GASTRIC DISEASES and their treatment

By : Abdul Hameed ( ahameed051@gmail.com)
Gastric
Diseases and
their
treatment

GERD………..from Page (03-11)By Dr Shoaib Ansari
PUD
Esophagus
Anatomy and Physiology……..
PAGE (13-81) Dr. Teresa Galdona PA-C
Batter Treatment
All PPI’s ;…………BY : ABDUL HAMEED

Courtesy : Dr Shoaib Ansari
Associate professor
Medical unit III
Slide 8 to 16

SURGERY
Esophagus
Dr. Teresa Galdona PA-C
Courtesy by:

Esophagus
 A) Function:
 1)passaje for ingested food
 2)emesis
 3)conduit for endoscopic evaluation
 4)evaluation of aorta and heart (TEE)
 B) Anatomy:
 Originates at cricoid cartilage
 and pharynx in the neck

Esophagus
 B) Anatomy:
 Posterior mediastinum behind aortic
 and (L) mainstem bronchus.
 Enters abd. cavity through esophageal
 hiatus of diaphragm.
 Mucosa and 2 muscular layers
 mucosa is stratified squamous epithelium

 B) Anatomy(cont)
 2 muscular layers, inner layer is circular outer
layer is longitudinal. There is not serosal layer
 Musculature of upper 1/3 is skeletal and
musculature of the lower 2/3 is smooth muscle.
 2 sphincters: one is physiological one in the
neck call upper esophageal sphincter, the other
is located at the diaphragm called lower
esophageal sphyncter
Esophagus

Esophagus
 C) Physiology:
 food is propelled down the esophagus by
a peristaltic wave.
 LES relaxes in anticipation of food, allows
food enter stomach then returns to its high
resting pressure, to prevent reflux.
 Pathophysiology:
 LES is to prevent reflux of gastric
content.

Esophagus
 D) Pathophysiology:
 1) Alteration of the mechanism of LES
allows reflux of acid content, on an
epithelial surface that is rich in sensory
innervation
 2) Failure of LES to relax, causes
proximal dilation with contractile disorders

Esophagus
 E) S/S:
 1) esophageal disorders per se
 2) other organ manifestation disorders
 like angina pectoris, asthma, Pneumonia.
 3) signs of systemic Ds, like collagen Ds
or neurological Ds, like scleroderma
(systemic sclerosis, LES,smooth muscle)
in CREST syndrome, or in stroke and
other neurologic diseases.

Esophagus
 in CREST syndrome. Also in
polymyositis/dermatomyositis, where ¼ of
pts have dysphagia that involves UES
(striated muscle) or in stroke and other
neurologic diseases.

Esophagus
 F) Clinical presentation:
 Dysphagia: difficulty with transition of
ingested food
 Odynophagia: painful swallowing
 Globus ictericus: lump in the throat,evaluate
carefully sensation b/c it may represent a
mass lesionand no a psychological symptom
 Pyrosis or water brash associated with
GERD,achalasia and esophageal strictures
 Regurgitation,vomiting

Esophagus
 Pyrosis or water brash associated with
GERD,achalasia and esophageal
strictures
 Regurgitation: passive return of ingested
food to oropharynx.
 Vomiting: active return of stomach content

By : Abdul Hameed (
ahameed051@gmail.com)

Esophagus
 Recurrent episodes of bronchitis or
pneumonia ( very young, elderly, may be
sing of recurrent aspiration of esophageal
or gastric content b/c of esophageal
obstruction, congenital malformation,
diverticula, or motility disorder).


