Upper gastrointestinal tract Dr.Ishara Maduka M.B.B.S. (Colombo)

Surgical conditions affecting upper GI tract Oral cancer Dysphagia and Oeasophageal cancer Dyspepsia and GORD Peptic ulcer Gastric carcinoma Upper GI bleeding

Oral cancers Oral cancer is the commonest cancer in males in Sri Lanka Accounts for 2-4 % of all malignant tumours in the western world Particularly common in some parts of Asia where betel chewing is common. Associated with other tumours of the aerodigestive tract In particular carcinoma of the : Larynx Bronchus Oesophagus 85% are squamous cell carcinomas

Risk factors Betel chewing Smoking Alcohol excess Syphilitic glossitis Sideropenic dysphagia

What is a premalignant lesion A Premalignant lesions is a morphologically altered tissue that has a greater risk than normal tissue for a malignancy to occur.

What are the premalignant lesions in the oral cavity Leucoplakia Erythroplakia Chronic hyperplastic candidiasis

Leucoplakia Erythroplakia

Clinical features of oral cancer Oral cancer produces symptoms early This allows the potential for early diagnosis and treatment Diagnosis is usually clinical Commonest sites with the mouth are Tongue Floor of the mouth Gingiva and alveolar ridge Buccal mucosa Hard palate Most tongue cancers occur on the lateral margin of the middle third of the tongue

Clinical features Contd… Tumours in the floor of the mouth often have early bone involvement Present as exophytic growths or ulcers Pain is a late symptom

Investigation Diagnosis can be confirmed by a biopsy under local anaesthetic FNA of palpable nodes is useful to confirm lymphatic spread CT is useful for assessing extent of nodal disease

Management Resection Reconstruction Radiotherapy Chemotherapy

Physiotherapists role Establish communication with the patient Preoperative assessment Post operative care Chest clearance exercises Shoulder and neck exercises Donor flap site exercise Mobility

Dysphagia

What’s meant by dyspahgia? Dysphagia means difficulty in swallowing. Orynophagia means pain when swallowing. Phagophobia means fear of swallowing.

What causes dysphagia Causes can be divided anatomically into mechanical and non mechanical causes Mechanical causes Non mechanical causes Oesophageal carcinoma Achalasia cardia Corrosive strictures Oesophageal spasms Mediastinal tumours compressing oesophagus Foreign bodies

Clinically categorized according to presentation Progressive dysphagia Non progressive dysphagia Oesophageal carcinoma Achalsia cardia Corrosive stricture Foreign body Mediastinal tumour compressing oesophagus Oesophageal spasms

Oesophageal carcinoma 2nd commonest cancer in males in Sri Lanka 90% are squamous cell carcinomas Occur in the upper or middle third of the oesophagus 8% are adenocarcinomas Occur in the lower third of the oesophagus Overall 5 year survival is very poor and is at best 20%

Risk factors Squamous cell carcinoma Adenocarcinoma Alcohol / tobacco Diet high in nitrosamines Trace element deficiency - molybdenum Vitamin deficiencies - vitamins A & C Achalasia Coeliac Disease Genetic - Tylosis High incidence in areas of Northern China and the Caspian region Adenocarcinoma 15% associated with Barrett's Oesophagus

Premalignant lesions in the oes. Barrett's oesophagus Consists of columnar-lined distal oesophagus Due intestinal metaplasia of distal oesophageal mucosa Can progress to dysplasia and adenocarcinoma Its is an acquired condition due to gastro-oesophageal reflux Bile reflux appears to be an important aetiological factor 10% of patients with GORD develop Barrett's oesophagus Approximately 1% of patients with Barrett's oesophagus per year progress to carcinoma Barrett's oesophagus increase the risk of cancer by x30

Clinical features Progressive dysphagia Respiratory symptoms due to overspill or occasionally a trachea-oesophageal fistula Weight loss

Investigations Diagnosis confirmed by: Endoscopy plus biopsy / cytology Barium swallow

Treatment Surgical Resection and anastomosis

Dyspepsia and GORD

What is dyspepsia characterized by chronic or recurrent pain in the upper abdomen, upper abdominal fullness and feeling full earlier than expected when eating. It can be accompanied by bloating, belching, nausea, or heartburn.

Conditions causing dyspepsia GORD (gastro-oeasophageal reflux disease) Peptic ulcer Carcinoma of the stomach Gall bladder stones

GORD (gastro-oeasophageal reflux disease) Occurs due to reflux of gastric contents in to oesophagus causing symptoms of dyspepsia. Risk factors – High fat diet, obesity, pregnancy, increased acid secretion, alcohol, smoking. Treatment – Advice to remain seated after eating, reduced amount of fatty food, weight control, antacid drugs.

Peptic ulcer

Peptic ulcer Occur due to increased acid secretion by parietal cells. Risk factors – NSAIDS, H. Pylori infection Sites of peptic ulceration Stomach Duodenum

Symptoms Dyspeptic symptoms Upper GI bleeding Symptoms due to complications

Complications Bleeding Gastric carcinoma Duodenal rupture Gastric ulcer Duodenal ulcer Bleeding Gastric carcinoma Duodenal rupture Gastric outlet obstruction Duodenal stricture

Helicobacter pylori H. pylori is gram-negative spiral flagellated bacterium Produces urease Important in the aetiology of peptic ulcers and gastric cancer Found in: 90% patients with duodenal ulceration 70% patients with gastric ulceration 60% patients with gastric cancer

Treatment of peptic ulcer Avoid NSAIDS as much as possible Eradicate H. pylori by antibiotics and proton pump inhibitors. Truncal vagotomy and highly selective vagotomy done in the past to reduce acid secretion Gastrectomy in untreatable gastric carcinoma Treat complications

Carcinoma of the stomach Risk factors Diet low in Vitamin C Blood group A Pernicious anaemia Hypogammaglobulinaemia Post gastrectomy Precursor states Helicobacter pylori infection Atrophic gastritis Intestinal metaplasia Gastric dysplasia Gastric polyps

Clinical features Dyspeptic symptoms Upper GI bleeding Loss of appetite Wasting/ cachexia

Management Surgical – gastrectomy Radiotherapy Chemotherapy

Gall stones and biliary conditions

Gall bladder stones Gallstones are found in 12% men and 24% women Prevalence increases with advancing age 10-20% become symptomatic Pathophysiology Three types of stones are recognised Cholesterol stones (15%) Mixed stones (80%) Pigment stones (5%)

Clinical presentation of gall stones Acute cholecystitis Biliary colic Dyspepsia Obstructive jaundice Pancreatitis

Acute cholecystitis 90% cases result from obstruction to the cystic duct by a stone Increased pressure within the gallbladder results in an acute inflammatory response Secondary bacterial infections occurs in 20% of cases of acute cholecystitis Most common organisms are E. coli, Klebsiella and strep. faecalis

Clinical features Constant pain (usually greater than 12 hours duration) in right upper quadrant Fever, tachycardia Tenderness in right upper quadrant

Investigations Ultrasound scan Serum bilirubin Serum amylase

Management Initial management is usually conservative Patient is fasted, given intravenous fluids and opiate analgesia Intravenous antibiotics (e.g. second generation cephalosporin) should be given to prevent secondary infection 80% patients improve with conservative treatment Surgical treatment of choice is delayed cholecystectomy

Cholecystectomy Open or closed

Laparoscopic cholecystectomy is the gold standard

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