The first case describes a 40-year-old man with progressive difficulty swallowing over 3 years. Tests show a dilated esophagus that fails to empty and a non-relaxing lower esophageal sphincter. The second case involves a 34-year-old with 9 months of swallowing issues and weight loss. The most likely diagnosis for both is achalasia, a disorder characterized by lack of esophageal peristalsis and failure of the lower esophageal sphincter to relax, causing food to get stuck in the esophagus.
This document provides an overview of gastrointestinal symptoms and their potential causes. It discusses symptoms related to the upper GI, lower GI, liver/biliary tract, pancreas, and general symptoms like abdominal pain and distention. For abdominal pain, it describes visceral, somatic and referred pain. Key symptoms reviewed include dysphagia, heartburn, dyspepsia, diarrhea, constipation, jaundice, itching, vomiting, lump in abdomen and altered sensorium. Potential causes are provided for each symptom. The document also reviews approaches to taking a history for abdominal pain.
Acute appendicitis is a common condition caused by obstruction of the appendix. It typically presents with abdominal pain that starts around the umbilicus and later localizes to the right lower quadrant, accompanied by nausea, vomiting, or fever. A clinical diagnosis is usually made based on history and physical exam findings like tenderness in the right lower quadrant. Imaging like CT can help when the diagnosis is unclear. Treatment involves antibiotics and surgical removal of the appendix (appendicectomy) which is usually performed laparoscopically. Delayed diagnosis and treatment can lead to complications from infection or perforation of the appendix.
1) Hepatic hemangiomas are benign liver tumors consisting of blood-filled cavities lined by endothelial cells.
2) They are usually asymptomatic but can sometimes cause pain, nausea, or other digestive symptoms. Complications include bleeding, infection, or mass effect.
3) Diagnosis is usually made using ultrasound, CT, or MRI which show characteristic patterns of enhancement. Treatment is usually conservative but resection may be considered for large or symptomatic hemangiomas.
This document discusses irritable bowel syndrome (IBS), defining it as a functional bowel disorder characterized by abdominal pain or discomfort along with changes in bowel habits without any detectable structural abnormality. The prevalence of IBS is 10-20% of the population, more common in females. Potential causes include altered gut motility, visceral hypersensitivity, gut-brain interaction disturbances, and environmental and psychological factors. Diagnosis is based on clinical criteria such as recurrent abdominal pain relieved by defecation and changes in stool frequency or form. Treatment focuses on lifestyle modifications, antispasmodics, antidepressants, and probiotics.
This document provides information on the anatomy, histology, staging, and risk factors of gastric cancer. It discusses the divisions and layers of the stomach, innervation, blood supply, and lymphatic drainage. It describes the epidemiology of gastric cancer including higher rates in East Asia and associations with H. pylori infection and dietary factors. The document outlines the Borrmann, Lauren, and WHO histological classifications. It provides details on clinical presentation and diagnostic evaluation. Finally, it explains the AJCC and Japanese TNM staging systems including criteria for tumor (T), nodal (N), and metastatic (M) designations.
Barrett's esophagus is a condition where the lining of the esophagus is replaced by intestinal-type mucosa. It is typically diagnosed via endoscopy with biopsy. Treatment options include antisecretory therapy using PPIs, surgery, ablation, and chemoprevention. Endoscopic mucosal resection is an alternative to surgery for high-grade dysplasia or intramucosal cancer after excluding nodal metastases with endoscopic ultrasound. Management depends on the grade of dysplasia, ranging from follow up endoscopy for no dysplasia to endoscopic eradication for high-grade dysplasia.
This document summarizes recent advances in the diagnosis and treatment of gastroesophageal reflux disease (GERD).
(I) New diagnostic tests include the PPI test, Bravo capsule, new acid exposure sensors, and multichannel intraluminal impedance to identify acid and non-acid reflux. (II) Therapeutic advances include new drugs targeting transient lower esophageal sphincter relaxations, combination therapy, long-term management strategies, prokinetics, and endoscopic procedures such as Endocinch, Stretta, Enteryx and Gatekeeper. (III) Barrett's esophagus screening and surveillance remains an area requiring further prospective studies to determine who and when to screen.
This document discusses intestinal malrotation, beginning with a definition and incidence. It describes the normal stages of intestinal rotation during embryonic development and defines different types of rotational disorders including nonrotation, incomplete rotation, and reverse rotation. Clinical presentations are outlined for acute midgut volvulus, chronic midgut volvulus, acute duodenal obstruction, and internal hernia. Radiologic findings that help diagnose malrotation are presented. Treatment involves reducing the risk of volvulus recurrence through the Ladd's procedure. Post-operative care and potential complications are also summarized.
This document provides an overview of gastrointestinal symptoms and their potential causes. It discusses symptoms related to the upper GI, lower GI, liver/biliary tract, pancreas, and general symptoms like abdominal pain and distention. For abdominal pain, it describes visceral, somatic and referred pain. Key symptoms reviewed include dysphagia, heartburn, dyspepsia, diarrhea, constipation, jaundice, itching, vomiting, lump in abdomen and altered sensorium. Potential causes are provided for each symptom. The document also reviews approaches to taking a history for abdominal pain.
Acute appendicitis is a common condition caused by obstruction of the appendix. It typically presents with abdominal pain that starts around the umbilicus and later localizes to the right lower quadrant, accompanied by nausea, vomiting, or fever. A clinical diagnosis is usually made based on history and physical exam findings like tenderness in the right lower quadrant. Imaging like CT can help when the diagnosis is unclear. Treatment involves antibiotics and surgical removal of the appendix (appendicectomy) which is usually performed laparoscopically. Delayed diagnosis and treatment can lead to complications from infection or perforation of the appendix.
1) Hepatic hemangiomas are benign liver tumors consisting of blood-filled cavities lined by endothelial cells.
2) They are usually asymptomatic but can sometimes cause pain, nausea, or other digestive symptoms. Complications include bleeding, infection, or mass effect.
3) Diagnosis is usually made using ultrasound, CT, or MRI which show characteristic patterns of enhancement. Treatment is usually conservative but resection may be considered for large or symptomatic hemangiomas.
This document discusses irritable bowel syndrome (IBS), defining it as a functional bowel disorder characterized by abdominal pain or discomfort along with changes in bowel habits without any detectable structural abnormality. The prevalence of IBS is 10-20% of the population, more common in females. Potential causes include altered gut motility, visceral hypersensitivity, gut-brain interaction disturbances, and environmental and psychological factors. Diagnosis is based on clinical criteria such as recurrent abdominal pain relieved by defecation and changes in stool frequency or form. Treatment focuses on lifestyle modifications, antispasmodics, antidepressants, and probiotics.
This document provides information on the anatomy, histology, staging, and risk factors of gastric cancer. It discusses the divisions and layers of the stomach, innervation, blood supply, and lymphatic drainage. It describes the epidemiology of gastric cancer including higher rates in East Asia and associations with H. pylori infection and dietary factors. The document outlines the Borrmann, Lauren, and WHO histological classifications. It provides details on clinical presentation and diagnostic evaluation. Finally, it explains the AJCC and Japanese TNM staging systems including criteria for tumor (T), nodal (N), and metastatic (M) designations.
