This document discusses upper gastrointestinal (UGI) symptoms including dysphagia, dyspepsia/heartburn, and nausea & vomiting. It provides details on the pathophysiology, causes, evaluation, and treatment of each condition. Dysphagia can be mechanical or motor in origin and caused by issues like esophagitis or achalasia. Dyspepsia is mostly functional but can be due to conditions like GERD. Nausea and vomiting are mediated by brain centers and receptors that can be stimulated by infections, medications, or other visceral issues. Treatment involves addressing the underlying cause, rehydration, and antiemetics as appropriate for the condition.

1. UGI symptoms
Dysphagia
Dyspepsia/Heartburn
Nausea & Vomiting

2. Dysphagia
Difficulty in swallowing

3. Pathophysiology
 Normal passage of an ingested bolus
depends on-
 Size of bolus
 Lumen of passage
 Peristaltic contraction
 Relaxation of upper & lower esophageal sphincter
 Types of dysphagia-
 Mechanical- large bolus, luminal narrowing
 Motor- incoordinated/weak peristalsis, impaired sphincter
relaxation

4. Causes
 Mechanical
 Esophagitis
 Carcinoma
 Stricture
 Esophageal
ring/web
 LN or L atrial (MS)
compression
 Motor
 Stroke
 Bulbar/pseudobulbar
palsy
 Myasthenia gravis
 Achalasia
 Esophageal spasm
 Scleroderma

5. Work-up
 History-
 Mechanical- solids>liquids
 Motor- liquids>solids
 Duration- transient, episodic, progressive
 Asso. symptoms-weight loss, regurgitation, aspiration,
hoarseness, hiccups, chest pain etc.
 Examination-
 Skin, oral cavity, neck, lungs, cranial nerve exam.
 Investigation-
 Esophagogastroduodenoscopy (EGD)

6. Treatment
Of underlying cause
Symptomatic/dilatation/
surgery ± RT/CT

7. Dyspepsia
Chronic/recurrent
pain/fullness in upper abdomen
associated with
bloating/belching/nausea/heartburn

8. Cause
Mostly functional
20% GERD, 10% PUD
Drugs- NSAIDs, Abx., Fe.,
steroids

9. Warning signs
 Weight loss
 Persistent vomiting
 Constant/severe pain
 Dysphagia
 Hematemesis/malena
 Anemia

10. Management
 UGI endoscopy in those with warning signs or non-
responders
 Stop offending drugs, if possible
 Empiric treatment in others
 H2RB/PPI for 4-8 weeks
 Metoclopramide- prokinetic
 Other
 Reduce fat, caffeine, alcohol intake
 Lifestyle changes

11. Nausea
Unease or discomfort,
with an urge to vomit

12. Vomiting/Emesis
Forceful oral expulsion
of gastric contents

13. Pathophysiology
 Vomiting center in medulla
 Afferent input
 Vagal & splanchnic fibres from GIT- 5-HT3 receptor
 Vestibular system- VIII nerve- muscarinic/H1 receptors
 Higher CNS centers- sight/smell/emotion
 CTZ- in area postrema of medulla- 5-HT3/NK1/D2 receptors
 Efferent output
 Phrenic nerve- to diaphragm
 Spinal nerves- to intercostal/abdominal muscles
 Visceral fibres in Vagus nerve
Phases- retchingexpulisve

14. Causes
 Visceral afferent
stimulation
 Infection/inflammation
 Obstruction
 Dysmotility
 Peritoneal irritation
 Alcohol/NSAIDs/Abx.
 Postoperative
 MI
 Ureteric calculi
 CNS disorders
 Motion sickness
 Migraine
 Raised ICT- hemorrhage,
infection, tumor
 Psychogenic
 Irritation of CTZ
 Chemotherapy/radiation
 Drug induced
 Systemic- DKA, uremia,
adrenal crisis, pregnancy

15. Complications of vomiting
 Aspiration
 Dehydration
 Electrolyte imbalance- hypokalemia
 Hypochloremic metabolic alkalosis
 Mallory-Weiss tear
 Boerhaave syndrome- eso. rupture

16. Evaluation
 History- onset, frequency, timing,
content, relation with meals,
associated symptoms
 Examination- vital signs, tenderness,
guarding/rigidity, any neuro. sign
 Investigation- electrolytes, RFT/LFT,
AxR, UGIE, CT scan-abdomen/head

17. Treatment
 Hydration
 Antiemetics
 Metoclopramide/Domperidon- UGI cause
 Corticosteroids- nonspecific, used as adjuvant
 5-HT3 receptor antagonist- CT/RT/postop. vomiting
 NK1 receptor antagonist- Aprepitant (post-CT vomiting)
 Benzodiazepines- anticipatory/psychogenic vomiting
 Antihistamines- motion sickness
 Marijuana
 Correct underlying cause, if any

18. UGIE- indication- diagnostic
 UGI bleed
 Unexplained iron deficiency anemia
 Dysphagia
 Persistent dyspepsia, specially age >45
 Persistent vomiting
 Dx & FU of Barrett’s esophagus

19. UGIE- therapeutic
 Banding/sclerotherapy of varices
 Injection of bleeding lesions
 Polypectomy
 Removal of foreign body
 Dilatation/stenting of stenotic lesions
 PEG- percut. endoscopic gastrostomy
 EUS
 ERCP
 Endoscopic trans-gastric laparoscopy