Disorders of the Upper Gastrointestinal Tract Dr. Aric Storck November 7, 2002 objectives Review diagnosis and management of common disorders of the esophagus, stomach and duodenum Will not discuss disorders of bowel GI bleed – covered next week Esophagus – anatomy 25-30 cm Relation to adjacent structures Prevertebral fascia posteriorly Trachea / L mainstem bronchus/ heart anteriorly Fixed at origin Mobile throughout mediastinum Two layers Inner layer – circular Outer layer – longitudinal NB: No serosal layer Proximal 1/3 Middle 1/3 Striated muscle Allows voluntary initiation of swallowing innvervated by spinal accessory nerve Striated and smooth muscle Dorsal motor nerve of vagus Distal 1/3 Smooth muscle Dorsal motor nerve of vagus Normal Healthy Esophagus Esophageal Obstruction 4 areas of narrowing Cricopharyngeus (upper esophageal sphincter) Aortic arch Left mainstem bronchus Diaphragmatic hiatus Large foreign body in esophagus can obstruct airway Esophageal obstruction clinical presentation Complete Unable to swallow Drooling Violent retching Pain from neck to epigastrium Proximal Sudden cyanosis • Compression of trachea by food in upper esophagus or oropharynx Esophageal obstruction causes Foreign bodies Anatomic anomalies Coins, food, batteries Carcinoma Schiatzki’s ring Peptic / chemical stricture Extrinsic compression Thyroid enlargement Zenker’s diverticulum Aortic arch Anomalous right subclavian artery Bronchogenic carcinoma Esophageal obstruction diagnostic strategies Endoscopy Plain radiographs Gastrograffin vs barium NB:radigraphs + contrast studies If foreign body suspected Not seeing it does not rule it out Contrast studies Gold standard for diagnosis and treatment False negatives <20% False positives <1% CT scan Esophageal obstruction foreign body management Oropharyngeal Esophageal Retrieve with Kelly / McGill forceps Endoscopic removal Foley catheter (controversial) Lower esophagus Often food impaction Glucagon 1mg iv (maximum 2mg) • Relax sphincter enough to allow passage of food in 50% of patients • Affects only smooth muscle, thus not useful for proximal obstructions Reflux esophagitis stricture pizza •Food impacted proximal to stricture •Could attempt glucagon Esophageal Strictures I. Caustic stricture • Narrowing of 2/3 of esophagus due to caustic ingestion years ago • Accidental in children • Suicide II. Radiation stricture • Smooth midesophageal stricture Esophageal obstruction foreign body management Effervescent agents (pop …) Sharp objects Urgent intervention Cause intestinal perforation in 15-35% Batteries “button” batteries – urgent removal • Zn, Li, Hg – leakage causes toxicity Did you know …. There is a National Button Battery Ingestion Hotline (202) 525-3333 Bell in esophagus Case A patient has been drinking heavily. He presents to the emergency room after several hours of severe vomiting and retching. He is complaining of severe epigastric pain radiating to the back. He has not had significant hematemesis. Diagnosis? Esophageal perforation Potentially life-threatening Boerhaave’s syndrome Valsalva maneuver Cough Childbirth Cough Iatrogenic Vomiting Endoscopy Foreign body ingestion Trauma Esophageal perforation clinical presentation Upper esophagus Neck / chest pain Dysphagia Respiratory distress Fever Lower esophagus Abdo pain / pain radiating to back Pneumothorax Pneumomediastinum Subcutaneous emphysema (Hamman’s Sign) Esophageal perforation Diagnosis CXR / upright AXR Contrast studies Subcutaneous emphysema Pneumomediastinum Mediastinal widening Pleural effusion Gastrograffin/barium CT Mediastinal air Extraluminal contrast Fluid collections Boerhaave’s Syndrome •Esophageal rupture •Contrast filling rounded area adjacent to distal esphagus •Arrows = rupture Esophageal Perforation Treatment Aggressive treatment Boerhaave’s Unstable Contamination of mediastinum/pleura Tx with broad spectrum ABX Conservative treatment Stable, afebrile Endoscopic injury Delayed presentation Case A 42 year old woman comes to emergency complaining of trouble swallowing. The food seems to get stuck in her throat. This has been happening for several weeks. What has she got? Dysphagia From Greek “dys” difficult “phagia” eating sensation of food getting “stuck” +/- pain indicates esophageal problem oropharyngeal esophageal 12% of patients in acute care hospital up to 50% of patients in chronic care Oropharyngeal dysphagia Inability to transfer food to esophagus food sticks immediately after swallowing neurological cortical - pseudobulbar palsy (UMN lesion) due to bilateral stroke bulbar - ischemia, tumour (LMN) peripheral - polio, ALS Oropharyngeal dysphagia Muscular muscular dystrophy cricopharyngeal incoordination • failure of UES to relax with swallowing Zenker’s diverticulum Esophageal Dysphagia Solid food only Solid or liquid food Mechanical obstruction Neuromuscular disorder intermittent intermittent progressive Reflux Sx Respiratory Lower esophageal ring/web progressive heartburn Age>50 Peptic stricture DES carcinoma scleroderma symptoms achalasia Achalasia Incomplete relaxation of LES (resting pressure >30mm Hg) etiology idiopathic - most common Chagas disease - Latin America secondary to cancer (esophagus, stomach) Achalasia - Complications Respiratory aspiration bronchiectasis lung abscesses GI malnutrition increased risk of esophageal cancer Achalasia - Diagnosis CXR absent air in stomach dilated fluid filled esophagus barium esophagogram prominent esophagus with “bird’s beak” esophageal motility study required for definitive diagnosis Achalasia - Treatment Nitrates, CCBs balloon dilatation of LES 50% successful 5% perforation Surgery Heller myotomy Achalasia Barium esophagogram. The dilated esophagus ends in a "bird's beak" that represents the nonrelaxing lower esophageal sphincter. Fluoroscopy during the swallow revealed no meaningful peristalsis in the esophageal body. Achalasia Manometry •Failure of LES relaxation •Failure of peristaltic conduction to LES Diffuse Esophageal Spasm Normal peristalsis interspersed with abnormal high pressure waves unknown etiology diagnosis barium esophagogram - corkscrew pattern manometry treatment medical - nitrates, CCB, anticholinergics surgery - long myotomy DES •Nutcracker esophagus •note pseudodiverticula caused by spasm CASE A 51 year old woman presents with trouble swallowing. You also note generally tight skin, particularly around the fingers. She says she has Reynaud’s phenomenon. What is the most likely diagnosis? Scleroderma Microvascular disease and intramural neuronal dysfunction aperistalsis & loss of LES tone … reflux … stricture … dysphagia Scleroderma - Treatment GERD prophylaxis anti-reflux surgery - last resort Scleroderma •Distal esophageal stricture CASE A teenager presents to the emergency department with a 2 day history of severe pain while swallowing. She has to spit out her saliva rather than swallow. She has acne and is taking tetracycline. Diagnosis? Esophagitis GERD (#1 cause) Infectious esophagitis Pill esophagitis Caustic ingestion Radiation Sclerotherapy Infectious Esophagitis Rare in immunocompetent hosts Risk factors DM, EtOH, GC’s, elderly Immunosuppressants, broad spectrum abx Candida albicans – most common Viral – HSV, CMV Bacterial – uncommon Trypanosoma cruzi, cryptosporidium Infectious esophagitis clinical manifestations +++ Odynophagia Dysphagia Solids & liquids Fever (uncommon) Bleeding (uncommon) Esophagitis - diagnosis Endoscopy Infectious • Candida – white plaques • Herpes – vesicles • Definitive dx via biopsy Candidal esophagitis •Common in •HIV •Antibiotics •Chemotherapy •+++dysphagia •Tx: fluconazole HSV Esophagitis •Common in: •Chemotherapy •HIV •Tx: acyclovir Esophagitis I. Early Esophagitis • II. Diffuse nodularity of mucosal surface Mod. Esophagitis • Thickened folds and nodularity in distal esophagus III. Severe Esophagitis • Diffuse ulcerations and stricture Infectious esophagitis treatment Candida HSV Fluconazole 200mg po od x 3-4 weeks Acyclovir 400mg po 5x/day x 2 weeks CMV Gancyclovir Foscarnet Antacids, topical anesthetics, sucralfate Pill esophagitis Pill fails to enter stomach and remains in esophagus Risk factors Age Decreased esophageal motility Compression Large pills Pill esophagitis clinical manifestations Sudden onset odynophagia +/- dysphagia Hx of pill ingestion Could be hours previously +/- sensation pill is “stuck” Pill esophagitis treatment Prevention 4oz liquid with any pill Medications taken in upright position Avoid use of pills if possible GERD Asymptomatic reflux in most people GERD = reflux plus one of Histopathologic changes of esophageal epithelial lining Symptoms of reflux Symptomatic reflux in 7% daily 14% weekly 40% monthly GERD – mechanisms Decreased LES pressure 1. • • • • • • • • Anticholinergics Benzos caffeine, CCBs Ethanol Nicotine Nitrates progesterone GERD - mechanisms 2. Decreased Esophageal Motility 3. Achalasia DM Scleroderma Increased gastric emptying time Anticholinergics DM gastroparesis GERD - symptoms Heartburn Regurgitation Dysphagia Odynophagia Asthma Beware - mimics ischemic heart pain Aspiration activation of vagal reflex arc Oropharyngeal Laryngitis, dental erosions, etc. GERD – complications Erosion, ulceration, scarring Esophagitis Stricture Columnar metaplasia Barrett’s esophagus • Predisposes to adenocarcinoma GERD - diagnosis History and physical Relief with antacids pH monitoring Esophageal manometry endoscopy Must R/O ischemic heart disease!! GERD •Erosions/ulcerations caused by acid reflux Barrett’s Esophagus I. Barrett’s esophagus – ulceration of posterolateral wall II. Midesophageal stricture from healed Barrett’s ulcer III. Adenocarcinoma secondary to Barrett’s esophagus GERD - treatment Lifestyle Sleep upright Avoid eating before bed Avoid agents that decrease LES tone • Nicotine, etoh, anticholinergics … Decrease acid production H2-blockers • eg: ranitidine 150mg po bid • Improvement in 70-90% of patients PPI GERD - treatment Acid neutralization OTC antacids Protect mucosa sucralfate Gastritis Histologic diagnosis of inflammation of gastric mucosa etiology H.pylori (#1) NSAIDs (#2) Ethanol, potassium, iron often underlying cancer, ulcer, etc. other infectious organisms (viral, mycobacterial, etc.) Corrosive agents • Bile • Ingested acids/alkali Gastritis - clinical presentation Variable & non-specific asymptomatic abdominal pain nausea and vomiting GI bleed (rare) shock (rare) Gastritis Complications Perforation Gastric outlet obstruction Diagnosis Usually clinical Must rule out other potential causes of pain Endoscopy +/- biopsy Gastritis - treatment H2 – antagonists Consider H.pylori eradication refer to GI as outpatient if persistent Gastric Volvulus Rare (400 cases in literature) Caused by >180 degree rotation of stomach upon itself Usually aged 40-50 y.o. 20% in children <1 Often have paraesophageal hernia Complications Gastric ischemia & perforation Death (15-20%) Gastric volvulus Clinical presentation Sudden, severe abdo pain • May radiate to chest or back Vomiting Borchardt’s triad • Epigastric pain & distension, vomiting, inability to pass NG tube Diagnosis AXR – large gas-filled loop of bowel Treatment Insertion of NG tube • Decompresses and may reduce volvulus Surgery Peptic Ulcer Disease Erosion superficial to muscularis mucosa no scarring Ulcer penetrates muscularis mucosa scarring PUD - epidemiology 4 million in US $15 billion in US PUD - etiology Duodenal Gastric H. pylori 90% 60% NSAIDs 7% 35% Stress-induced <3% <5% Zollinger-Ellison <1% <1% PUD & H. pylori Gram negative rod Lives in upper GI tract between epithelial surface and mucus fecal-oral transmission Increases risk of gastric cancer Almost all non-NSAID ulcers are due to H.pylori (95% duodenal, 84% gastric as per Rosen) Dx: serology, biopsy, C14 breath test Not practical for emergency medicine PUD & NSAIDs Direct effect Diffuse into mucosal cells Become trapped and directly damage cell • Inhibition of prostaglandin secretion • Reduced mucus production • Reduced cell turnover Indirect effect Systemic inhibition of COX decreases production of protective prostaglandins PUD – Hx and Px Abdominal pain (94%) Generally epigastric Usually worst 2-4 hours after meal Often between 2-3AM (HCl secretion highest) Relieved with antacids Duodenal ulcer Pain worst before meal Relieved by meal PUD – Diagnosis & Workup History and clinical exam Endoscopy Upper GI series Labs: CBC, lytes, LFT, lipase Imaging: CXR / AXR if suspected perforation Cardiac workup if suspect MI/ACS Duodenal Ulcer (Huge!) •Note fresh bleeding at edge •>90% H.pylori •NSAIDS Gastric Ulcer •Clean, well demarcated, benign looking •All should be biopsied as high risk of cancer Stomach Ulcer •Upper GI with barium contrast •Arrow = ulceration PUD - complications Upper GI bleed (15%) Posterior surface (gastroduodenal art.) Tx: resuscitation, endoscopy, PPI, surgery Perforation (7%) Usually anterior duodenal ulcers Sudden generalized peritonitis Dx: free air on CXR Tx: surgery – oversew ulcer and Graham patch, antrectomy & vagotomy PUD - complications Gastric outlet obstruction (2%) Nausea / Vomiting Caused by edema and scarring Tx: surgery Penetration Posterior duodenal ulcers erode into pancreas Hx of epigastric pain that worsens and radiates to back. Becomes refractory to tx Lab: elevated amylase PUD - treatment Lifestyle modifications Reduce caffeine, EtOH, spicy foods Smoking cessation Stop NSAIDs NSAID induced ulcer Stop NSAID PPI H2-blocker (less effective than PPI) PUD - treatment PUD in patient not taking NSAIDs Treat for H.pylori PPI H2-blocker H.pylori eradication Multiple regimes and commercially packaged products eg: PrevPac x 14 days • Lansoprazole 500 po bid, clarithromycin 500 po bid, amoxicillin 1g po bid x 14 days Many other acceptable cocktails