Barrett's esophagus is a condition where the lining of the esophagus is replaced by intestinal-type mucosa. It is typically diagnosed via endoscopy with biopsy. Treatment options include antisecretory therapy using PPIs, surgery, ablation, and chemoprevention. Endoscopic mucosal resection is an alternative to surgery for high-grade dysplasia or intramucosal cancer after excluding nodal metastases with endoscopic ultrasound. Management depends on the grade of dysplasia, ranging from follow up endoscopy for no dysplasia to endoscopic eradication for high-grade dysplasia.
This document summarizes recent advances in the diagnosis and treatment of gastroesophageal reflux disease (GERD).
(I) New diagnostic tests include the PPI test, Bravo capsule, new acid exposure sensors, and multichannel intraluminal impedance to identify acid and non-acid reflux. (II) Therapeutic advances include new drugs targeting transient lower esophageal sphincter relaxations, combination therapy, long-term management strategies, prokinetics, and endoscopic procedures such as Endocinch, Stretta, Enteryx and Gatekeeper. (III) Barrett's esophagus screening and surveillance remains an area requiring further prospective studies to determine who and when to screen.
This document discusses intestinal malrotation, beginning with a definition and incidence. It describes the normal stages of intestinal rotation during embryonic development and defines different types of rotational disorders including nonrotation, incomplete rotation, and reverse rotation. Clinical presentations are outlined for acute midgut volvulus, chronic midgut volvulus, acute duodenal obstruction, and internal hernia. Radiologic findings that help diagnose malrotation are presented. Treatment involves reducing the risk of volvulus recurrence through the Ladd's procedure. Post-operative care and potential complications are also summarized.
- Abdominal pain has many potential causes and determining the origin requires a detailed history, physical exam, and sometimes diagnostic tests.
- The location, character, timing and associated symptoms of the pain provide clues to its underlying mechanism, such as inflammation, obstruction, vascular or nerve issues.
- A thorough physical exam including inspection, abdominal palpation, and assessment of vital signs can help identify conditions like peritonitis but may not reveal the specific cause.
- Pelvic pain can have many causes involving the reproductive, gastrointestinal, genitourinary, and musculoskeletal systems.
- A thorough history and physical exam are essential to determine the underlying cause, which can be acute (less than 3 months), chronic (greater than 3 months), or recurrent.
- Common causes of acute pelvic pain include pelvic inflammatory disease, ectopic pregnancy, ovarian cysts, and endometriosis. Chronic causes include endometriosis, pelvic congestion syndrome, and irritable bowel syndrome.
Acute pancreatitis is an inflammatory process of the pancreas with varying involvement of surrounding tissues. Ultrasound typically shows an enlarged, hypoechoic pancreas with blurred margins due to edema. CT shows pancreatic enlargement with heterogeneous enhancement and infiltration of surrounding fat planes. Complications include pancreatic pseudocysts and fluid collections, as well as vascular complications. The document provides details on the diagnostic evaluation, treatment, and prognosis of acute pancreatitis.
Neuroendocrinal tumor of stomach and duodenumanirudha doshi
Multiple Endocrinal Neoplasm (MEN) syndromes are hereditary conditions characterized by tumors in multiple endocrine glands. There are two main types: MEN1, caused by a mutation in the MEN1 gene, and MEN2, caused by a mutation in the RET proto-oncogene. MEN1 is associated with tumors of the parathyroid glands, pancreas, and pituitary gland. MEN2 causes medullary thyroid cancer and other tumors. Gastrointestinal neuroendocrine tumors (NETs) are classified based on location, hormones produced, and grade. Treatment involves surgical removal when possible as well as other approaches depending on tumor characteristics and stage.
This document discusses perinephric abscesses. It defines the perinephric space as the area surrounding the kidney that contains fat, vessels and lymphatics. A perinephric abscess can result from a ruptured renal abscess, direct spread from pyelonephritis, or other inflammatory processes outside Gerota's fascia. Ultrasound and CT are used to identify fluid or soft tissue in the perinephric space. Percutaneous drainage under imaging guidance and antibiotics is the primary treatment, with surgery reserved for cases that do not respond to drainage and medication.
This document provides information on erectile dysfunction (ED), including its definition, causes, evaluation, and treatment options. It defines ED as the persistent inability to attain or maintain an erection sufficient for sexual activity. ED can be caused by physical factors like vascular disease or neurological issues, as well as psychological factors like depression or relationship problems. Evaluation involves a medical history, physical exam, and sometimes lab tests or nocturnal penile tumescence testing. Treatment ranges from lifestyle changes and oral medications to devices like pumps or implants. The goal is to help patients achieve erections sufficient for sexual intercourse.
This document summarizes recent advances in the diagnosis and treatment of gastroesophageal reflux disease (GERD). It discusses definitions, pathophysiology, epidemiology, clinical presentation, diagnostic tests including 24-hour pH monitoring and endoscopy, and treatment options including lifestyle modifications, medications like PPIs, and surgical procedures. Key recent advances mentioned include new diagnostic markers, multichannel intraluminal impedance pH monitoring, narrow-band imaging, and endoscopic assessment of mucosal impedance. Surgical treatments discussed are laparoscopic anti-reflux surgery and the Linx device, and recent studies comparing partial versus complete fundoplication and surgical versus medical therapy.
Norman Barrett was a British surgeon who first described Barrett's esophagus in 1950. Barrett's esophagus is a complication of chronic GERD where the normal squamous lining of the lower esophagus is replaced by intestinal-type mucosa. This condition confers an increased risk of esophageal adenocarcinoma. Diagnosis requires endoscopic visualization of abnormal mucosa in the esophagus and histological confirmation of intestinal metaplasia. While most with Barrett's esophagus will not develop cancer, periodic surveillance is recommended due to the premalignant potential.
This document provides information about testicular torsion, including:
- Testicular torsion occurs when the testicle twists around the spermatic cord, cutting off blood flow and requiring emergency surgery to untwist within 6 hours to save the testicle.
- It is most common in males under 25 and can be caused by an unattached "bell clapper" deformity allowing the testicle to twist easily.
- Symptoms include sudden severe pain in one testicle. Diagnosis involves physical exam and sometimes ultrasound, and treatment is always surgery to untwist and add sutures to prevent future twisting.
This document discusses Achalasia, a primary motor disorder of the esophagus characterized by failure of the lower esophageal sphincter to relax during swallowing and loss of peristalsis in the esophageal body. It covers the pathophysiology, classification, clinical presentation, diagnostic tests including manometry, and treatment options for Achalasia such as botulinum toxin injection, pneumatic dilation, Heller's myotomy, and POEM. It also discusses other esophageal motility disorders like DES, jackhammer esophagus, hypertensive LES, and IEM and their associated symptoms, diagnostic findings, and treatment approaches.
The document discusses the development of the anal canal and the surgical anatomy of the anal canal. It describes different types of imperforate anus including low and high anomalies. Low anomalies include covered anus, ectopic anus, and stenosed anus. High anomalies include anorectal agenesis, rectal atresia, and cloaca. Initial management involves assessing whether temporary colostomy is needed. Treatment of low anomalies involves dilatations or procedures like V-Y anoplasty or cutback procedure. Treatment of high anomalies includes initial colostomy followed by posterior sagittal anorectoplasty to reconstruct the anal canal. Surgical outcomes vary depending on the type of anomaly repaired.
