Seminars 5th year
Seminar No 7
Prof. J. Horák
Diseases of the esophagus and stomach
Achalasia
Def: motor disorder, in which the LES does not relax properly with swallowing
Pathophys.: loss of intramural inhibitory neurons containing VIP and NOsynthase
Clin: dysphagia, chest pain, regurgitation (→ pulmonary aspiration)
Dg: chest X-ray, barium swallow (loss of normal peristalsis), endoscopy to
exclude carcinoma
Th: - medical Th usually unsatisfactory. Nitroglycerin 0.5 mg sublingually or
isosorbide dinitrate 2.5 – 5 mg sublingually or 10 – 20 mg orally can relieve
symptoms
- injection of botulinum toxin in the LES
- balloon dilatation is effective in 85% of patients
- Heller‘s extramucosal myotomy
- laparoscopic myotomy
Gastroesophageal reflux disease and esophagitis
Def: esophageal mucosa damage caused by reflux of gastric contents
Pathophysiol.:
reflux episode – gastric contents ready to reflux + the
antireflux mechanism of the lower end of the esophagus must be compromised
Clin: Heartburn, angina-like or atypical chest pain. Peptic stricture →
dysphagia. Mucosal erosions → bleeding. Pulmonary aspiration
Dg: history, barium swallow, esophagoscopy, mucosal biopsy, motility and
pH testing
Compl.:
esophageal peptic stricture, ulcer, adenocarcinoma (Barrett‘s
esophagus)
Th: general: weight reduction, sleeping with the head of the bed elevated,
elimination of factors that increase abdominal pressure. Avoid smoking, fatty
foods, coffee, chocolate, alcohol, orange juice
medical Th: H2 receptor blocking agents, metoclopramide, cisapride,
omeprazole
surgery: antireflux surgery (fundoplication – laparoscopic or open). In highgrade dysplasia and early carcinoma esophagectomy and esophagogastric
anastomosis
Diverticula
Zenker‘s diverticulum
midesophageal diverticulum
epiphrenic diverticulum
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Seminars 5th year
Seminar No 7
Prof. J. Horák
Webs and rings
Plummer-Vinson syndrome: hypopharyngeal web + iron-deficiency anemia in
middle-aged women
Schatzki ring: at or near of the LES
Hiatal hernia
- sliding
- paraesophageal
Mallory-Weiss syndrome (mucosal tear)
- caused by vomiting or vigorous coughing
Esophageal tumours
malignant: squamous cell carcinoma, adenocarcinoma, sarcoma
benign:
leiomyoma, adenoma, cysts
Clin:
dysphagia, pain, weight loss, anemia
Th of squanmous cell Ca:
radical (surgery or radiotherapy)
palliative (radiotherapy, dilatation, intubation)
Peptic ulcer disease
Def: mucosal lesion of the stomach or duodenum in which acid and pepsin play
major pathogenic roles
Pathogenesis:
Aggressive factors: acid and pepsin, Helicobacter pylori,
NSAIDs etc., genetic factors, smoking
Clin:
pain, anorexia, weight loss
Compl:
GIT bleedin, perforation or penetration, gastric outflow obstruction
Dg: endoscopy, barium studies
Tests for H. pylori:
culture, urea breath test, histology, serum antibodies
Th: - H2-receptor antagonists (cimetidine, ranitidine, famotidine)
- proton pump inhibitors (omeprazole, pantoprazole)
- antacids (aluminium hydroxide, magnesium trisilicate)
- mucosal protection (carbenoxolone, sucralfate)
- anticholinergic (pirenzepine)
- prostaglandin analogues (misoprostol)
- H. pylori eradication (antibiotics + omeprazole + bismuth)
Indications for surgery: - failure of healing on medical Th
- repeated relapses despite Th
- non-compliance to medical Th
- severe haemorrhage
- perforation
- gastric outflow obstruction
- ulcuscarcinoma
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Seminars 5th year
Seminar No 7
Prof. J. Horák
Gastritis
acute – associated with infection, NSAIDs, alcohol or iron itake, and renal
failure
chronic – a) superficial – often associated with H. pylori
b) atrophic – vitamin B12 malabsorption, increased incidence of
gastric adenocarcinoma
Tumours of the stomach
Adenocarcinoma
risk factors: pernicious anemia, H. pylori, previous partial gastrectomy, blood
group A
Clin: anorexia, nausea, vague abdominal discomfort, Virchow‘s lymph node
Dg: endoscopy, biopsy, barium meal
Lymphoma (MALTOMa)
- a tumour of B lymphocytes
- the role of H. pylori
Th: H. pylori eradication, surgery, chemotherapy
Benign: leiomyoma, gastric polyps
Diseases of the small intestine
Coeliac disease (gluten-sensitive enteropathy, non-tropical sprue)
Aetiology: gluten toxicity → inflammation of small bowel mucosa with loss of
villi, crypt hyperplasia, inflammatory cell infiltration
