Dysphagia and Hiatal Hernia

Dysphagia

• Dysphagia is difficulty swallowing or the sensation of food being stuck in the throat.
• Nerve or muscle problems, such as stroke, neuromuscular diseases (e.g., Parkinson's, Alzheimer's), or tumors, are common causes.
• Increased age can weaken the epiglottis, affecting its ability to cover the trachea properly
• A swallow study, particularly a barium swallow, is used to diagnose dysphagia, using fluoroscopy to visualize swallowing.
• Treatment is specific to the cause but almost always includes speech therapy.
• Complications of dysphagia include:
  • Malnutrition, leading to weight loss and dehydration due to difficulty or discomfort in eating.
  • Aspiration pneumonia, where food or liquid enters the lungs, causing infection.

Hiatal Hernia

• A hiatal hernia involves a section of the stomach protruding upward through the diaphragm opening towards the lung.
• This can cause the esophageal sphincter to stay open, leading to stomach contents and acid reflux.
• Potential causes involve weakening of the diaphragm muscle, increased intrathoracic or intra-abdominal pressure, trauma, and congenital defects.
• Risk factors include getting older and cigarette smoking.
• Severity varies, ranging from mild symptoms manageable with acid reducers to severe symptoms requiring surgery.
• Manifestations often mirror GERD symptoms, including indigestion, heartburn, nausea, chest pain, dysphagia, and strictures.
• Symptoms worsen with recumbent positioning, bending over, and after large meals.
• Coughing and burping are common due to reflux irritating the throat
• Diagnosis involves history, physical examination, and upper endoscopy (esophagogastroduodenoscopy).
• Treatment strategies:
  • Eating small meals
  • Avoiding trigger substances like alcohol
  • Maintaining a high Fowler's position after meals
  • Cessation of smoking
  • Stress reduction
  • Using antacids or acid-reducing agents.
  • Surgical repair is considered for severe cases.

Gastroesophageal Reflux Disease (GERD)

• GERD involves stomach contents backing up into the esophagus, irritating the esophageal mucosa.
• Unlike a hiatal hernia, GERD doesn't necessarily involve stomach protrusion through the diaphragm.
• Causes include specific foods (chocolate, caffeine, carbonated beverages, spicy/fatty foods, peppermint), alcohol, smoking, hiatal hernia, pressure from obesity or pregnancy and certain medications.
• Delayed gastric emptying or the presence of an NG tube can also be contributing factors.
• Manifestations are similar to hiatal hernia:
  • Heartburn
  • Epigastric pain
  • Dysphagia
  • Dry cough
  • Laryngitis
  • Regurgitation of food
  • Sensation of a lump in the throat.
• Common symptoms are a dry cough and laryngitis
• These symptoms can be confused with symptoms of angina, necessitating cardiac disease rule-out.
• Potential complications:
  • Esophagitis
  • Strictures
  • Ulcerations
  • Which can lead to Barrett's esophagus and esophageal cancer.
• Diagnosis is based on history, physical examination, and upper GI endoscopy.
• Treatment involves avoiding triggers, wearing loose clothing, eating small frequent meals, maintaining a high Fowler's position after meals, weight loss, stress reduction, elevating the head, and using antacids or acid reducing agents.
• Nissen fundoplication, a surgical procedure to tighten the esophageal sphincter, may be necessary