1. Choledochal cysts are abnormal dilations of the bile ducts that are more common in Asia and women.
2. They are classified into 5 types based on location and extent of dilation.
3. Presentation varies from jaundice and abdominal mass in children to pain and cholangitis in older patients.
4. Investigation involves ultrasound, CT, MRCP and cholangiography to determine type and rule out complications.
5. Treatment is complete excision of the cysts and biliary tree with Roux-en-Y hepaticojejunostomy, except for type III which can be managed endoscopically.
Renal cell carcinoma (RCC) arises from the renal tubular epithelium. It is more common in males aged 60-80. Risk factors include chronic renal failure and von Hippel-Lindau disease. The main types are clear cell carcinoma (70-80%), papillary carcinoma (10-15%) and chromophobe renal carcinoma (5%). Symptoms include hematuria, flank pain, and an abdominal mass. Treatment is usually nephrectomy or partial nephrectomy to remove the tumor.
This document provides an overview of acute abdominal pain, including classifications, causes, symptoms, diagnostic tests, and treatment considerations. It describes three types of abdominal pain - visceral, parietal, and referred - and covers common intra-abdominal etiologies like appendicitis, cholecystitis, small bowel obstruction, and ischemic bowel. It also discusses extra-abdominal, toxic, metabolic, and neurogenic causes of abdominal pain and emphasizes the importance of thorough history taking and physical exam in diagnosing the source.
BENIGN PROSTATIC HYPERPLASIA: Epidemiology, Etiology, Pathophysiology, and ev...Gagan Adhikari
This document discusses the embryology, anatomy, etiology, and pathophysiology of benign prostatic hyperplasia (BPH). It notes that BPH originates from the transition zone of the prostate and results from an increase in epithelial and stromal cells. The precise causes are unknown but factors discussed include aging, genetics, androgens, estrogens, impaired programmed cell death, and interactions between stromal and epithelial cells. Androgens are required for normal prostate development and maintenance but do not directly cause BPH; their role may involve inhibiting cell death.
This document summarizes appendicitis, including the anatomy of the appendix, aetiology, clinical presentation, diagnosis, and treatment. Key points include:
- The appendix is a tubular structure located in the lower right abdomen that can become inflamed (appendicitis).
- Appendicitis is caused by obstruction of the appendix lumen, often by a fecolith. Common symptoms include abdominal pain that starts around the navel and moves lower.
- Diagnosis is usually clinical but can be supported by blood tests showing leukocytosis and imaging like CT scans. Treatment involves intravenous fluids, antibiotics, and an appendectomy to remove the appendix.
Irritable bowel syndrome (IBS) is a common gastrointestinal disorder characterized by abdominal pain and altered bowel habits without any organic cause. It affects 3-22% of the population worldwide. While the exact cause is unclear, it is believed to involve altered gut motility, hypersensitivity, and psychosocial factors. Diagnosis is made based on symptoms according to the Rome criteria and excludes other conditions. Treatment involves dietary modifications, medications to target predominant symptoms such as fiber for constipation or alosetron for diarrhea, and treatment of accompanying psychiatric conditions like anxiety or depression.
Chronic pancreatitis is a progressive inflammatory condition of the pancreas characterized by irreversible morphological changes and loss of function. It is most commonly caused by long term heavy alcohol use. Symptoms include recurrent abdominal pain, steatorrhea due to exocrine insufficiency, and diabetes mellitus due to endocrine insufficiency. Diagnosis involves functional tests like fecal elastase and imaging modalities like CT, MRI, ERCP and EUS which demonstrate findings of pancreatic duct abnormalities, parenchymal changes and calcifications.
This document discusses the approach to recurrent acute pancreatitis. It begins by defining recurrent acute pancreatitis as more than two attacks of acute pancreatitis without evidence of chronic pancreatitis, with more than three months between attacks. The document then discusses the epidemiology and various etiologies of recurrent acute pancreatitis including metabolic, mechanical, genetic, and idiopathic causes. It provides details on evaluation methods for recurrent acute pancreatitis such as bile microscopy, EUS, MRCP, and genetic testing. The document concludes that even after extensive evaluation, some cases remain undiagnosed and are termed idiopathic recurrent acute pancreatitis.
Peritonitis is inflammation of the peritoneum lining the abdominal cavity. It is commonly caused by bacterial infection entering the cavity from a perforation or rupture. Clinical presentation includes sudden onset of severe abdominal pain, fever, and tenderness. Investigation involves blood tests, imaging, and diagnostic procedures. Treatment depends on the severity and includes antibiotics, source control surgery if indicated, and intensive post-operative care. Outcomes are predicted by factors like the patient's age, underlying health conditions, severity of infection, and whether the source of infection is cleared.
Achalasia is a motility disorder of the esophagus characterized by lack of peristalsis and failure of the lower esophageal sphincter to relax. This causes food to become obstructed at the esophagogastric junction. The cause is unknown but may involve the degeneration of inhibitory neurons in the esophageal wall. Symptoms include dysphagia, regurgitation, chest pain, weight loss and coughing when lying down. Diagnosis involves barium swallow, endoscopy and manometry. Treatment aims to reduce lower esophageal sphincter pressure and may include botulinum toxin injections, medications, surgery or dilation. Complications can include weight loss, pneumonia, esophagitis and
The document summarizes key aspects of esophageal anatomy and physiology. It describes the esophagus as a muscular tube divided into cervical, thoracic, and abdominal segments. It discusses the layers of the esophageal wall, blood supply, innervation, and functions of the upper and lower esophageal sphincters. Common esophageal disorders like GERD, diverticula, and motility disorders are also summarized.
- Abdominal pain has many potential causes and determining the origin requires a detailed history, physical exam, and sometimes diagnostic tests.
- The location, character, timing and associated symptoms of the pain provide clues to its underlying mechanism, such as inflammation, obstruction, vascular or nerve issues.
- A thorough physical exam including inspection, abdominal palpation, and assessment of vital signs can help identify conditions like peritonitis but may not reveal the specific cause.
- Pelvic pain can have many causes involving the reproductive, gastrointestinal, genitourinary, and musculoskeletal systems.
- A thorough history and physical exam are essential to determine the underlying cause, which can be acute (less than 3 months), chronic (greater than 3 months), or recurrent.
- Common causes of acute pelvic pain include pelvic inflammatory disease, ectopic pregnancy, ovarian cysts, and endometriosis. Chronic causes include endometriosis, pelvic congestion syndrome, and irritable bowel syndrome.
Acute pancreatitis is an inflammatory process of the pancreas with varying involvement of surrounding tissues. Ultrasound typically shows an enlarged, hypoechoic pancreas with blurred margins due to edema. CT shows pancreatic enlargement with heterogeneous enhancement and infiltration of surrounding fat planes. Complications include pancreatic pseudocysts and fluid collections, as well as vascular complications. The document provides details on the diagnostic evaluation, treatment, and prognosis of acute pancreatitis.
