UPPER GI DISEASES Epigastric pain
158
UPPER GI DISEASES Epigastric pain Ferenc Szalay professor emeritus Lecture for students 16 June 2020 Clinic of Internal Medicine and Oncology of Semmelweis University Budapest, Hungary
Transcript of UPPER GI DISEASES Epigastric pain
1. diaClinic of Internal Medicine and Oncology of
Semmelweis University Budapest, Hungary
imported from internet, from
Vena mesenterica superior Arteria mesenterica superior
The border: upper-lower
Motility disorders, Diverticulum
45 y F kidney transplanted, Esophageal pain
72 y F dysphagia
83 y F achalasia
33 y M heartburn
46 y M hematemesis
Swallowing
Stages
Foreign body in
Aorta
AIDS
injury
Cytomegalovirus esophagitis
Candida esophagitis. Multiple yellow plaques in the
midesophagus are shown. In some areas, the plaque material becomes confluent.
The surrounding uninvolved mucosa is normal with a normal vascular pattern.
This patient had long-standing poorly controlled diabetes mellitus and presented with dysphagia
and odynophagia.
elements, bacteria, and inflammatory
squamous epithelia.
Histoplasma capsulatum
Womiting, Hearburn
Pathophysiology of EoE
Pill induced esophageal mucosal lesion
Pill induced
mucosal lesion
Motility disorders
• Neurologic disorders (stroke) Cerebrovascular diseases, Poliomyelitis Amyotrophic lateral sclerosis, Multiple sclerosis, Brain stem tumor
• Skeletal muscular disorders Myastenia gravis, Metabolic myopathy (T4 toxicosis, myxedema, steroid)
Muscular dystrophies
Motility disorders of oropharynx
with poor prognosis owing to a high incidence of aspiration
Motility disorders of the esophagus
Smooth muscle diseases (scleroderma)
Nervous system d. (intrinsic)
LES
Models of Primary Achalasia Auerbach’s plexus (myenteric)
Myenteric neurons
Smooth muscle
past years
Dysphagia, regurgitation,
SA - splenic artery
GERD Gastro esophageal
Klinikai panaszok
GERD Gastro-oesophageal reflux disease
Z- line gastroesophageal junction
Gastric pepsin
Duodenogastric reflux
Weight loss unexpected weight loss
Symptoms of
Impaired mucosal defence
– transient LES
acid output (smoking, coffee)
Pathophysiology of GERD
• Barium swallow
• E. manometry
• Bernstein test
• pH monitoring
extend between the
breaks, more than 5 mm
long, that do not extend
between the tops of two
mucosal folds
Grade B
mucosal folds, but which
the circumference
Grade C
Los Angeles classification system for oesophagitis
Grade I - V
Gr. I. One or several erosions in one mucosal fold
Gr. II. Several erosions in several mucosal folds,
the erosions can merge
circumference
Gr.V. Barrett’s epithelium
Quigley, Eur J Gastroenterol Hepatol 2001; 13(Suppl 1): S13–18.
Nathoo, Int J Clin Pract 2001; 55: 465–9.
www.gastrolab.net
Grade III oesophagitis
Grade IV oesophagitis
Savary-Miller
classification
Grade V oesophagitis
Moderate Barrett’s
Grade V oesophagitis
Severe Barrett’s
Normal With reflux
Extraesophageal symptome of GERD
Barrett
esophagus
Squamous epithelium
has been
recurrent pneumonia.
the level of the cricopharyngeus (arrow).
Zenker's diverticulum is a pulsion diverticulum and is the result of increased
intrapharyngeal pressures during swallowing
nonrelaxing UES.
of severe symptoms is usually
cricopharyngeal myotomy.
Hypertensive E. peristalsis
Diffuse E. spasm
mail > femail
adenocarcinoma in western countries
Feldman (series editor), Roy C. Orlando. ©2002 Current Medicine LLC.
Epidemiologic
features
M o
in England and Wales
Enviromental factors: tobacco
GERD
5 y survival
GI bleeding occult iron deficient anemia
massive and fatal if erodes aorta
CLINICAL MANIFESTATION
Echoendoscopic picture
infiltrates the mucosa and
submucosa (7.5 MHz, radial
submucosa, represented by a
but not completely through
TREATMENT
Palliation: radiation
normal mucosa.
Plummer Vinson syndrome
- upper E web
- sudden: “steak house syndrome”
Watermelone esophagus
Pinhole quality
Hemorrhages from lacerations of the cardiac
orifice of the stomach due to vomiting G. Kenneth Mallory, Soma Weiss.
American Journal of the Medical Sciences,
Thorofare, N.J., 1929, 178: 506-15.
