GI ONE PART 1

• Dysphagia: Difficulty in swallowing.

Symptoms of Dysphagia

• Sensation of something sticking in the throat or chest during or immediately after swallowing.

Oesophageal Reasons for Dysphagia

• Tumours
  • SCC (majority) or adenocarcinoma (lower 1/3rd).
  • Gradual onset.
  • Can spread to lymph nodes or fungate into the lumen.
    • Local spread effects: tracheo-oesophageal fistulation, recurrent laryngeal nerve palsy.
• Inflammation: Caused by acid reflux, drugs, or chemical burns.
• Stricture: Caused by radiation or acid reflux, leading to narrowing of the oesophagus.
• Foreign body
  • Soft food bolus: Can be treated with muscle relaxants.
  • Impacted coins (smooth): Requires prompt removal.
  • Bones (sharp): Requires emergency removal to prevent perforation.
• Trauma: Due to bones or surgery.
• Web
  • Atrophic mucosa leads to a fibrous stricture at the upper oesophagus.
    • Appears as a web on barium swallow.
    • Premalignant.
    • Made up of glossitis, iron deficiency, anaemia, dysphagia, koilonychias.
    • Seen in middle-aged women.
• External Compression from: Goitre, enlarged left atrium, mediastinal glands.
• Oesophageal Spasms: Due to atypical achalasia, acid reflux, neuromuscular disorders, or cardia obstruction.
• Achalasia
  • Loss of ganglia leads to failure of cardiac sphincter relaxation.
    • Obstructs oesophageal emptying with dysphagia for solids and liquids.
    • Failure of peristalsis causes further dilation.
      • Retained contents may regurgitate, causing respiratory issues.

Oral and Pharyngeal Reasons for Dysphagia

• Tumours: SCC.
• Inflammation
  • Severe candidiasis.
  • Herpes.
  • Tonsillitis, glossitis.
• Fibrosis: Scleroderma (increased collagen, decreased elastin, microstomia, and fibrosis).
• Trauma: Due to bones or surgery.
• Pouch
  • Herniation of mucosa through the inferior pharyngeal constrictor muscle (cricopharyngeus).
  • Pulsion diverticulum forms and collects food.
    • Can regurgitate into mouth or lungs at night, causing secondary pneumonia.
    • Swelling in the lower neck, usually on the left.
• Deformity of cervical spine.
• Xerostomia: Sjogren's or drugs (e.g., TCAs).
• Stroke.
• Neurological Conditions: Parkinson’s, MS, MG, Bulbar Palsy (motorneurone disease).
• Globus Hystericus
  • Not true dysphagia; intermittent sensation of a lump in the throat.
    • Perceived to be in the midline at the level of the cricoid cartilage.
    • Worse when swallowing saliva, less obvious with food or liquids.

Symptoms of GI Disease

• Abdominal pain.
• Dysphagia: Difficulty in swallowing.
• Heartburn: Retrosternal burning discomfort due to acid reflux.
• Dyspepsia: Range of upper GI symptoms (nausea, heartburn, acidity, pain); general term is ‘indigestion.’
• Flatulence: Excessive wind.
• Vomiting: Stimulation of the vomiting centres in the medulla.
• Constipation.
• Diarrhoea.
• Steatorrhoea: Pale, bulky, fatty stools.

Oesophagus Overview

• Musclotendinous tube connecting the pharynx to the stomach.
  • Symptoms: Dysphagia, pain (from acid reflux), cough or vomiting (reflux), bleeding (haematemesis).
  • Diseases: Pharyngeal pouch, achalasia, oesophageal spasm, oesophageal web, peptic ulcer disease/reflux, carcinoma.

Oesophagus Muscles and Structure

• Muscles
  • Superior, Middle, Inferior constrictor muscles.
  • Weak Point: Meeting point of thyropharyngeus and cricopharyngeus.
    • Also known as: Killian’s dehiscence.
      • Can become: Zenker’s Diverticulum.
    • Layers: Inner circular, outer longitudinal.
    • Composition: Upper 2/3 striated, lower 2/3 non-striated, middle 1/3 mixed.
    • Innervation: Vagus nerve (X) for motor and sensory nerves in the oesophageal plexus.
    • Lining: Stratified squamous non-keratinising epithelium.
    • Swallowing: Peristaltic wave triggered, food bolus pushed to the stomach via depolarisation and action potential.
    • Cardiac Sphincter: Gastro-oesophageal junction described as weak.

Specific Oesophageal Conditions

• Pharyngeal Pouch
  • Herniation of mucosa through a weakness in the pharyngeal constrictor muscles.
    • The pouch hangs down due to gravity.
      • Symptoms: Dysphagia, vomiting, respiratory symptoms.
  • Also known as: Zeneker’s Diverticulum forms, as it passes through Killian’s Dehiscence.
• Oesophagitis
  • Inflammation due to acidic reflux from the stomach.
  • Candida Oesophagitis: Occurs in immunocompromised individuals (transplant, chemo, HIV infection).
• Achalasia of the Cardia
  • Loss of ganglia leads to the relaxation of the gastro-oesophageal sphincter.
  • Neuromuscular dysfunction where the cardiac sphincter fails to relax during swallowing.
    • Results in Functional obstruction of oesophageal emptying with dysphagia for solids and liquids.
    • Failure of peristalsis can lead to progressive dilatation.
      • Treatments: Drugs (nifedipine), balloon dilatation, cardiomyotomy.
• Oesophageal Spasm
  • Attack of dysphagia and pain due to various causes.
    • Causes: Atypical achalasia, gastro-oesophageal reflux, motor disorders, symptomatic peristalsis, obstruction at the cardia, neuromuscular disorders.
      • May result in "corkscrew oesophagus," causing pain from reflux and heartburn.
      • Treated with Muscle relaxants.
• Oesophageal Web
  • Consists of glossitis, iron deficiency anaemia, dysphagia, koilonychia.
    • Most common in middle-aged women.
    • Important to identify due to premalignant potential.
      • With a barium swallow: Atrophic mucosa, fibrous structure forms at upper end, the stricture forms creating a web.
      • Treatment
        • Dilatation of the stricture .
        • Correction of the iron deficiency.
        • Occasionally webs excised.