pneumonitis, asthma or chronic laryngitis.  Other presentation can be a complain of a “lump or food stuck” below xiphoid process due to muscular spasm of esophagus.  Many pts with type I have no sympyoms. By : Abdul Hameed (
  45. 45. Esophagus  Other forms of presentations are vomiting and dysphagia (suggest stricture).  Type II HH give symptoms mostly when incarcerated and isquemic, and presents with dysphagia, bleeding and respiratory distress.  K) Dx:  Barium swallow (mostly for Dx. of HH type I and II) By : Abdul Hameed (
  46. 46. Esophagus  EGD (esophagogastroduodenoscopy) and  Bx (mostly for reflux esophagitis).  L) Tx: medical, 80% respond to medical treatment and only 20% do not respond to it and ½ of this (10%) require surgery.  Medical treatment:  No gastric irritants like  Alcohol, chocolate, caffeine, tobacco By : Abdul Hameed (
  47. 47. Esophagus  Avoid tight gardments that rise intraabdominal pressure  Avoid drinking or eating within several hours of sleeping  Regular use of: antiacids, H2 blokers, PPI’s.  Elevation of head’s bed at least 6 inches  to avoid nocturnal reflux. By : Abdul Hameed (
  48. 48. Esophagus  Weight loss in obese pts.  Surgical Tx is to correct or repair the anatomic defect and prevent reflux,  2) Achalasia is the MC motility disorder of esophagus and it means “failure to relax”. The affected area is distal esophageal circular muscle. By : Abdul Hameed (
  49. 49. Esophagus  It is caused by failure of relaxation of high pressure zone sphincter, the proximal esophagus dilates resulting in a painless dysphagia.  Symptoms are dysphagia, regurgitation of indigested food, some weight loss, pain is not a hallmark.  Drinking large amounts of liquid necessary to push down food. By : Abdul Hameed (
  50. 50. Esophagus  Aspiration pneumonia is common.  Very common complain of spitting up foul smelling secretions when lean forward.  Dx is made by Barium swallow, by dilation of proximal esophagus, “bird-beak” deformity.  Tx : is surgical, 95% pts have complete relief. Procedure is known as esophageal myotomy (Heller myotomy). Medical Tx can use CCBlokers, and dilation at the esphagogastric junction By : Abdul Hameed (
  51. 51.  Achalasia  Bird-beak By : Abdul Hameed (
  52. 52. Esophagus  3) Diverticula.  2nd MC motility disorder. It is an out- pouching of all or part of the wall of the esophagus. May ocurred at any level in esophagus. Can be classified as pulsion (as cervical Zenker’s diverticula) and traction.  Symptoms same as achalasia like regurgitation, choking, or putrid breath odor.  Pts with traction diverticula are asymptomatic, which is the contrary for pulsion diverticula By : Abdul Hameed (
  53. 53. Diverticula  Mid-esophageal diverticulum By : Abdul Hameed (
  54. 54. Diverticula  Epiphrenic diverticulum By : Abdul Hameed (
  55. 55. Esophagus  Tx is mostly excision of diverticula.  Other disorders of esophagus:  Scleroderma: 70% of pts have esophageal abnormalities with progressive decline in muscular contractility towards LES.  Dx is made by Barium swallow xrays.  MC GI symptom is dysphagia.  Progressive reflux, ulceration of distal esophagus, strictures. By : Abdul Hameed (
  56. 56. Esophagus  Nutcracker esophagus:  Painful diffuse esophageal spasm of circular muscle through the length of esophagus that can be confused with angina pectoris.  Dysphagia:  associated with stress, or psychological factors. By : Abdul Hameed (
  57. 57. Esophagus  4)Esophagus tumors:  Benign tumor: leiomyoma  Most common in middle and distal thirds, usualy asymptomatic.  Malignant tumors:  Most common are:  Squamous Ca ---- 85%  Adenocarcinoma ----10% By : Abdul Hameed (
  58. 58. Esophagus  Sarcomas ----0.8%  Primary esophgeal lymphoma ----very rare  APUDomas (tumors of amine precursor uptake and decarboxilation system) 0.8%,  very malignant (already met when initial presentation).  Epidemiology:  Environmental factors are involved as etiology. By : Abdul Hameed (
  59. 59. Esophagus  Low dietary levels of ascorbic acid, alphatocoferol, retinol, riboflavine, high levels of nitrosamines in fungus infected food are associated with Esophageal cancer in China.  In Western hemisphere (USA and other countries) alcohol, tobacco, achalasia, Barret’s esophagus and caustic injuries play as etiologies for esophageal cancer. By : Abdul Hameed (
  60. 60.  Squamous cell Ca By : Abdul Hameed (
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  64. 64. Esophagus Also, poor oral hygiene, surgical procedures and pre-malignant conditions besides Barret’s esophagus, like radiation, or Plummer-Vinson syndrome (iron anemia, esophageal webs). Great risk factor is consumption of alcohol of more or equal to 9 g of ethanol and same if person smokes more than 20 cig per day. By : Abdul Hameed (
  65. 65. Esophagus  10% of pts with Barret’s will develop adenocarcinoma.  Tylosis (hyperkeratosis of palms and soles) is the only genetic disorder associated to esophageal cancer, 95% chance of esophageal cancer if live long. By : Abdul Hameed (
  66. 66. Esophagus  Squamous cell Carcinoma of esophagus arises from squamous epithelium,from the upper part of esophagus  Adenocarcinoma of esophagus arises from transformation of columnar epithelium that replaces normal squamous epithelium of distal esophagus as a result of chronic acid reflux. Metaplasia like this is known as Barret’s esophagus By : Abdul Hameed (