Mallory-Weiss syndrome
Mallory-Weiss syndrome
Bleeding from
rupture of
Variceal
bleeding
P > 100/min
The goals of management of GI bleeding
in order of priority
invasive means
OESOPHAGEAL VARICEAL BLEEDING
30-40% mortality in cirrhosis
Repeated bleeding in 70%
Ballon (STB, Linton, Min.) GAIN TIME !
Sengstaken-Blakemore Linton-Nachlas
Endoscopic – 75-85% successfull
Endoscopic – 75-85% successfull
Sclerotisation – massive bleeding
Endoscopic – 75-85% successfull
Sclerotisation – massive bleeding
Endoscopic – 75-85% successfull
Sclerotisation – massive bleeding
(ISMN-R, AT-II receptor antagonists, Losartan)
Secundary
Propanolol
malignancy
Infectious
Gastric ulcer disease H.p.
Tumors Benign - polyps, lipoma
Motility disorders Gastroparesis – diabetes
Complications
Bleeding
Lifestile – stop smoking, stop alcohol, regular eating, avoid extra spisy
Reduction of acid - PPI, H2 blocker, antacides
H.p. eradication
STOMACH / GASTRIC CANCER 1.
5th most-common cancer worldwide
Diet –smoked meat. Obesitiy – risk factor
Genetic – hereditary diffuse gastric cancer (CDH1 gene defect on chr.16)
Other – atrophic gastritis,anemia perniciosa,
intestinal metaplasia
size of the tumor
metastatic or nonmetastatic
Upper endoscopy
BIOPSY histology
Endoscopic sonography
with adenocarcinoma
Curative for early gastric cancer
Survival for most patients< 5%
Total or Subtotal gastrectomy
LYMPHOMA OF THE STOMACH
increased in frequency durint the past 25 ys
Non-Hodgkin’s lymphoma (vast majority)
Hodgkin’s lymphoma is uncommon
MALT (mucosa associated lymphoid tissue) - H.p.
Treatment: Subtotal gastrectomy, combination chemotherapy,
Helicobacter pylori eradication
All such tumors should be analyzed for mutation in the
c-kit receptor
a selective inhibitor of the c-kit tyrosinase kinase
ÁLTALÁNOS ORVOSTUDOMÁNYI KAR I. sz. Belgyógyászati Klinika
SZALAY Ferenc professor emeritus
>1018 diseases
Acute or chronic (recurrent)
History – 8 mandatory question
Imaging
US
ECG
Alleviation or aggravating circumstances
meal? anacids? alcohol? constipation?
Drug (aspirin)? Body position?
Semmelweis University Budapest, Hungary
imported from internet, from
Vena mesenterica superior Arteria mesenterica superior
The border: upper-lower
Motility disorders, Diverticulum
45 y F kidney transplanted, Esophageal pain
72 y F dysphagia
83 y F achalasia
33 y M heartburn
46 y M hematemesis
Swallowing
Stages
Foreign body in
Aorta
AIDS
injury
Cytomegalovirus esophagitis
Candida esophagitis. Multiple yellow plaques in the
midesophagus are shown. In some areas, the plaque material becomes confluent.
The surrounding uninvolved mucosa is normal with a normal vascular pattern.
This patient had long-standing poorly controlled diabetes mellitus and presented with dysphagia
and odynophagia.
elements, bacteria, and inflammatory
squamous epithelia.
Histoplasma capsulatum
Womiting, Hearburn
Pathophysiology of EoE
Pill induced esophageal mucosal lesion
Pill induced
mucosal lesion
Motility disorders
• Neurologic disorders (stroke) Cerebrovascular diseases, Poliomyelitis Amyotrophic lateral sclerosis, Multiple sclerosis, Brain stem tumor
• Skeletal muscular disorders Myastenia gravis, Metabolic myopathy (T4 toxicosis, myxedema, steroid)
Muscular dystrophies
Motility disorders of oropharynx
with poor prognosis owing to a high incidence of aspiration
Motility disorders of the esophagus
Smooth muscle diseases (scleroderma)
Nervous system d. (intrinsic)
LES
Models of Primary Achalasia Auerbach’s plexus (myenteric)
Myenteric neurons
Smooth muscle
past years
Dysphagia, regurgitation,
SA - splenic artery
GERD Gastro esophageal
Klinikai panaszok
GERD Gastro-oesophageal reflux disease
Z- line gastroesophageal junction
Gastric pepsin
Duodenogastric reflux
Weight loss unexpected weight loss
Symptoms of
Impaired mucosal defence
– transient LES
acid output (smoking, coffee)
Pathophysiology of GERD
• Barium swallow
• E. manometry
• Bernstein test
• pH monitoring
extend between the
breaks, more than 5 mm
long, that do not extend
between the tops of two
mucosal folds
Grade B
mucosal folds, but which
the circumference
Grade C
Los Angeles classification system for oesophagitis
Grade I - V
Gr. I. One or several erosions in one mucosal fold
Gr. II. Several erosions in several mucosal folds,
the erosions can merge
circumference
Gr.V. Barrett’s epithelium
Quigley, Eur J Gastroenterol Hepatol 2001; 13(Suppl 1): S13–18.