Neuroendocrinal tumor of stomach and duodenumanirudha doshi
Multiple Endocrinal Neoplasm (MEN) syndromes are hereditary conditions characterized by tumors in multiple endocrine glands. There are two main types: MEN1, caused by a mutation in the MEN1 gene, and MEN2, caused by a mutation in the RET proto-oncogene. MEN1 is associated with tumors of the parathyroid glands, pancreas, and pituitary gland. MEN2 causes medullary thyroid cancer and other tumors. Gastrointestinal neuroendocrine tumors (NETs) are classified based on location, hormones produced, and grade. Treatment involves surgical removal when possible as well as other approaches depending on tumor characteristics and stage.
This document discusses perinephric abscesses. It defines the perinephric space as the area surrounding the kidney that contains fat, vessels and lymphatics. A perinephric abscess can result from a ruptured renal abscess, direct spread from pyelonephritis, or other inflammatory processes outside Gerota's fascia. Ultrasound and CT are used to identify fluid or soft tissue in the perinephric space. Percutaneous drainage under imaging guidance and antibiotics is the primary treatment, with surgery reserved for cases that do not respond to drainage and medication.
This document provides information on erectile dysfunction (ED), including its definition, causes, evaluation, and treatment options. It defines ED as the persistent inability to attain or maintain an erection sufficient for sexual activity. ED can be caused by physical factors like vascular disease or neurological issues, as well as psychological factors like depression or relationship problems. Evaluation involves a medical history, physical exam, and sometimes lab tests or nocturnal penile tumescence testing. Treatment ranges from lifestyle changes and oral medications to devices like pumps or implants. The goal is to help patients achieve erections sufficient for sexual intercourse.
This document summarizes recent advances in the diagnosis and treatment of gastroesophageal reflux disease (GERD). It discusses definitions, pathophysiology, epidemiology, clinical presentation, diagnostic tests including 24-hour pH monitoring and endoscopy, and treatment options including lifestyle modifications, medications like PPIs, and surgical procedures. Key recent advances mentioned include new diagnostic markers, multichannel intraluminal impedance pH monitoring, narrow-band imaging, and endoscopic assessment of mucosal impedance. Surgical treatments discussed are laparoscopic anti-reflux surgery and the Linx device, and recent studies comparing partial versus complete fundoplication and surgical versus medical therapy.
Norman Barrett was a British surgeon who first described Barrett's esophagus in 1950. Barrett's esophagus is a complication of chronic GERD where the normal squamous lining of the lower esophagus is replaced by intestinal-type mucosa. This condition confers an increased risk of esophageal adenocarcinoma. Diagnosis requires endoscopic visualization of abnormal mucosa in the esophagus and histological confirmation of intestinal metaplasia. While most with Barrett's esophagus will not develop cancer, periodic surveillance is recommended due to the premalignant potential.
This document provides information about testicular torsion, including:
- Testicular torsion occurs when the testicle twists around the spermatic cord, cutting off blood flow and requiring emergency surgery to untwist within 6 hours to save the testicle.
- It is most common in males under 25 and can be caused by an unattached "bell clapper" deformity allowing the testicle to twist easily.
- Symptoms include sudden severe pain in one testicle. Diagnosis involves physical exam and sometimes ultrasound, and treatment is always surgery to untwist and add sutures to prevent future twisting.
This document discusses Achalasia, a primary motor disorder of the esophagus characterized by failure of the lower esophageal sphincter to relax during swallowing and loss of peristalsis in the esophageal body. It covers the pathophysiology, classification, clinical presentation, diagnostic tests including manometry, and treatment options for Achalasia such as botulinum toxin injection, pneumatic dilation, Heller's myotomy, and POEM. It also discusses other esophageal motility disorders like DES, jackhammer esophagus, hypertensive LES, and IEM and their associated symptoms, diagnostic findings, and treatment approaches.
The document discusses the development of the anal canal and the surgical anatomy of the anal canal. It describes different types of imperforate anus including low and high anomalies. Low anomalies include covered anus, ectopic anus, and stenosed anus. High anomalies include anorectal agenesis, rectal atresia, and cloaca. Initial management involves assessing whether temporary colostomy is needed. Treatment of low anomalies involves dilatations or procedures like V-Y anoplasty or cutback procedure. Treatment of high anomalies includes initial colostomy followed by posterior sagittal anorectoplasty to reconstruct the anal canal. Surgical outcomes vary depending on the type of anomaly repaired.
1. Choledochal cysts are abnormal dilations of the bile ducts that are more common in Asia and women.
2. They are classified into 5 types based on location and extent of dilation.
3. Presentation varies from jaundice and abdominal mass in children to pain and cholangitis in older patients.
4. Investigation involves ultrasound, CT, MRCP and cholangiography to determine type and rule out complications.
5. Treatment is complete excision of the cysts and biliary tree with Roux-en-Y hepaticojejunostomy, except for type III which can be managed endoscopically.
Renal cell carcinoma (RCC) arises from the renal tubular epithelium. It is more common in males aged 60-80. Risk factors include chronic renal failure and von Hippel-Lindau disease. The main types are clear cell carcinoma (70-80%), papillary carcinoma (10-15%) and chromophobe renal carcinoma (5%). Symptoms include hematuria, flank pain, and an abdominal mass. Treatment is usually nephrectomy or partial nephrectomy to remove the tumor.
This document provides an overview of acute abdominal pain, including classifications, causes, symptoms, diagnostic tests, and treatment considerations. It describes three types of abdominal pain - visceral, parietal, and referred - and covers common intra-abdominal etiologies like appendicitis, cholecystitis, small bowel obstruction, and ischemic bowel. It also discusses extra-abdominal, toxic, metabolic, and neurogenic causes of abdominal pain and emphasizes the importance of thorough history taking and physical exam in diagnosing the source.
BENIGN PROSTATIC HYPERPLASIA: Epidemiology, Etiology, Pathophysiology, and ev...Gagan Adhikari
This document discusses the embryology, anatomy, etiology, and pathophysiology of benign prostatic hyperplasia (BPH). It notes that BPH originates from the transition zone of the prostate and results from an increase in epithelial and stromal cells. The precise causes are unknown but factors discussed include aging, genetics, androgens, estrogens, impaired programmed cell death, and interactions between stromal and epithelial cells. Androgens are required for normal prostate development and maintenance but do not directly cause BPH; their role may involve inhibiting cell death.
This document summarizes appendicitis, including the anatomy of the appendix, aetiology, clinical presentation, diagnosis, and treatment. Key points include:
- The appendix is a tubular structure located in the lower right abdomen that can become inflamed (appendicitis).
- Appendicitis is caused by obstruction of the appendix lumen, often by a fecolith. Common symptoms include abdominal pain that starts around the navel and moves lower.
- Diagnosis is usually clinical but can be supported by blood tests showing leukocytosis and imaging like CT scans. Treatment involves intravenous fluids, antibiotics, and an appendectomy to remove the appendix.
Irritable bowel syndrome (IBS) is a common gastrointestinal disorder characterized by abdominal pain and altered bowel habits without any organic cause. It affects 3-22% of the population worldwide. While the exact cause is unclear, it is believed to involve altered gut motility, hypersensitivity, and psychosocial factors. Diagnosis is made based on symptoms according to the Rome criteria and excludes other conditions. Treatment involves dietary modifications, medications to target predominant symptoms such as fiber for constipation or alosetron for diarrhea, and treatment of accompanying psychiatric conditions like anxiety or depression.
