Dysphagia and Gastric Disorders

Dysphagia - Difficulty Swallowing

• The esophagus transports food while the trachea carries air.
• Fistulas are abnormal connections linking the esophagus and trachea.
• Diverticulum form pouches trapping food, predisposing to necrosis.
• Peristalsis is driven by muscle contractions to facilitate movement through the system.
• Achalasia results in the absence of peristalsis in the system.
• Tumors below the esophagus can be esophageal cancer or lung cancer if located on the outside.
• Neurological influence relies on cranial nerves, affected by conditions like strokes or CNS damage.
• Cranial Nerve 5 (trigeminal) facilitates chewing.
• Cranial Nerve 10 (vagus) facilitates swallowing.

Gastric Disorders

Hiatal Hernia

• Hernias feature protrusions of organs into regions where they don't belong.
• The lower esophageal sphincter is impacted in hiatal hernias.
• Type 1 Hiatal Hernia: Stomach displacement above the diaphragm (~90% of cases)
• Type 2 Hiatal Hernia: The sphincter is correctly positioned while the upper stomach protrudes through the top opening (~5% of cases).
• Heartburn, acid reflux, pyrosis, and elevated risk of esophageal cancer are key signs.
• Endoscopy is critical for diagnostic purposes.
• Type 1 hernias can be managed with laparoscopic surgery, whereas type 2 may warrant surgical removal if the stomach risks necrosis.
• Crush injuries, the Heimlich maneuver, and pregnancy are possible causes.

Gastritis

• Gastritis refers to inflammation of the stomach lining.
• Spicy food, alcohol, and medications are potential causes.
• Pain is typically reported in the Left Upper Quadrant (LUQ).

Pyloric Stenosis

• Characterized by a narrowed opening between the stomach and duodenum.
• Thickening of the pyloric sphincter obstructs food passage, potentially triggering decomposition or vomiting.

Peptic Ulcer

• Manifests as ulcers in the stomach or duodenum
• H. pylori infection or NSAID overuse serve as common causes (e.g., ibuprofen, naproxen).

H. pylori Pathogenesis

• Transmission occurs directly between individuals via gastro-oral routes, such as through shared food
• H. pylori generates urease, neutralizing stomach acid by converting urea into alkaline ammonia (NH3).
• Diagnosis is achieved through urea breath tests to detect carbon 13 and stool samples
• Clarithromycin, amoxicillin, and pantoprazole form a triple therapy; metronidazole is used in place of penicillin/amoxicillin with allergies; bismuth (Pepto Bismol) serves as an alternative option for quadruple therapy.

Dumping Syndrome

• Gastric bypass addresses obesity by promoting weight loss.
• Accelerated gastric emptying is observed.
• Extreme diarrhea may occur, resulting in dehydration, electrolyte volume loss, and water imbalance.
• Sugar should be avoided on an empty stomach

IBS (Irritable Bowel Syndrome)

• Sporadic, abnormal contractions occur in Irritable Bowel Syndrome (IBS).
• Controlled by the vagus nerve.
• Up to 15% of people may be affected, showing altered bowel habits plus pain alleviated with bowel movements.
• Influenced by stress (brain-gut axis), altered gut microbiome (e.g., antibiotics, food sensitivities) and serotonin imbalance.

Splenic Flexure Syndrome

• Pressure is exerted on the spleen where the large intestine curves downward.

Intestinal Obstructions

Inguinal Hernia

• The small intestine protrudes through the abdominal wall, more typical in males.

Volvulus

• Volvulus involves the intestine twisting upon itself.
• Ischemia occurs, necessitating immediate correction to avert necrosis and potential sepsis from bacterial leakage.

Telescoping (Intussusception)

• Occurs when one part of the intestine slides into another.

Internal Tumor

• Can indicate intestinal cancer
• The tumor develops within the intestine.

Diverticulitis

• Diverticulum becomes filled with feces, leading to inflammation.

Inflammatory Bowel Disease

Crohn's Disease

• Onset: 15-35 y/o, 55-70 y/o
• Includes abdominal pain, diarrhea, weight loss, and fatigue.
• Potential blood presence in stools.
• Patchy inflamed tissue (skipped lesion) and fissures noted during colonoscopies.
• Targets both small and large intestines.
• Risk factors: fistulas developing from intestinal wall erosion, leading to toxic megacolon, necessitating surgical care and increased risk of sepsis.
• Rectovaginal fistulas in women and enterovesical fistulas in males.

