Upper GI Pathology Overview

Upper GI Pathology

• Upper GI system encompasses the organs from the mouth to the duodenum.
• Learning objectives include clinical presentations of upper GI diseases, characterizing the upper GI system, and introducing diseases of the esophagus, stomach, and duodenum.

Upper GI System

• Duodenoyeyunal flexure (Angle of Treitz): The junction of the duodenum and jejunum.
• Suspensory muscle of the duodenum (Treitz ligament): Anatomical structure in this region.
• Duodenum blockage: Potentially occurs due the superior mesenteric artery.

Clinical Manifestations

• Bleeding: A symptom associated with upper GI diseases.
• Obstruction: Characterized by vomiting without abdominal distension, often involving acid and bile.
• Acid and bile: Found in vomitus in certain cases of upper GI obstruction.

Diagnostic Implications

• Upper GI endoscopy: Diagnostic tool for upper GI pathology.
• ERCP (Endoscopic Retrograde Cholangiopancreatography) and ultrasonography: Used in conjunction with endoscopy for comprehensive assessment.

Mouth

• Inflammatory conditions: Gingivitis, dental caries, glossitis, tonsilitis, pharyngitis, and parotiditis.
• Infections and other factors: Infections, radiation exposure, and autoimmune diseases can cause mouth inflammation.
• Motor impairment: Difficulties with chewing and swallowing (dysphagia).
• Neuropathies, myopathies and Collagenopathies: Related to nerve, muscle or connective tissue diseases.
• Salivation disturbances: Disruptions in saliva production, often linked to inflammation, obstructions or tumors.
• Neoplasms: Epidermoid carcinoma, lymphoma, Kaposi's sarcoma are potential cancers affecting the mouth.

Esophagus

• Inflammations (esophagitis): Infections, radiation therapy, and autoimmune disorders often lead to esophageal inflammation.
• Motor impairment: Affecting swallowing (dysphagia), often due to conditions involving nerves, muscles or connective tissue.
• Neoplasms: Epidermoid carcinoma, adenocarcinoma, and lymphoma are examples of esophageal cancers.
• Anatomical alterations: Fistulas, atresia, and perforations can be present in the esophagus.
• Tumors and cysts: Malignant and benign lesions in the esophagus.

Dysphagia

• Oropharyngeal dysphagia: Issues with initial stages of swallowing (movement coordination, swallowing initiation, choking, and aspiration).
• Esophageal stenosis: Difficulty swallowing, progressing from solids to liquids, and resulting in food retention and regurgitation.

Esophago-gastric Junction

• Achalasia: Condition impacting the lower esophageal sphincter (LES).
• GERD (Gastroesophageal reflux disease): Stomach contents returning to the esophagus, leading to symptoms like heartburn and regurgitation.
• Hiatal hernia: Passage of abdominal contents through the esophageal hiatus; can produce GERD-like symptoms.
• Cancer: Cancers impacting the esophagogastric junction

Achalasia

• Reduced ganglionic cells in LES: Leading to hypertonic LES.
• Progressive dysphagia: Swallowing difficulty worsening over time.
• Esophageal dilation: Enlargement of the esophagus.
• Diagnosis: Manometry, biopsy
• Treatment: Dilatation, sphincterotomy

GERD

• Hypotonic LES: Lower esophageal sphincter doesn't function effectively, allowing stomach contents to reflux.
• Symptoms: Heartburn, regurgitation, and nonspecific symptoms.
• Esophagitis and Barrett's esophagus: Inflammation and precancerous changes in the esophagus.
• Diagnosis: pH monitoring, endoscopy
• Treatment: Medications (PPIs), dietary changes, fundoplication

Hiatal Hernia

• Passage of abdominal contents through esophageal hiatus: Portion of stomach protruding into the chest.
• Types of hiatal hernias: Sliding, paraesophageal, and mixed.
• Symptoms: Can cause GERD-like symptoms; symptoms may depend on the type of hernia.
• Diagnosis: Upper endoscopy, gastrointestinal transit studies.
• Treatment: Medications, dietary changes, fundoplication.

Cancer

• Neoplasms (cancers) in the esophagus and stomach: Epidermoid carcinoma, adenocarcinoma.
• Symptoms: Obstruction, weight loss, and distant disease.
• Diagnosis: Endoscopy and imaging techniques assessing distant disease.
• Treatment: Surgery, chemotherapy, radiation therapy, and palliative care.

Stomach

• Inflammations (Gastritis): Acute or chronic conditions, including infections, drug reactions, and autoimmune diseases can all lead to gastric inflammation.
• Motor impairment (Gastroparesis): Slowed emptying of the stomach, causing symptoms like nausea, vomiting, and early satiety (feeling full quickly).
• Neoplasms: Adenocarcinoma, GIST (Gastrointestinal stromal tumor) and MALT (mucosa-associated lymphoid tissue).
• Anatomical alterations/ulcers: Ulcers of the stomach lining.
• Pyloric obstruction: Blockage of the stomach opening (pylorus) to the small intestine.

Gastroparesis - Causes and Diagnosis

• Defective gastric emptying without physical obstruction: Stomach cannot empty properly.
• Types of gastroparesis: Primary (related to gastric pacemaker dysfunction), secondary (due to autonomic nerve dysfunction, muscular disorders, medications).
• Diagnostic tests: History, physical examination, motility studies like gastric emptying tests.

Acute and chronic Gastritis

• Acute gastritis: Sudden inflammation of the stomach, often caused by NSAIDs, alcohol, or infections like H. pylori.
• Chronic gastritis: Long-term inflammation, can be associated with autoimmune conditions or persistent infections.
• Pernicious anemia: Deficiency in Vitamin B12.
• Menetrier's disease: Characterized by inflammation.
• Specific systemic diseases: e.g Crohn's disease

Helicobacter pylori (H. pylori)

• Gram-negative spiral bacteria: Causes gastritis.
• Adhesion proteins: Aid bacterial attachment to gastric mucosa.
• Urease enzyme: Facilitates bacterial survival in the stomach's acidic environment.
• Toxins: GagA, VacA cause inflammation.
• Pathology: Acute and chronic gastritis, peptic ulcers, and stomach cancer.

Peptic Ulcer

• Duodenal ulcers: Most frequent type.
• Gastric ulcers: Occur later in life; often asymptomatic.
• Clinical manifestations: Epigastric pain or discomfort (often relieved by food).
• Diagnosis: Endoscopy.

Complications of Peptic Ulcer

• Perforation: A serious complication, potentially fatal.
• Outlet obstruction: Narrowing of the pyloric opening.
• Bleeding: Significant blood loss, potentially life-threatening.
• Penetration and fistulas: Perforation of adjacent organs leading to an abnormal connection or fistula.

Upper GI Bleeding

• Most common GI emergency: Represents a significant clinical concern.
• Mortality: Can range from 10%.
• Causes: Varices (due to liver disease), peptic ulcers, hiatal hernias, gastric cancers, and vascular malformations.
• Clinical manifestations: Hematemesis (vomiting blood), melena (black, tarry stools), hematochezia (bright red blood in stools), and cardiovascular compromise.
• Management: Endoscopy, resuscitation, surgical interventions (e.g., Sengstaken-Blakemore tube), and consideration of liver transplantation in certain cases.