Chronic pancreatitis is a progressive inflammatory condition of the pancreas characterized by irreversible morphological changes and loss of function. It is most commonly caused by long term heavy alcohol use. Symptoms include recurrent abdominal pain, steatorrhea due to exocrine insufficiency, and diabetes mellitus due to endocrine insufficiency. Diagnosis involves functional tests like fecal elastase and imaging modalities like CT, MRI, ERCP and EUS which demonstrate findings of pancreatic duct abnormalities, parenchymal changes and calcifications.
This document discusses the approach to recurrent acute pancreatitis. It begins by defining recurrent acute pancreatitis as more than two attacks of acute pancreatitis without evidence of chronic pancreatitis, with more than three months between attacks. The document then discusses the epidemiology and various etiologies of recurrent acute pancreatitis including metabolic, mechanical, genetic, and idiopathic causes. It provides details on evaluation methods for recurrent acute pancreatitis such as bile microscopy, EUS, MRCP, and genetic testing. The document concludes that even after extensive evaluation, some cases remain undiagnosed and are termed idiopathic recurrent acute pancreatitis.
Peritonitis is inflammation of the peritoneum lining the abdominal cavity. It is commonly caused by bacterial infection entering the cavity from a perforation or rupture. Clinical presentation includes sudden onset of severe abdominal pain, fever, and tenderness. Investigation involves blood tests, imaging, and diagnostic procedures. Treatment depends on the severity and includes antibiotics, source control surgery if indicated, and intensive post-operative care. Outcomes are predicted by factors like the patient's age, underlying health conditions, severity of infection, and whether the source of infection is cleared.
Achalasia is a motility disorder of the esophagus characterized by lack of peristalsis and failure of the lower esophageal sphincter to relax. This causes food to become obstructed at the esophagogastric junction. The cause is unknown but may involve the degeneration of inhibitory neurons in the esophageal wall. Symptoms include dysphagia, regurgitation, chest pain, weight loss and coughing when lying down. Diagnosis involves barium swallow, endoscopy and manometry. Treatment aims to reduce lower esophageal sphincter pressure and may include botulinum toxin injections, medications, surgery or dilation. Complications can include weight loss, pneumonia, esophagitis and
The document summarizes key aspects of esophageal anatomy and physiology. It describes the esophagus as a muscular tube divided into cervical, thoracic, and abdominal segments. It discusses the layers of the esophageal wall, blood supply, innervation, and functions of the upper and lower esophageal sphincters. Common esophageal disorders like GERD, diverticula, and motility disorders are also summarized.
This document discusses disorders of the esophagus, including achalasia and esophageal spasm. It provides objectives, an introduction to the anatomy and function of the esophagus, and defines achalasia as the absence of peristalsis and failure of the lower esophageal sphincter to relax. Symptoms of achalasia include dysphagia and regurgitation. Diagnosis involves x-rays, endoscopy, and manometry. Treatments include dilation, botox injections, and surgery. Esophageal spasm is also covered, defining diffuse and hypertensive types, with dysphagia and chest pain as symptoms. Calcium channel blockers are a conservative treatment option.
1) The document discusses motility disorders of the esophagus, including achalasia, diffuse esophageal spasm, nutcracker esophagus, and ineffective esophageal motility.
2) It provides details on the anatomy, physiology and functions of the esophagus, as well as the classification, symptoms, investigations and treatments of various esophageal motility disorders.
3) Achalasia is characterized by failure of the lower esophageal sphincter to relax during swallowing, leading to symptoms like dysphagia and regurgitation. It is diagnosed using barium swallow, chest X-ray and manometry. Treatment involves botox injections or surgical myotomy.
Achalasia is a motility disorder of the esophagus characterized by absence of peristalsis and failure of relaxation of the lower esophageal sphincter. This causes obstruction at the esophagogastric junction. The cause is unknown but may involve the degeneration of inhibitory neurons in the esophageal wall. Patients experience dysphagia, regurgitation, chest pain, weight loss, and coughing when lying down. Diagnosis involves barium swallow, endoscopy, and manometry. Treatment aims to reduce lower esophageal sphincter pressure and may include botulinum toxin injections, medications, surgery, or dilation. Complications can include weight loss, pneumonia, esophagitis, and es
This document discusses two main types of dysphagia: oropharyngeal dysphagia and esophageal dysphagia. Oropharyngeal dysphagia involves difficulty moving food from the mouth to the esophagus, often due to neuromuscular conditions. Esophageal dysphagia involves difficulty moving food through the esophagus and can be caused by mechanical obstruction or motility disorders like achalasia. Achalasia is characterized by failure of the lower esophageal sphincter to relax along with lack of peristalsis in the esophagus. It discusses evaluation and treatment of achalasia, including pneumatic dilation and surgery.
This document discusses gastroesophageal reflux disease (GERD). It defines GERD as a chronic condition caused by prolonged reflux of gastric contents into the esophagus, potentially causing esophagitis. It describes the anatomy and physiology related to GERD, including the lower esophageal sphincter. Risk factors include hiatal hernia, obesity, smoking, diet, medications and certain diseases. Diagnosis involves history, physical exam, barium swallow, endoscopy and pH monitoring. Treatment includes lifestyle changes, antacids, H2 blockers, PPIs, surgery and endoscopic procedures. Complications can include esophagitis, stricture, Barrett's esophagus and adenocarc
Lecture 16 esophagus and stomach disorders - PathologyAreej Abu Hanieh
The document provides information on the esophagus and stomach disorders. It discusses the anatomy and physiology of the esophagus and stomach. Key points include that the esophagus transports food to the stomach through peristaltic movements. The lower esophageal sphincter separates the esophagus and stomach. Gastroesophageal reflux disease is caused by disruption of protective mechanisms in the esophagus. Common esophagus and stomach disorders mentioned include achalasia, hiatal hernia, Barrett's esophagus, dyspepsia, gastritis, and esophagitis. Treatment options focused on lifestyle changes and pharmacologic interventions like proton pump inhibitors.
This document discusses the anatomy, physiology, and motility disorders of the esophagus. It begins by describing the anatomy of the esophagus, including its layers, blood supply, drainage, and normal narrowings. It then discusses the physiology of swallowing and peristalsis. Several esophageal motility disorders are described, including achalasia, diffuse esophageal spasm, and scleroderma-related disorders. Diagnosis involves history, imaging like barium swallows, and manometry studies. Treatment aims to relieve obstruction and includes medications, botulinum toxin injections, dilation, and surgery. Barrett's esophagus, a complication of longstanding reflux, is also summarized.
approach to Disphagia for medical studentsYahyia Al-abri
The document discusses dysphagia (difficulty swallowing) including the anatomy of the pharynx, phases of swallowing, types of dysphagia, causes, diagnosis, and treatment. It describes oropharyngeal dysphagia involving problems initiating a swallow versus esophageal dysphagia where food feels stuck after swallowing. Causes include mechanical obstruction from rings/webs, peptic strictures, cancer, and neuromuscular disorders like esophageal spasm, scleroderma, and achalasia. Evaluation involves history, examination, endoscopy, barium swallow, and manometry. Treatment depends on the underlying cause but may include dilation, acid suppression, botulinum toxin injections,
The document discusses the anatomy and physiology of the esophagus. It describes the esophagus as a muscular tube that extends from the pharynx to the stomach. It has three portions - cervical, thoracic, and abdominal. The document outlines the relations of the esophagus in each portion and describes conditions like dysphagia, esophageal sphincters, gastroesophageal reflux disease, achalasia, Zenker's diverticulum and their clinical features and treatments.