Nathoo, Int J Clin Pract 2001; 55: 465–9.
www.gastrolab.net
Grade III oesophagitis
Grade IV oesophagitis
Savary-Miller
classification
Grade V oesophagitis
Moderate Barrett’s
Grade V oesophagitis
Severe Barrett’s
Normal With reflux
Extraesophageal symptome of GERD
Barrett
esophagus
Squamous epithelium
has been
recurrent pneumonia.
the level of the cricopharyngeus (arrow).
Zenker's diverticulum is a pulsion diverticulum and is the result of increased
intrapharyngeal pressures during swallowing
nonrelaxing UES.
of severe symptoms is usually
cricopharyngeal myotomy.
Hypertensive E. peristalsis
Diffuse E. spasm
mail > femail
adenocarcinoma in western countries
Feldman (series editor), Roy C. Orlando. ©2002 Current Medicine LLC.
Epidemiologic
features
M o
in England and Wales
Enviromental factors: tobacco
GERD
5 y survival
GI bleeding occult iron deficient anemia
massive and fatal if erodes aorta
CLINICAL MANIFESTATION
Echoendoscopic picture
infiltrates the mucosa and
submucosa (7.5 MHz, radial
submucosa, represented by a
but not completely through
TREATMENT
Palliation: radiation
normal mucosa.
Plummer Vinson syndrome
- upper E web
- sudden: “steak house syndrome”
Watermelone esophagus
Pinhole quality
Hemorrhages from lacerations of the cardiac
orifice of the stomach due to vomiting G. Kenneth Mallory, Soma Weiss.
American Journal of the Medical Sciences,
Thorofare, N.J., 1929, 178: 506-15.
Mallory-Weiss syndrome
Mallory-Weiss syndrome
Bleeding from
rupture of
Variceal
bleeding
P > 100/min
The goals of management of GI bleeding
in order of priority
invasive means
OESOPHAGEAL VARICEAL BLEEDING
30-40% mortality in cirrhosis
Repeated bleeding in 70%
Ballon (STB, Linton, Min.) GAIN TIME !
Sengstaken-Blakemore Linton-Nachlas
Endoscopic – 75-85% successfull
Endoscopic – 75-85% successfull
Sclerotisation – massive bleeding
Endoscopic – 75-85% successfull
Sclerotisation – massive bleeding
Endoscopic – 75-85% successfull
Sclerotisation – massive bleeding
(ISMN-R, AT-II receptor antagonists, Losartan)
Secundary
Propanolol
malignancy
Infectious
Gastric ulcer disease H.p.
Tumors Benign - polyps, lipoma
Motility disorders Gastroparesis – diabetes
Complications
Bleeding
Lifestile – stop smoking, stop alcohol, regular eating, avoid extra spisy
Reduction of acid - PPI, H2 blocker, antacides
H.p. eradication
STOMACH / GASTRIC CANCER 1.
5th most-common cancer worldwide
Diet –smoked meat. Obesitiy – risk factor
Genetic – hereditary diffuse gastric cancer (CDH1 gene defect on chr.16)
Other – atrophic gastritis,anemia perniciosa,
intestinal metaplasia
size of the tumor
metastatic or nonmetastatic
Upper endoscopy
BIOPSY histology
Endoscopic sonography
with adenocarcinoma
Curative for early gastric cancer
Survival for most patients< 5%
Total or Subtotal gastrectomy
LYMPHOMA OF THE STOMACH
increased in frequency durint the past 25 ys
Non-Hodgkin’s lymphoma (vast majority)
Hodgkin’s lymphoma is uncommon
MALT (mucosa associated lymphoid tissue) - H.p.
Treatment: Subtotal gastrectomy, combination chemotherapy,
Helicobacter pylori eradication
All such tumors should be analyzed for mutation in the
c-kit receptor
a selective inhibitor of the c-kit tyrosinase kinase
ÁLTALÁNOS ORVOSTUDOMÁNYI KAR I. sz. Belgyógyászati Klinika
SZALAY Ferenc professor emeritus
>1018 diseases
Acute or chronic (recurrent)
History – 8 mandatory question
Imaging
US
ECG
Alleviation or aggravating circumstances
meal? anacids? alcohol? constipation?
Drug (aspirin)? Body position?