Esophagus
 Also,
 Anemia (ulcerative esophagitis mcc of
esophageal bleeding, occult blood in
stools)
 Hiccups or singultus (sign of
diaphragmatic irritation and early sign of
 stomach dilation, MI or diaphragmatic
hernia)

Esophagus
 Esophageal diseases may mimic other
process like angina pectoris. Must do
cardiac and esophageal evaluation
simultaneously b/c both processess are
common diseases.
 G) esophagus examination:
 1) H/P

Esophagus
 2) stools (check for blood)
 3) xray: PA and lateral to r/o thoracic pathologies
 4) Barium swallow: esophageal anatomy and
function. It is safe and highly cost-effective.
 5) CT scan: relation to other anatomic structures
and, mediastinum, esophgeal cancer.
 6) MRI (no advantage over CT)
 7) Esophagoscopy: allows direct visualization of
lumen of esophagus, can get directed Bx and treat
like esophageal varices (injecting sclerosing
substances)
 8) Manometry and fluoroscopy

Esophagus
 7) Esophagoscopy: allows direct
visualization of lumen of esophagus, can
get directed Bx and treat like esophageal
varices (injecting sclerosing substances)
 8) Manometry and fluoroscopy, mostly for
Dx of esophgeal motility disorders.

Esophagus
 H) Pathologies:
 1) Hiatal Hernia:
 MCC in women who have been pregnant,
and in both women and men when there is
increased intraabdominal pressure, for
example obesity, it predisposes to reflux of
gastric acid into distal esophagus. It is
important to know that GERD and HH are
separated conditions. Although, 80% of pts
with reflux have demostrable HH.

Esophagus
 type I: sliding hernia
 Allows the GEJ and a portion of the
stomach to slide into the mediastinum.
 Only important when there is association
with reflux of gastric acid into the lower
esophagus.

 Sliding Hiatal Hernia
By : Abdul Hameed (

Esophagus
 Type II: paraesophageal hernia.
 GEJ is normal in position, reflux is
uncommon.
 Portion of the gastric fundus that herniates
alonside esophagus is prone to herniation
and incarceration.
 Surgical repair is necessary to avoid
strangulation or incarceration.

Esophagus
 Sliding and paraesophageal Hiatal hernia
By : Abdul Hameed (

Hiatal Hernia
 Figure 1 shows a normal connection between the
esophagus in the chest cavity and the stomach in the
abdomen. Figure 2 shows a small portion of the
stomach pushing upward into the chest cavity from the
abdomen, causing a hiatal hernia.
By : Abdul Hameed (

Esophagus
 Type III: combination of I and II.
 It is a very large defect at esophageal
hiatus.
 Other abdominal organs may be found in
the mediastinum like stomach.
 Surgical repair is necessary.
 I) Pathophysiology:
 Loss of anatomic relationship between the
diaphragmatic hiatus and esophagus

Esophagus
 Reflux of gastric acid causes burn of
esophageal mucosa.
 Very important the degree of mucosal injury
is due to duration of acid contact and not to
excessive gastric acidity (normal acid in the
wrong place).
 Continue inflammation of distal esophagus
may cause mucosal erosion, ulceration,
scarring, stricture, chronic reflux,
transformation of epithelium to columnar (
Barret’s esophagus), to Ca
(adenocarcinoma)

Esophagus

Esophagus
 J) Most commonly presentation is:
 Reflux,(GERD) a burning epigastric or
substernal pain or tightness. 10% of pts can
be confused with MI.Becomes worse when
supine or leaning over.
 GERD symptoms are non specific and can
mimic other processes for example:
 a) angina of cardiac origin must be evaluated
if pt has a sensation of substernal pressure
that is not relieved by belching or antiacids.

Esophagus
 b) Occult blood in stools due to erosive
esophagitis.
 c) Schatzki ring is a variant of GERD, it is a
muscular constriction of distal esophagus
due to irritaton of circular muscle by refluxed
acid. 10% becomes fibrotic and requires
dilation and or excision.
 d) Dysphagia is a symptom of oropharyngeal
Ca or altered esophagial motility 2nd to
achalasia or stroke.