Achalasia is a rare disorder where the esophagus becomes dilated and loses the ability to squeeze food into the stomach, making swallowing difficult. It occurs when nerves in the esophagus become damaged and the cause is poorly understood, though viral infection or autoimmune responses have been suspected. Treatment focuses on relaxing the lower esophageal sphincter through nonsurgical methods like balloon dilation or Botox injections, or through surgery to cut the sphincter muscles.
Achalasia is a rare disorder where the esophagus becomes dilated and loses the ability to squeeze food into the stomach. This is caused by damage to nerves in the esophagus. Symptoms include difficulty swallowing, regurgitation of food, and weight loss. Diagnosis involves tests like esophageal manometry and endoscopy. Treatment focuses on relaxing the lower esophageal sphincter through nonsurgical methods like balloon dilation or Botox injections, or through surgery. Nursing care involves addressing risks of malnutrition, aspiration, and social isolation due to eating difficulties.
This document provides an overview of Achalasia cardia, a rare esophageal motility disorder characterized by a failure of the lower esophageal sphincter to relax during swallowing. It discusses the epidemiology, pathophysiology, clinical presentation, diagnostic evaluation including radiology, manometry and endoscopy findings, and treatment options including pharmacological agents, pneumatic dilation, surgical and endoscopic myotomy. The goal of treatment is to reduce the pressure gradient across the LES to relieve symptoms while preventing progression to megaesophagus. With treatment, over 90% of patients experience relief of dysphagia and regurgitation, though the disease is never cured and additional interventions may be needed over time.
This document provides an overview of a 22 hour course on gastrointestinal and biliary tract disorders. It covers the anatomy and physiology of the gastrointestinal tract, common manifestations of gastrointestinal disorders, assessment of patients with gastrointestinal issues, and diseases and conditions of the gastrointestinal tract and biliary system including their management. Specific topics discussed include the esophagus, stomach, liver, gallbladder, pancreas, and large intestine. Diseases like achalasia, gastroesophageal reflux disease, and cancer of the esophagus are described in detail.
This document summarizes the anatomy, pathophysiology, diagnosis, and treatment of spontaneous esophageal rupture (SER), also known as Boerhaave's syndrome. It describes the anatomy of the esophagus and explains that SER usually occurs due to vomiting against a closed upper esophageal sphincter, which increases intraesophageal pressure and can cause a tear. Diagnosis involves considering the patient's history, symptoms of chest and abdominal pain, and findings on imaging tests. Treatment involves antibiotics, nothing by mouth, gastric decompression, and possibly surgery if symptoms do not improve with initial non-operative management. Early diagnosis and treatment are important for prognosis.
This document provides information about Achalasia, including its pathophysiology, symptoms, diagnosis, and treatment options. Achalasia is caused by the loss of inhibitory neurons in the esophagus which leads to failure of the lower esophageal sphincter to relax during swallowing. Patients experience symptoms of dysphagia and regurgitation. Diagnosis involves barium swallow, esophageal manometry, and endoscopy. Treatment options include medications, balloon dilation, botulinum toxin injection, and surgical myotomy, with the goal of weakening the lower esophageal sphincter to improve swallowing.
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2. A 40-year old man complains of
increasing difficulty in swallowing
over the past 3 years. He reports a
feeling of pressure in his chest
occurring 2-3 seconds after
swallowing a solid bolus. He also
experiences regurgitation of
undigested food eaten hours
previously. A radiograph taken after
swallowing barium shows a distended
esophageal body with a smooth
tapering at the lower esophageal
sphincter LES. Manometry shows the
absence of esophageal peristalsis with
swallowing and a lower esophageal
sphincter that fails to relax. What is
the most likely diagnosis?
A 34-year-old bus driver presents with
complaints of difficulty swallowing. The
symptoms began gradually, approximately
9 months ago, and have prevented him
from chewing solids or drinking liquids
comfortably. He finds himself awakened at
night with cough and occasional morning
regurgitation of recognizable food from the
night before. He has learned to reduce his
oral intake and has lost 6 pounds over the
past 2 months. He does not smoke or drink
and has no family history of esophageal or
other gastrointestinal illnesses. His physical
examination is unremarkable. Which of the
following is the most likely diagnosis?
6. ESOPHAGUS ANATOMY
OVERVIEW
• A flattened muscular tube
• About 18 to 26 cm in length
• Striated muscle in the upper part, smooth
muscle in the lower part, and a mixture of
the two in the middle
• The esophageal tube has neither mesentery
nor serosal coating
14. PHYSIOLOGY
ESOPHAGEAL PERISTALSIS
ESOPHAGEAL STAGE OF SWALLOWING
Primary peristalsis
Peristalsis in the striated muscle of the esophagus
Continuation of the peristaltic wave that begins in the
pharynx and spreads into the esophagus during the
pharyngeal stage of swallowing
15. PHYSIOLOGY
ESOPHAGEAL PERISTALSIS
ESOPHAGEAL STAGE OF SWALLOWING
Secondary peristalsis
Peristalsis in the smooth muscle of the esophagus
Result from distention of the esophagus itself by the
retained food
16. PHYSIOLOGY
NERVE SUPPLY
the upper part
• Striated muscle
• Innervated by vagus nerve
• The cell bodies are located in
nucleus ambiguus
• The nerves terminate directly on
striated muscle cells with
cholinergic (nicotinic) receptors
17. PHYSIOLOGY
NERVE SUPPLY
the lower part
• Smooth muscle
• Vagus nerve carries preganglionic
fibers of neurons located in the
dorsal motor nucleus
• The vagal preganglionic fibers
innervate the LES smooth muscle via
the postganglionic myenteric
neurons
18. PHYSIOLOGY
NERVE SUPPLY
the lower part
Vagal postganglionic neurons
• Submucosal plexus – Meissner’s plexus
• Myenteric plexus – Auerbach’s plexus
• Excitatory
Contracts the smooth muscle
Releasing: Ach, …
• Inhibitory
Dilates the smooth muscle
Releasing: NO, VIP (vasoactive
intestinal polypeptide), …
20. PHYSIOLOGY
LOWER ESOPHAGEAL SPHINCTER (LES)
LES normally remains tonically
constricted with an intraluminal pressure
of about 30 mmHg
The tonic constriction of the LES helps to
prevent significant reflux of stomach
contents into the esophagus
25. OTHER CLASSIFICATION OF ESOPHAGEAL MOTILITY DISORDERS
Classic classification
• Primary disorders (motor disorders):
Achalasia
Diffuse esophageal spasm (DES)
Nutcracker (jackhammer)