Clin: malaise, anorexia, diarrhoea, steatorrhoea, weight loss, abdominal pain,
bloating, dermatitis herpetiformis, edema, pigmentation, hypovitaminoses,
anaemia, glossitis, increased risk of lymphoma
Dg: small bowel histology, malabsorption, improvement after gluten-free diet
Whipple‘s disease
Aetiol:
G-negative actinomycete Tropheryma whipelii
Clin: diarrhea, abdominal pain, arthralgia, malabsorption, weight loss, systemic
changes
Dg: large, foamy PAS positive macrophages within the lamina propria
Th: antibiotics (trimethoprim-sulfamethoxazole) for 1 year
Inflammatory bowel disease
Crohn‘s disease (regional enteritis, terminal ileitis)
Def: Granulomatous disease of unknown etiology most commonly affecting
the terminal ileum. The whole width of the wall of the intestine is involved
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Seminars 5th year
Seminar No 7
Prof. J. Horák
Clin: mild fever, general malaise, malabsorption, colicky abdominal pain,
diarrhoea, clubbing, anaemia, koilonychia
Dg: X-ray meal – strictures, ulcers, proximal dilatation, fistula formation
colonoscopy – biopsy of the colon and terminal ileum
Complications: acute toxic colonic dilatation, subacute small bowel
obstruction, fistula formation, renal oxalate stones, carcinoma of the colon,
amyloidosis, perforation, haemorrhage
Th: balanced diet with an adequate amount of fibre, oral prednisone (starting
at 30 – 40 mg/day), azathioprine, 5-aminosalicylate, elemental diet
surgery:
limited resections
Ulcerative colitis
Def: chronic inflammation of unknown aetiology affecting the colon and
rectum. Only mucosa is involved
Clin: acute attack – frequent passage of small-volume, loose stools with fresh
blood and mucus, cramping abdominal pains, tenesmus, anaemia,
hypoproteinemia, edema. Fever and tachycardia in severe disease. Toxic colonic
dilatation (toxic megacolon)
Chronic ulcerative colitis: periods of remission and exacerbation, increased risk
of colonic carcinoma
Dg: rectoscopy + biopsy, colonoscopy, barium enema
Th: acute attack: corticosteroids; milder disease: 5-aminosalicylic acid or
prednisolone; maintenance Th: 5-aminosalicylic acid
Pseudomembranous colitis
Aet: usually due to a toxin produced by Clostridium difficile following the use
of broad-spectrum antibiotis
Clin: cramping abdominal pains, diarrhoea with mucus and sometimes blood
Th: vancomycine or metronidazole; cholestyramine binds the toxin and
reduces diarrhoea
Functional bowel disorders
Aet: unknown
Clin: irritable colon, dyspepsia, diarrhoea, constipation, pain
Th: reassurance, modifications in lifestyle
Diverticulosis
Def: herniation of mucosa and submucosa through the wall of the large bowel,
sigmoid being the most common site
Clin: uncomplicated diverticula are asymptomatic; bleeding may occur
Diverticulitis: inflammatory mass, fever, abdominal pain, pericolic abscess,
perforation
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Seminars 5th year
Seminar No 7
Prof. J. Horák
Dg:
Th:
X-ray, colonoscopy
in complications surgery
Intestinal tumours
Small bowel
Tumours are rare (adenocarcinoma, leiomyoma, adenoma, carcinoid)
Large bowel
Polyps
Potentially malignant
Adenomas
tubular
villous
tubulovillous
Carcinoid
Dg:
Th:
No malignant potential
Hyperplastic polyps
Connective tissue polyps
lipomas
fibromas
leiomyomas
Hamartomas
Peutz-Jeghers‘
colonoscopy + biopsy, barium enema
endoscopic polypectomy, surgery
Multiple polyposis coli
Familial adenomatous polyposis – dominantly inherited, carcinoma development
Gardner‘s syndrome - + osteomas and epidermoid cysts
Th: panproctocolectomy
Carcinoma of the large bowel
Importance: the second most common malignancy in ČR
Aet: unknown; diet (high animal fat, low fibre), genetic factors
Pathol: most commonly rectum, then sigmoid and right side of the rectum
Clin: initially asymptomatic; later rectal blood loss, constipation (left-sided
tumour) or diarrhoea, anaemia (right-sided tumour)
Dg: test for occult GIT bleeding, colonoscopy, double contrast barium enema
Th: right or left hemicolectomy; laser or local diathermy for palliation
Prognosis: the over-all 5-year survival is about 25% (80% for Dukes‘ stage A,
60% for stage B, 20% for stage C). Most patients with stage D die within a year
Endocrine tumours of the gastrointestinal tract
Insulinoma, gastrinoma, glucagonoma, VIPoma, carcinoid
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