  67. 67. Esophagus  S/S of esophgeal malignancy:  Slow onset  Dysphagia (MC symptom)  Starts with solids to liquids  2nd MC symptom is odinophagia (retrosternal pain with swallowing)  Rare symptom is constant mid-back or midchest pain By : Abdul Hameed (
  68. 68. Esophagus  Hoarseness (when Tumor invade locally)  Can have episodes of aspiration pneumonia.  When Ds is too advance pts can’t swallow  their own saliva.  Very important is that no serosa layer in esophagus it allows tumors spread early to adjacent structures like aorta, lymph nodes. By : Abdul Hameed (
  69. 69. Esophagus  Dx:  Barium contrast studies, “apple core” image.  Endoscopy  Bx  Ct scan used to stage esophageal Ca.  PET (positron emission tomography) for staging mediastinal and distant mts. By : Abdul Hameed (
  70. 70. Esophagus  Tx:  When possible, depending of stage, surgical approach is definitely the treatment. It may depend of level of the lesion and if pt has a curable lesion. Taking this in consideration upper esophagus lesions require surgical removal of esophagus en bloc with larynx, permanent tracheostomy and restoration of swallowing By : Abdul Hameed (
  71. 71. Esophagus  In lesions that involve middle third of esophagus are treated by stage procedure, total thoracic esophagectomy and bypass.  Lower third of esophagus is treated by esophagogastric resection and end to end anastomosis in the mid-chest.  When prognosis is not good then radiation and /or intubation are the Tx By : Abdul Hameed (
  72. 72. Esophagus SCC and ADC have per se bad prognosis. Cure rate for a favorable case is only 20%, but in general cure rate for esophageal cancer is about 5%  Because SCC and ADC of esophagus have a very poor prognosis treatment is directed to restore swallowing.  Radiation and/or intubation are more used Tx for advanced cases. By : Abdul Hameed (
  73. 73. Esophagus Strictures  MCC = sequelae of GERD –induced esophagitis  Causes:  Diffuse esophageal spasm (DES)  Scleroderma  Rings & Webs  Hiatal Hernia  Dysfunctional LES  Motility Disorders  Cancer  Dx:  Manometry (records pressures)  Tx:  Pneumatic (balloon dilation) By : Abdul Hameed (
  74. 74. Esophagus Mallory-Weiss Tear  Repeated strenuous retching or vomiting may be responsible for the tears in the mucosa  results from prolonged and forceful vomiting, coughing or convulsions  Significant hemorrhage can occur  It may occur as a result of excessive alcohol ingestion.  This is an acute condition which usually resolves within 10 days without special treatment. By : Abdul Hameed (
  75. 75. Esophagus  Esophageal perforation:  Instrumentation 1st cause: endoscopy, biopsy, nasogastric tube, dilation procedures, inflation of devices to tamponade esophageal varices (Seng-staken- Blakemore tube), balloon dilation for achalasia, or spontaneous perforation due to forcefull vomiting or retching that increases intraesophageal pressure (Boerhaave’s syndrome) By : Abdul Hameed (
  76. 76. Esophagus  In esophageal perforation you will find a pt that after few hours of perforated presents with deep shock due to mediastinal sepsis, and death.  Other presentation is almost immediately the pt goes with severe pain chest, hypotension, diaphoresis, nausea and vomiting then collapse and death. By : Abdul Hameed (
  77. 77. Esophagus  Tx is aggressive surgical intervention.  Mortality is directly directed to time between perforation and intervention.  Foreign body:  Toddlers, mentally ill adults.  Dx. is confirm based on imaging studies (plain films, detect radio opaque object, and/or barium swallow) By : Abdul Hameed (
  78. 78. Esophagus  Tx:  Endoscopic removal.  Ingestion of caustic material:  Accidental  Intentional  Most damaging are alkaline containing products (Drano, Liquid Plumr). Alkalinity above pH12.0 very corrosive By : Abdul Hameed (
  79. 79. Esophagus  They destroy from lips to small intestine. Acidic material are a bit less damaging. 1st )identification (early) of product.  each product has different approach.  2nd) Thorough H/P to stimate damage.  Pt presents with burning pain in upper GI tract, nausea, vomit, difficulty swallowing and breathing.  3rd )Xrays, emergency endoscopy. By : Abdul Hameed (
  80. 80. Esophagus  TX:  A glass of water in case of caustic and mlik and/or water for acids  No induced vomit (aspiration and/or further damage).  Airway and  esophagus patency  Steroids to avoid strictures if no perforation  Use of ANTB controversial  Long term dilation in case of strictures. By : Abdul Hameed (
  81. 81. Esophagus  Very important:  caustic or alkaline substances cause liquefaction necrosis  Acidic substances cause coagulation necrosis By : Abdul Hameed (
  82. 82. By : Abdul Hameed ( Batter Treatment
  83. 83. By : Abdul Hameed ( PPI’s and their Mode of actions
  84. 84. Note: Pantoprazole MOA is available only. Other will be uploaded soon…..
  85. 85. By : Abdul Hameed (
  87. 87. Long lasting suppressive effect of ( Pantoprazole )  Only binds to cysteine 822 in the core of proton pump. Therefore will have longer period of action and supresses gastric acid secretion for longer duration. Drug 2003;63 (1) Page;107 By : Abdul Hameed (
  88. 88. FDA WarningNov. 17 , 2009 “Patients should avoid using Omeprazole with Clopidogrel ’’ By : Abdul Hameed ( Note; Latest FDA studies showing that all PPI Including pantoprazole have interaction with clopidogrel %age will be differ.