esophagus
Hypertensive lower esophageal
sphincter (LES)
Ineffective esophageal motility
(IEM)
• Secondary disorders:
Scleroderma
Dermatomyositis
Polymyositis
Lupus erythematosus
Chagas disease
Myasthenia gravis
The Chicago Classification of Esophageal Motility
• Achalasia and Esophagogastric Junction
Outflow Obstruction
Type I achalasia (classic)
Type II achalasia (with esophageal compression)
Type III achalasia (spastic achalasia)
Esophagogastric junction outflow obstruction
(achalasia in evolution)
• Major Disorders of Peristalsis
Absent contractility
Distal esophageal spasm
Hypercontractile esophagus (jackhammer)
• Minor Disorders of Peristalsis
Ineffective esophageal motility
Fragmented peristalsis
Normal esophageal motility
26. SURGICAL CLASSIFICATION OF
ESOPHAGEAL MOTILITY DISPORDERS
• Motility Disorders of the Esophageal Body
Diffuse Esophageal Spasm
Nutcracker Esophagus
• Motility Disorders of the Lower Esophageal Sphincter
Hypertensive Lower Esophageal Sphincter
• Motility Disorders Affecting Both Body and Lower Esophageal
Sphincter
Achalasia
Ineffective Esophageal Motility
27. DEFINITION - EPIDEMIOLOGY - ETIOLOGY
• Achalasia is a primary motor disorder of the esophagus
characterized by insufficient LES relaxation and loss of
esophageal peristalsis
• Rare, the incidence is 6/100.000 persons/year
Usually presenting between age 25 and 60, with a
predilection to affect young women
28. DEFINITION - EPIDEMIOLOGY - ETIOLOGY
• Its pathogenesis is presumed to be idiopathic or infectious
neurogenic degeneration, such as:
Severe emotional stress
Trauma
An autoimmune process attributable to a latent infection
with HSV 1
Chagas disease (parasitic infection with Trypanosoma cruzi)
…
29. PATHOPHYSIOLOGY
• Progressive neuronal degeneration / damage in the
mesenteric plexus, which results in a nonrelaxing,
hypertensive lower esophageal sphincter (LES) and
aperistalsis of the body of the esophagus
• The cause of the neuronal degeneration is unknown
30. PHYSIOLOGY
NERVE SUPPLY
the lower part
Vagal postganglionic neurons
• Submucosal plexus – Meissner’s plexus
• Myenteric plexus – Auerbach’s plexus
• Excitatory
Contracts the smooth muscle
Releasing: Ach, …
• Inhibitory
Dilates the smooth muscle
Releasing: NO, VIP, …
31. DIAGNOSIS
SYMPTOMATOLOGY
• Dysphagia
• Regurgitation
• Substernal chest pain
• Weight loss
• Heartburn
• Nocturnal coughing
• …
Symptoms at presentation may have persisted for months to years
Patients adapt their lifestyle to accommodate the inconveniences
that accompany this disease
34. DIAGNOSIS
SYMPTOMATOLOGY
• Substernal chest pain
50%
Unrelated to meals or exercise and may last up to hours
Predominantly present in patients with type III achalasia
35. DIAGNOSIS
SYMPTOMATOLOGY
• Weight loss
35–91%
Because of poor esophageal emptying and decreased or
modified food intake
Usually minimal some patients are obese
36. DIAGNOSIS
SYMPTOMATOLOGY
• Heartburn
Production of lactic acid from retained food or exogenous
ingested acidic materials such as carbonated drinks
• Nocturnal coughing, nocturnal regurgitation
Substantial stasis of large amounts of food and secretions
Substernal discomfort or fullness may be noted after eating
Physical examination is unhelpful
40. ENDOSCOPY – ESOPHAGOGASTRODUODENOSCOPY (EGD)
• Evaluating the mucosa for evidence of esophagitis or cancer to
rules out benign strictures or malignancy
• Reveal a dilated esophagus with retained food and increased
resistance at the gastroesophageal junction
• Intubation of the stomach through the EGJ may be associated
with mild resistance; however, stronger resistance should
prompt an evaluation for pseudoachalasia with further imaging
41. ENDOSCOPY – ESOPHAGOGASTRODUODENOSCOPY (EGD)
Pseudoachalasia
• When these symptoms are caused by malignancy, the syndrome
is referred to as pseudoachalasia
• Accounts for up to 5% of suspected cases
• CT scanning or EUS may be of value
Achalasia Pseudoachalasia
between age 25 and 60 advanced age
persisted for months to years abrupt onset of symptoms (<1 year)
weight loss weight loss #
dysphagia for solids and liquids
dysphagia for solids then liquids or uniquely
solid food dysphagia
43. MANOMETRY
PRESSURE TOPOGRAPHIC METRICS (INTRODUCE)
IRP – Integrated Relaxation Pressure (mmHg)
• Address issue: "Does the EGJ
(esophagogastric junction) relax
normally with swallowing?" or “Is
there abnormal resistance to bolus
movement across the EGJ?” to
evaluate EGJ function
• The upper limit of normal for IRP is
15 mmHg
44. MANOMETRY
PRESSURE TOPOGRAPHIC METRICS (INTRODUCE)
ICL – 20 mmHg isobaric contour line
• Address issue: “Is peristalsis present and if so is it a continuous
process?” to evaluate of esophageal motor function
45. MANOMETRY
PRESSURE TOPOGRAPHIC METRICS (INTRODUCE)
CDP – contractile deceleration point
• CDP is the time at which
esophageal peristalsis
terminates, and the LES
begins to descend to its
resting position
46. MANOMETRY
PRESSURE TOPOGRAPHIC METRICS (INTRODUCE)
CFV – contraction front velocity
• Be used to evaluate
propagation of esophageal
pressure waves
• CFV measures peristaltic
velocity in the smooth muscle
esophagus, normal: 9 cm/s
47. MANOMETRY
PRESSURE TOPOGRAPHIC METRICS (INTRODUCE)
DL – distal latency
• Be used to evaluate
propagation of esophageal
pressure waves
• Measures post deglititive
inhibition and adequacy of
inhibitory neuromuscular
function in the smooth muscle
esophagus, the lower limit of
normal for DL is 4.5 seconds
48. MANOMETRY
DCI – distal contractile integral (mmHg.s.cm)
• Measure of how robust peristalsis is in
the smooth muscle esophagus
• DCI is the amplitude × duration × length
(mmHg.s.cm) of the distal esophageal
contraction exceeding 20 mmHg from the
transition zone to the proximal margin of
the lower esophageal sphincter
• Hypercontraction: DCI < 8000
Normal contraction: 450 < DCI < 8000
Weak contraction: 100 < DCI < 450
Failed contraction: DCI < 100
50. DIAGNOSIS
MANOMETRY
• The LES is hypertensive, with pressures
usually higher than 35 mmHg (integrated
relaxation pressure >15 mmHg)
• The LES fails to relax with deglutition
• Simultaneous mirrored contractions with no
evidence of progressive peristalsis
• Low-amplitude waveforms indicating a lack
of muscle tone
61. DIFFERENTIAL DIAGNOSIS
Pseudoachalasia
• Accounts for up to 5% of suspected cases
• Advanced age
• Abrupt onset of symptoms (<1 year)
• Weight loss
• Endoscopy is a necessary part of the evaluation of achalasia
62. ACHALASIA
COMPLICATION
• Aspiration can become life-threatening, pneumonia, lung
abscess, and bronchiectasis often result from long-standing
achalasia
• Esophagitis
• Esophageal adenocarcinoma
• Malnutrition
63. TREATMENT
• Achalasia is a chronic condition without cure
• The goals in treating achalasia:
Relieve patient ’s symptoms
Improve esophageal emptying
Prevent further dilation of the esophagus
• Surgical and nonsurgical treatment options
64. TREATMENT – ORAL PHARMACOLOGIC THERAPY
• Calcium channel blockers and long-acting nitrates