Ulcerative Colitis

• Onset: 15-35, 55-70
• Symptoms: urgent bowel movements, fatigue, increased frequency, mucus and blood in stool, nocturnal activity, and stomach pain.
• Bloody stool is a frequent occurrence
• Continuous inflammation is seen at the surface level, affecting the mucosa. and large intestine.

Celiac Disease

• Autoimmune nature.
• Gluten binds to gliadin, which then attaches to tissue transglutaminase triggering antibody production.
• Antibodies target tissue transglutaminase (TTG) and gliadin.
• Deterioration of intestinal lumen due to inflammation which causes poor nutrient absorption.

Labs (Celiac Disease)

IgA deficiency:

• Individuals deficient in IgA are more susceptible to infections due to antibody dysregulation.

Acute Appendicitis

• Begins with general pain around the umbilicus.
• Progresses to severe RLQ pain, plus deep tenderness.
• Rupture causes temporary pain relief followed by peritoneal cavity contamination.
• Peritonitis causes worsening pain as infection spreads through the abdomen.
• Obstruction of the appendix, stemming from fecaliths, calculi, infections, neoplasms, or certain medications leads to it.
• RLQ pain plus belly button pain manifest, with a firm and hard abdomen with percussion, maybe distention.

Liver and Pancreatic Functions

Cholelithiasis

• Gallstones are solid objects formulated from either bilirubin or cholesterol.
• Risk factors involve obesity, female gender, sedentary habits, hypertension, older age, fair skin color, high fertility, plus being over 40.
• Presence of viscous small particles from bile is biliary sludge.

Cholestasis

• Oral contraceptives (estrogen and progesterone) often trigger gallstones.
• Estrogen decreases movement of your gallbladder increasing bile collection promoting stone formation.
• Localized in the RUQ
• Composed of cholesterol, therefore, they are pale yellow, caviar-like.
• Blockage of either cystic or bile ducts occurs; stool may appear clay-colored.
• The pancreatic duct is often obstructed as well.

Acute Pancreatitis

• Gallstones, alcohol, elevated triglycerides, mumps virus, medications (e.g. ozempic), post-ERCP problems, biliary issues, in addition to pregnancy serve as triggers.
• Enzymes that leak into the circulation result in hypovolemic and neurogenic shock, Disseminated Intravascular Coagulation and / or Acute Respiratory Distress Syndrome.
• Septic shock and peritonitis might trigger tenderness of the inner abdominal wall.
• Treatment centers on hemodialysis to promote stabilization.

Endoscopic Retrograde Cholangiopancreatography

• A camera is snaked down the esophagus to the duodenum for visualization purposes.
• The pancreas has the potential of becoming irritated.

Chronic Pancreatitis

• Extended inflammation leads to scarring (fibrosis).
• Characterized via low fecal elastase in stool.
• Includes alcohol and smoking abuse, the presence of gallstones plus autoimmune pancreatitis, the possibility of cystic fibrosis among other triggers.
• Can affect abdominal pain, N/V, weight loss via reduced appetite, steatorrhea in addition to secondary diabetes.

Cirrhosis

• Autoimmune responses cause Primary Biliary Cholangitis (PBC) through damage to intrahepatic bile ducts.
• Immunological response within bile ducts, leading to Primary Sclerosing Cholangitis (PSC), may be related with UC.
• Hepatitis C, B, as well as D, are typical causes.
• Autoimmune-linked Autoimmune Hepatitis (AiH) is the cause.
• Iron and copper overload plus alpha 1 antitrypsin deficiencies may cause cirrhosis.
• Deficiencies that cause resistance to BF through fibrotic liver, impairing hepatocytes.

Portal Circulation

• Relates to liver circulation issues
• Scar tissue hampers fluid flow through the liver, causing HTN which causes a high pressure in the portal vein
• Elevated blood pressure results in development of hemorrhoids.
• Proper nutrient absorption impaired.
• Backup of blood flow leads to splenomegaly.
• Presence of esophageal varices forming, creating concern about bleeding by vomiting, perforation, or aspiration risks.
• Cirrhosis may preclude organs for transplantation due to irreversible damage.

Overview of dysphagia, esophageal issues like fistulas and achalasia, and gastric disorders such as hiatal hernias. Covers peristalsis, tumors, and the neurological aspects of swallowing. Also discusses the roles of cranial nerves 5 and 10.