Esophagus
 f) DGER is bile and pancreatic enzimes
reflux, this process can complicate GERD
when both processes coexist.
 Recurrent pneumonia may indicate
advance GERD and distal esophageal
stricture

Esophagus
 Immunocompromised pts with GERD may
present with candida esophagitis, CMV or
Herpes virus infection.
 Gastric irritants and stimulants like
chocolate, caffeine, alcohol, tobacco,
ASA,
 NSAID’s,can increase symptoms.

Esophagus
 Other way of presentation can be chronic
aspiration pneumonitis, asthma or chronic
laryngitis.
 Other presentation can be a complain of a
“lump or food stuck” below xiphoid
process due to muscular spasm of
esophagus.
 Many pts with type I have no sympyoms.

Esophagus
 Other forms of presentations are vomiting
and dysphagia (suggest stricture).
 Type II HH give symptoms mostly when
incarcerated and isquemic, and presents
with dysphagia, bleeding and respiratory
distress.
 K) Dx:
 Barium swallow (mostly for Dx. of HH type
I and II)

Esophagus
 EGD (esophagogastroduodenoscopy) and
 Bx (mostly for reflux esophagitis).
 L) Tx: medical, 80% respond to medical
treatment and only 20% do not respond to
it and ½ of this (10%) require surgery.
 Medical treatment:
 No gastric irritants like
 Alcohol, chocolate, caffeine, tobacco

Esophagus
 Avoid tight gardments that rise
intraabdominal pressure
 Avoid drinking or eating within several
hours of sleeping
 Regular use of: antiacids, H2 blokers,
PPI’s.
 Elevation of head’s bed at least 6 inches
 to avoid nocturnal reflux.

Esophagus
 Weight loss in obese pts.
 Surgical Tx is to correct or repair the
anatomic defect and prevent reflux,
 2) Achalasia is the MC motility disorder of
esophagus and it means “failure to relax”.
The affected area is distal esophageal
circular muscle.

Esophagus
 It is caused by failure of relaxation of high
pressure zone sphincter, the proximal
esophagus dilates resulting in a painless
dysphagia.
 Symptoms are dysphagia, regurgitation of
indigested food, some weight loss, pain is
not a hallmark.
 Drinking large amounts of liquid
necessary to push down food.

Esophagus
 Aspiration pneumonia is common.
 Very common complain of spitting up foul
smelling secretions when lean forward.
 Dx is made by Barium swallow, by dilation of
proximal esophagus, “bird-beak” deformity.
 Tx : is surgical, 95% pts have complete relief.
Procedure is known as esophageal myotomy
(Heller myotomy). Medical Tx can use
CCBlokers, and dilation at the
esphagogastric junction

 Achalasia
 Bird-beak

Esophagus
 3) Diverticula.
 2nd MC motility disorder. It is an out-
pouching of all or part of the wall of the
esophagus. May ocurred at any level in
esophagus. Can be classified as pulsion (as
cervical Zenker’s diverticula) and traction.
 Symptoms same as achalasia like
regurgitation, choking, or putrid breath odor.
 Pts with traction diverticula are
asymptomatic, which is the contrary for
pulsion diverticula

Diverticula
 Mid-esophageal
diverticulum
By : Abdul Hameed (

Diverticula
 Epiphrenic
diverticulum
By : Abdul Hameed (

Esophagus
 Tx is mostly excision of diverticula.
 Other disorders of esophagus:
 Scleroderma: 70% of pts have esophageal
abnormalities with progressive decline in
muscular contractility towards LES.
 Dx is made by Barium swallow xrays.
 MC GI symptom is dysphagia.
 Progressive reflux, ulceration of distal
esophagus, strictures.

Esophagus
 Nutcracker esophagus:
 Painful diffuse esophageal spasm of
circular muscle through the length of
esophagus that can be confused with
angina pectoris.
 Dysphagia:
 associated with stress, or psychological
factors.