Intestinal Obstruction

• Characterized by a blockage inside the intestine, and divided into mechanical and functional types.
• Mechanical obstructions are caused by a physical barrier:
  • Adhesions from previous surgeries (especially gynecological) are the most common cause.
  • Other factors include hernias, tumors, intussusception (telescoping of the bowel), volvulus (twisting of the bowel), and diverticulitis.
• Functional obstructions involve GI tract dysfunction without a physical barrier:
  • Paralytic ileus, where the bowel stops moving, is a primary example.
  • It can occur post-operatively due to anesthesia and narcotics.
• Mechanical obstruction examples:
  • Intussusception: Telescoping of one part of the intestine into another.
  • Volvulus: The sigmoid colon twists around itself, causing a blockage.
  • Hernia: Intestine protrudes through the abdominal wall (e.g., inguinal hernia).
• Obstructions can develop suddenly or gradually, and can be partial or complete.
• Colicky pain is common
• Potential complications include perforation, pH imbalances, fluid disturbances, peritonitis (intestinal contents leaking into the peritoneum), shock, and death.
• Key manifestations:
  • Abdominal distension
  • Cramping with colicky pain
  • Nausea and vomiting
  • Constipation or diarrhea
  • Decreased or absent bowel sounds
  • Restlessness
  • Diaphoresis
  • Tachycardia
  • Confusion
  • Shock
• Diagnosis:
  • Abdominal X-ray or CT scan.
• Treatment aims to correct fluid, electrolyte, and pH imbalances.
• Nasogastric tube placement for intermittent suction helps decompress the bowel.
• Fasting, with possible TPN if malnourished.
• Ambulation is encouraged to increase motility.
• Laxatives should be avoided until the obstruction is resolved.
• Surgery may be necessary for certain cases

Gastritis

• Gastritis: Inflammation of the stomach's mucosal lining.
  • Acute: Sudden onset, can range from mild irritation to ulceration with hemorrhage.
  • Chronic: Gradual development
    • Associated with H. pylori (95% of cases) or atrophic gastritis (5% of cases)
• Chronic gastritis may be asymptomatic or cause dull epigastric pain and fullness, even with small meals.
• Causes of Gastritis:
  • Acute gastroenteritis (often called "stomach flu" but not related to influenza).
    • Viral (e.g., norovirus)
    • Bacterial
    • Allergic reactions
  • H. pylori: Bacteria erodes the protective mucosal barrier.
  • Other causes:
    • Organisms transmitted through contaminated food and water
    • Long-term NSAID use
    • Excessive alcohol consumption
    • Severe stress
    • Autoimmune conditions
• Potential Complications of chronic gastritis:
  • Peptic ulcers, gastric cancer, GI bleeding.
• Manifestations:
  • Indigestion
  • Heartburn
  • Epigastric pain
  • Abdominal cramping
  • Nausea and vomiting
  • Loss of appetite
  • Fever
  • Malaise
  • Hematemesis or melena may indicate ulceration and bleeding.
• Diagnosis:
  • History and physical exam
  • EGD (esophagogastroduodenoscopy)
  • Testing for H. pylori via serum antibody levels, breath test, or stool analysis.
• Treatment:
  • Acute gastritis: Self-limiting, resolves within a few days.
    • Antacids, acid-reducing agents (PPIs, H2 antagonists), mucosal barrier agents (e.g., sucralfate). -H. pylori-positive
    • Antibiotics to kill H. pylori
    • All strategies used to treated GERD

Peptic Ulcer Disease

• Lesions affecting the lining of the stomach or duodenum
• Common causes: H. pylori and NSAIDs. -Varies from superficial erosion to complete GI wall penetration.
• Risk factors: smoking, alcohol, increased stress, and spicy foods.
• Different types of peptic ulcers:
  • Duodenal ulcers:
    • Epigastric pain relieved by food.
    • Do not develop into cancer.
  • Gastric ulcers:
    • Pain worsens with eating.
    • Have the potential to develop into cancer.
• Stress ulcers:
  • Major physiological stress on the body due to tissue ischemia, acidosis, or decreased GI motility.
  • Curling's ulcer:
    • Associated with burns.
  • Cushing's ulcer:
    • Associated with head injuries.
    • Increased vagal nerve stimulation leading to gastric acid secretion.
• Complications
  • Hemorrhage
  • Obstructions
  • Perforation
  • Peritonitis
• Clinical manifestations include epigastric abdominal pain/cramping, heartburn, indigestion, nausea, vomiting, bloating, belching, and burning stomach pain.
• Severe symptoms: vomiting blood, dark bloody stools, unexplained weight loss, and appetite changes.