• Transiently reduce LES pressure by smooth muscle relaxation, facilitating
esophageal emptying
• SAGES Guidelines:
Limited role in the treatment
Should be used in very early stages of the disease, temporizing measures
until more definitive treatments
Patients who fail or are not candidates for other treatment modalities
• Side-effects such as hypotension, headache, and dizziness in up to 30% of
patients. Moreover, drug tolerance develops with time
65. TREATMENT
PHARMACOLOGIC THERAPY VIA ENDOSCOPY
• Endoscopic injection of botulinum toxin (Botox®) directly into
the LES
• Blocks acetylcholine release
→ Revenges smooth muscle contraction
→ Effectively relaxes the LES
• With repeated treatments, Botox may offer symptomatic relief
for years, but symptoms recur more than 50% of the time
within 6 months
66. TREATMENT
PHARMACOLOGIC THERAPY VIA ENDOSCOPY
SAGES Guidelines
• Botulinum toxin can be administered safely, but its effectiveness
is limited especially in the long term
• Reserved for poor candidates for other more effective
treatment options such as surgery or dilation
68. TREATMENT
PNEUMATIC DILATION (PD)
• The most effective nonsurgical option
• Tears the LES by forceful stretching with air-filled balloons
• Under fluoroscopic guidance, the balloon is positioned across
the LES and gradually inflated until the waist is flattened
• A risk of esophageal perforation of less than 4%
70. TREATMENT
SURGICAL MYOTOMY
When performed adequately (i.e., reducing
sphincter pressure to <10 mmHg), and done
early in the course of disease, LES myotomy
results in symptomatic improvement with the
occasional return of esophageal peristalsis
71. TREATMENT
MYOTOMY OF THE LES (HELLER MYOTOMY)
• Surgical myotomy of the muscle layer of the distal esophagus and LES
• Maybe perform an antireflux procedure after main surgery
75. TREATMENT
ESOPHAGECTOMY
• Is considered in any symptomatic patient with a tortuous
esophagus (megaesophagus), sigmoid esophagus, failure of more
than one myotomy, or reflux stricture that is not amenable to
dilation
• Definitively treating the end-stage achalasia patient
• Eliminates the risk for carcinoma in the resected area
77. PD VS. BOTOX
• A recent Cochrane database review of 6 studies involving 178 patients
found no significant difference in remission between PD and botox
treatment within 4 weeks of the initial intervention
• A study of 42 patients who were randomized to botox injection or graded
PD with 30 and 35 mm Rigiflex balloons reported success of 70 % for PD
and 32 % for botox at 12 months
• Three studies included in the review had 12-month data with remission in
33 of 47 PD patients compared with 11 of 43 botox patients
PD is more effective than botox in the long term for patients with achalasia
78. PD VS. HELLER MYOTOMY
• The greater likelihood of reducing
sphincter pressure to <10 mmHg
by surgical myotomy compared
with hydrostatic balloon dilation
• Patients whose sphincter
pressure has been reduced by
hydrostatic balloon dilation to
<10 mmHg have an outcome
similar to those after surgical
myotomy
79. PATIENT FOLLOW-UP
Recommendations
• Patient follow-up after therapy may include assessment of both
symptom relief and esophageal emptying by barium esophagram
(strong recommendation, low-quality evidence)
• Surveillance endoscopy for esophageal cancer is not
recommended (strong recommendation, low-quality evidence).
Short term
Long term
80. QUESTIONS
A 34-year-old bus driver presents with complaints of difficulty swallowing. The
symptoms began gradually, approximately 9 months ago, and have prevented him
from chewing solids or drinking liquids comfortably. He finds himself awakened at
night with cough and occasional morning regurgitation of recognizable food from
the night before. He has learned to reduce his oral intake and has lost 6 pounds
over the past 2 months. He does not smoke or drink and has no family history of
esophageal or other gastrointestinal illnesses. His physical examination is
unremarkable. Which of the following is the most likely diagnosis?
A. Achalasia
B. Esophageal adenocarcinoma
C. Schatzki ring
D. Peptic stricture
E. Progressive systemic sclerosis
81. Explanation
Esophageal carcinoma may occur in patients with a history of Barrett's esophagus secondary
to longstanding GERD. In any case, this patient is far younger than the typical patient who
develops esophageal adenocarcinoma seen later in life
A Schatzki’s ring produces episodic dysphagia to large solids that are greater in diameter than
the size of the ring, typically at the beginning of a meal
A peptic stricture presents with a mechanical-type dysphagia, typically cause progressive
dysphagia, first for solids, then for liquids. It usually occurs in patients with a longstanding
history of GERD
Progressive systemic sclerosis (PSS) is far more likely to occur in women. Like achalasia, it has
reduced or absent motility in the body of the esophagus. In PSS, however, there is reduced
LES pressure at rest that predisposes to severe GERD and its possible sequelae. Unless there
are symptoms of a mechanical obstruction secondary to a stricture, esophageal retention of
food does not occur
82. SUMMARY
• Achalasia is a rare disease caused by loss of ganglion cells within the
esophageal myenteric plexus with a population incidence of about
6:100.000 and usually presenting between age 25 and 60
• Achalasia is a primary motor disorder of the esophagus characterized by
insufficient LES relaxation and loss of esophageal peristalsis
• Gradual, progressive dysphagia for solids and liquids, regurgitation of
undigested food, barium esophagogram with "bird's beak" distal
esophagus, esophageal manometry confirms diagnosis
• Treatment is contented with pharmacologic therapy, pneumatic balloon
dilatation, or surgical myotomy
84. REFERENCES
1. Jonathan D. Spicer, Rajeev Dhupar, Jae Y. Kim, Boris Sepesi, Wayne Hofstetter. Esophagus.
In Sabiston textbook of surgery 20th edition, 2017: 1013-42.
2. Blair A. Jobe, John G. Hunter, and David I. Watson. Esophagus and Diaphragmatic Hernia.
In Schwartz’s Principles of Surgery 10th edition, 2015: 941-1024.
3. Peter J. Kahrilas, Ikuo Hirano. Diseases of the Esophagus. In Harrison principles of internal
medicine 19th edition, 2015: 1900-11.
4. John E. Hall, Ph.D., arthur C. Guyton Professor and Chair. Gastrointestinal Physiology. In
Guyton and Hall textbook of medical physiology 12th edition, 2011: 753-805.
5. Kahrilas PJ, Bredenoord AJ, Fox M, Gyawali CP, Roman S, Smout AJ, Pandolfino JE;
International High Resolution Manometry Working Group, 2014. The Chicago Classification
of esophageal motility disorders v3.0.
6. Dimitrios Stefanidis, William Richardson, Timothy M. Farrell, Geoffrey P. Kohn, Vedra
Augenstein, Robert D. Fanelli, 2011. SAGES guidelines for the surgical treatment of
esophageal achalasia.
85. THANK YOU FOR WATCHING!
“ A person who never made a mistake, never tried anything new.”
Albert Einstein