Esophagus
 4)Esophagus tumors:
 Benign tumor: leiomyoma
 Most common in middle and distal thirds,
usualy asymptomatic.
 Malignant tumors:
 Most common are:
 Squamous Ca ---- 85%
 Adenocarcinoma ----10%

Esophagus
 Sarcomas ----0.8%
 Primary esophgeal lymphoma ----very rare
 APUDomas (tumors of amine precursor
uptake and decarboxilation system) 0.8%,
 very malignant (already met when initial
presentation).
 Epidemiology:
 Environmental factors are involved as
etiology.

Esophagus
 Low dietary levels of ascorbic acid,
alphatocoferol, retinol, riboflavine, high
levels of nitrosamines in fungus infected
food are associated with Esophageal
cancer in China.
 In Western hemisphere (USA and other
countries) alcohol, tobacco, achalasia,
Barret’s esophagus and caustic injuries
play as etiologies for esophageal cancer.

 Squamous cell Ca
By : Abdul Hameed (

Esophagus
Also, poor oral hygiene, surgical procedures
and pre-malignant conditions besides
Barret’s esophagus, like radiation, or
Plummer-Vinson syndrome (iron anemia,
esophageal webs).
Great risk factor is consumption of alcohol
of more or equal to 9 g of ethanol and
same if person smokes more than 20 cig
per day.

Esophagus
 10% of pts with Barret’s will develop
adenocarcinoma.
 Tylosis (hyperkeratosis of palms and
soles) is the only genetic disorder
associated to esophageal cancer, 95%
chance of esophageal cancer if live long.

Esophagus
 Squamous cell Carcinoma of esophagus
arises from squamous epithelium,from the
upper part of esophagus
 Adenocarcinoma of esophagus arises
from transformation of columnar
epithelium that replaces normal squamous
epithelium of distal esophagus as a result
of chronic acid reflux. Metaplasia like this
is known as Barret’s esophagus

Esophagus
 S/S of esophgeal malignancy:
 Slow onset
 Dysphagia (MC symptom)
 Starts with solids to liquids
 2nd MC symptom is odinophagia
(retrosternal pain with swallowing)
 Rare symptom is constant mid-back or
midchest pain

Esophagus
 Hoarseness (when Tumor invade locally)
 Can have episodes of aspiration
pneumonia.
 When Ds is too advance pts can’t swallow
 their own saliva.
 Very important is that no serosa layer in
esophagus it allows tumors spread early
to adjacent structures like aorta, lymph
nodes.

Esophagus
 Dx:
 Barium contrast studies, “apple core”
image.
 Endoscopy
 Bx
 Ct scan used to stage esophageal Ca.
 PET (positron emission tomography) for
staging mediastinal and distant mts.

Esophagus
 Tx:
 When possible, depending of stage, surgical
approach is definitely the treatment. It may
depend of level of the lesion and if pt has a
curable lesion. Taking this in consideration
upper esophagus lesions require surgical
removal of esophagus en bloc with larynx,
permanent tracheostomy and restoration of
swallowing

Esophagus
 In lesions that involve middle third of
esophagus are treated by stage
procedure, total thoracic esophagectomy
and bypass.
 Lower third of esophagus is treated by
esophagogastric resection and end to end
anastomosis in the mid-chest.
 When prognosis is not good then radiation
and /or intubation are the Tx

Esophagus
SCC and ADC have per se bad prognosis.
Cure rate for a favorable case is only 20%,
but in general cure rate for esophageal
cancer is about 5%
 Because SCC and ADC of esophagus
have a very poor prognosis treatment is
directed to restore swallowing.
 Radiation and/or intubation are more used
Tx for advanced cases.

Esophagus
Strictures
 MCC = sequelae of GERD –induced esophagitis
 Causes:
 Diffuse esophageal spasm (DES)
 Scleroderma
 Rings & Webs
 Hiatal Hernia
 Dysfunctional LES
 Motility Disorders
 Cancer
 Dx:
 Manometry (records pressures)
 Tx:
 Pneumatic (balloon dilation)

Esophagus
Mallory-Weiss Tear
 Repeated strenuous retching or vomiting
may be responsible for the tears in the
mucosa
 results from prolonged and forceful vomiting,
coughing or convulsions
 Significant hemorrhage can occur
 It may occur as a result of excessive alcohol
ingestion.
 This is an acute condition which usually
resolves within 10 days without special
treatment.

