Diseases of Esophagus & Stomach Dr.S.Nandakumar Professor of Medicine FOM-AIMST University

LESION IN THE MOUTH  Aphthous Ulcer  Candidiasis  Cheilitis (angular stomatitis)  Gingivitis  Leucoplakia  Koplick’s spot  Malignant erosion

SYMPTOMS OF ORAL LESIONS  Bad odour  Pain over the teeth, floor and angle  Sore throat  Nausea  Referred pain – headache  Bleeding from mouth

DYSPHAGIA (Difficulty in swallowing) Causes:  Mechanical block  Motility Disorder  Other causes :  Oesophagitis  Hysteria

MECHANICAL BLOCK  Malignant stricture Cancer of esophagus, stomach, pharynx  Benign stricture  peptic stricture  Extrinsic pressure  Lung cancer, lymph nodes, retrosternal goitre, aneurysm of aorta, left atrium enlargement  Pharyngeal pouch

MOTILITY DISORDERS  Achalasia  Diffuse esophageal spasm  Myasthenia gravis  Neurological lesions involving brain stem E.g.. Syringomyelia, poliomyelitis etc.

Causes: Upper GI Bleeding Causes: Upper GI Bleeding

HEART BURN  Burning retrosternal discomfort.  Gastric reflux into esophagus due to loss of anti reflux mechanism.  Inflammatory response secondary to reflux (Reflux Oesophagitis)  Gastro-esophageal reflux disease (GERD) affects 7–15% of population.  Also due to hiatus hernia.

DYSPEPSIA  Non-specific group of symptoms:  Epigastric pain related to hunger, specific food or time of day  Pain with bloating, or fullness after meals.  Includes heart burn.  Causes include gastric ulcer, gastritis, duodenal ulcer, duodenitis, malignancy and reflux oesophagitis

d) Mallory-Weiss tear Definiton : A syndrome characterized by upper gastrointestinal bleeding secondary to longitudinal mucosal lacerations at the gastro esophageal junction or gastric cardia. Etiology:  prolonged and forceful vomiting, coughing or convulsions- most common  straining  hiccupping  blunt abdominal trauma  cardiopulmonary resuscitation  Chronic alcoholism-common

b) Oesophagitis Definition: inflammation of the inner lining of the esophagus Etiology :  GERD(common cause)  Vomiting  Infectious agents( Candida, Herpes simplex virus, Cytomegalovirus, Epstein-Barr virus, Varicella-zoster )  Medications(alendronate, tetracycline, doxycycline, VIT C,NSAIDs,  Swallowing a toxic substance  Radiation injury (after receiving radiation for cancer treatment)  Immunocompromised(HIV) Pathophysiology a.Reflux oesophagitis b. Infectious esophagitis c. Medication induced esophagitis Muscle between the esophagus & stomach (LES) fail to close This causes stomach contents including gastric acid to flow back into the esophagus Stomach acid can irritate the lining of the esophagus Results in irritation, inflammation & bleeding

1. Oesophagitis heartburn (burning, retrosternal discomfort related meals,lying down) belching (burp) excessive salivation odynophagia (painful swallowing) nausea, vomiting 2. Mallory Weiss Hematemesis: episode of vomiting up blood after violent retching or vomiting. Melena Light-headedness, dizziness, or syncope secondary to dehydration Abdominal pain, dyspepsia

f) Gastric erosions(gastritis) Definition: Inflammation, irritation, or erosion of the lining of the stomach. It can occur suddenly (acute) or gradually (chronic) Etiology:  excessive alcohol use  chronic vomiting,  Stress  NSAIDs  Helicobacter pylori (H. pylori)  Pernicious anemia  Bile reflux  Infections by bacteria and viruses.

Pathophysiology :  H pylori infection :induces a severe inflammatory response with gastric mucin degradation and increased mucosal permeability, which is directly cytotoxic to the gastric epithelium.  NSAIDs and alcohol :decrease gastric mucosal blood flow with loss of the mucosal protective barrier.NSAIDs inhibit prostaglandin production, whereas alcohol promotes depletion of sulfhydryl compounds in gastric mucosa.  The low pH of the gastric fluid normally does not allow bacterial growth, but when the gastric mucosa is damaged (e.g., gastric ulcer or carcinoma), ingested bacteria may become invasive resulting in severe gastritis.

a) Peptic ulcer Definition: are sores in the lining of the stomach or duodenum. Pathophysiology Etiology :  Helicobacter pylori  NSAID(Non Steroidal Anti Inflammatory Drugs) Invades the gastric epithelial cells Helicobacter pylori Release of urease, cytokines, lipolysaccharides, heat shock protein enzymes Inflammatory cascade initiated (cytokines, neutrophils& lymphocytes) Mucosal damage & ulceration Further exposure to gastric acid Chronic peptic ulcer

4. Peptic ulcer Abdominal pain  burning, aching, and it might feel similar to hunger pains.  Duodenal ulcers -after eating experience relief with food.  Gastric ulcers -worsen with food and result in pain immediately after a meal. Nausea and Vomiting Bleeding  Symptoms of light-headedness and dizziness signify large amounts of blood loss.  a slow bleed tends to be dark or black blood. This blood has time to react with acids in the stomach.  A bleeding ulcer cause a patient to pass stools that is black & look like tar. Weight Loss

c) Gastroesophageal varices Definition: abnormal, enlarged veins in the lining of the lower esophagus near the stomach. Etiology:  Severe liver scarring (cirrhosis)-most common  Blood clot (thrombosis) in portal vein  Parasitic infection (Schistosomiasis)-less common Pathophysiology Scarring of liver(liver cirrhosis) Blood flow through the liver is slowed down Blood starts to back up in the portal vein This "back up" causes high blood pressure in the portal vein Portal Hypertension This pressure forces the blood into the nearby smaller veins, such as in the esophagus These fragile, thin-walled veins begin to dilate with the added blood. can rupture and bleed.

e) Cancer of stomach or esophagus Etiology :  smoking  age over 50  being male: both cancers are more common in men than in women  alcohol  obesity (adenocarcinoma of the oesophagus is related to being overweight or obese)  long-term gastro-oesophageal reflux disease (GERD)  frequent drinking of very hot liquids

Pathophysiology  Two types of esophagus and stomach cancer--- squamous cell carcinoma and adenocarcinoma.  Squamous cell carcinoma: tends to develop on the outside tissue areas of the esophagus and stomach.  Adenocarcinoma: is a type of cancer that forms in the glandular tissue areas of an organ.  Squamous cell types are generally less aggressive than adenocarcinoma, but in their early stages, both respond well to treatment.

3. Cancer of Stomach  Early stomach cancer often does not cause symptoms. As the cancer grows, the most common symptoms are:  Discomfort or pain in the stomach area  Difficulty in swallowing  Nausea and vomiting  Weight loss  Feeling full or bloated after a small meal  Vomiting blood and having blood in stools