Esophagus
 Esophageal perforation:
 Instrumentation 1st cause: endoscopy,
biopsy, nasogastric tube, dilation procedures,
inflation of devices to tamponade esophageal
varices (Seng-staken- Blakemore tube),
balloon dilation for achalasia, or spontaneous
perforation due to forcefull vomiting or
retching that increases intraesophageal
pressure (Boerhaave’s syndrome)

Esophagus
 In esophageal perforation you will find a pt
that after few hours of perforated presents
with deep shock due to mediastinal
sepsis,
and death.
 Other presentation is almost immediately
the pt goes with severe pain chest,
hypotension, diaphoresis, nausea and
vomiting then collapse and death.

Esophagus
 Tx is aggressive surgical intervention.
 Mortality is directly directed to time
between perforation and intervention.
 Foreign body:
 Toddlers, mentally ill adults.
 Dx. is confirm based on imaging studies
(plain films, detect radio opaque object,
and/or barium swallow)

Esophagus
 Tx:
 Endoscopic removal.
 Ingestion of caustic material:
 Accidental
 Intentional
 Most damaging are alkaline containing
products (Drano, Liquid Plumr). Alkalinity
above pH12.0 very corrosive

Esophagus
 They destroy from lips to small intestine.
Acidic material are a bit less damaging.
1st )identification (early) of product.
 each product has different approach.
 2nd) Thorough H/P to stimate damage.
 Pt presents with burning pain in upper
GI tract, nausea, vomit, difficulty
swallowing and breathing.
 3rd )Xrays, emergency endoscopy.

Esophagus
 TX:
 A glass of water in case of caustic and mlik
and/or water for acids
 No induced vomit (aspiration and/or further
damage).
 Airway and
 esophagus patency
 Steroids to avoid strictures if no perforation
 Use of ANTB controversial
 Long term dilation in case of strictures.

Esophagus
 Very important:
 caustic or alkaline substances cause
liquefaction necrosis
 Acidic substances cause coagulation
necrosis

Batter
Treatment

PPI’s and their
Mode of
actions

Note: Pantoprazole MOA is
available only. Other will be
uploaded soon…..

WHAT IS 822?
CODE FOR COMPLIENCE &
CONVIENCE

Long lasting suppressive effect of
( Pantoprazole )
 Only binds to cysteine 822 in the core of
proton pump. Therefore will have longer
period of action and supresses gastric
acid secretion for longer duration.
Drug 2003;63 (1) Page;107

FDA WarningNov. 17 , 2009
“Patients should avoid
using Omeprazole with
Clopidogrel ’’
Note; Latest FDA studies showing that all PPI Including pantoprazole have
interaction with clopidogrel %age will be differ.

PANTOPRAZOLE SHOULD BE
USED IN PATIENTS WHO ARE
RECEIVING CLOPIDOGREL
CMAJ,MARCH 31, 2009
Highly Safety Profile

SIGNIFICANTLY LOWER RE- BLEEDING RATE THAN OMEPRAZOLE
I.V TO ORAL SWITCH PROVIDES SIGNIFICANT RELIEF OF
SYMPTOMS AND ENDOSCOPIC HEALING.
HIGHER SAFETY PROFILE: PANTOPRAZOLE ( ZOPENT ) SHOULD
BE USED PREFERENTLY IN PATIENTS WHO ARE RECEIVING
CLOPIDOGREL ’’
Provide acid suppression with in 1 hour and continues up to 21
hrs.
Provide marked improvement in acid regurgitation , heart burn &
pain on swallowing

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