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GIT1: Upper Gastrointestinal GIT1: Upper Gastrointestinal TractTractDR GAN SENG CHIEWDR GAN SENG CHIEWAssociate ProfessorAssociate Professor

Faculty of Medicine & Health Sciences

University Tunku Abdul Rahman

Learning Outcomes• The causes, symptoms and treatment of diseases of the

oesophagus [heartburn, reflux, oesophagitis, ulcer, varices, hiatal hernia and cancer].

• The causes, symptoms and treatment (include self-treatment) of common stomach diseases [Dyspepsia, pyrosis, gastroesophageal reflux disease (GERD), peptic ulcer, Helicobacter pylori infection, gastritis and stomach cancer].

• The characteristics and symptoms of other digestive diseases [Watermelon stomach, abdominal migraine, dumping syndrome, gas in the digestive tract, gastroparesis, Menetrier diseases, motility disorder of the stomach, stomach noise, stomach polyps and abdominal pain].

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The oesophagus is a muscular tube in the chest that connects the mouth and throat to the stomach.

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What does the oesophagus do?

• Muscles in the wall of the oesophagus work in a coordinated manner to push food and liquids down into the stomach. This muscular movement is called peristalsis.

• Peristalsis involves a series of muscular contractions and relaxations, which propel food forward until it reaches a ring-like valve called the 'sphincter' at the junction of the oesophagus and the stomach.

• The sphincter valve is normally closed, but as food approaches it, the muscles surrounding the sphincter relax, causing it to open and allowing the food to pass through into the stomach.

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Diseases of the Oesophagus

• Reflux oesophagitis• Ulcer• Barrett's Ulcer• Oesophageal carcinoma• Oesophageal varices• Hiatal hernia

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Diseases and disorders of the oesophagus

1. Heartburn• Heartburn (or reflux or oesophageal reflux) is very common.

Almost everyone has it at some time. It is a feeling of discomfort or burning or even pain felt rising up from the lower chest into the neck. Some people call it indigestion. Heartburn is due to stomach acid rising up into the oesophagus, where it can cause pain and inflammation.

• FOODS WHICH CAN make heartburn worse include fatty foods, chocolate, coffee, alcohol, cigarettes, cola drinks and peppermint.

• Occasionally heartburn is associated with food or fluid coming into the mouth. This is called regurgitation. If heartburn occurs regularly, say, a few days a week or even every day, it can be distressing and need treatment.

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2. Reflux in Children

• Gastro-oesophageal reflux, or "reflux" occurs when fluid in the stomach spills back or regurgitates into the oesophagus (gullet) or mouth. The valve (sphincter) at the lower end of the oesophagus prevents reflux when it is closed. However, this sphincter does open to allow swallowed food or saliva to enter the stomach. It also opens briefly at other times, especially after meals. It is during these openings that gastro-oesophageal reflux commonly occurs. Most episodes of reflux are not recognised as fluid rarely enters the mouth.

• INFANTS NORMALLY have more episodes of reflux than adults, but the number decreases through their first and second years.

3. Oesophagitis

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What are reflux and oesophagitis? • Acid reflux is when some acid leaks up (refluxes) into the

oesophagus. • Oesophagitis means inflammation of the lining of the

oesophagus. Most cases of oesophagitis are due to reflux of stomach acid which irritates the inside lining of the oesophagus.

• The lining of the oesophagus can cope with a certain amount of acid. However, it is more sensitive to acid in some people. Therefore, some people develop symptoms with only a small amount of reflux. However, some people have a lot of reflux without developing oesophagitis or symptoms.

Gastro-oesophageal reflux disease (GORD) :This is a general term which describes the range of situations - acid reflux, with or without oesophagitis and symptoms.

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What are the symptoms of acid reflux and oesophagitis? • Heartburn is the main symptom. This is a burning feeling which rises

from the upper abdomen or lower chest up towards the neck. (It is confusing as it has nothing to do with the heart!)

• Other common symptoms include: pain in the upper abdomen and chest, feeling sick, an acid taste in the mouth, bloating, belching, and a burning pain when you swallow hot drinks. Like heartburn, these symptoms tend to come and go, and tend to be worse after a meal.

• Some uncommon symptoms may occur. If any of these symptoms occur it can make the diagnosis difficult as these symptoms can mimic other conditions. For example:

1. A persistent cough, particularly at night sometimes occurs. This is due to the refluxed acid irritating the trachea (windpipe). Asthma symptoms of cough and wheeze can sometimes be due to acid reflux.

2. Other mouth and throat symptoms sometimes occur such as gum problems, bad breath, sore throat, hoarseness, and a feeling of a lump in the throat.

3. Severe chest pain develops in some cases (and may be mistaken for a heart attack).

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What causes acid reflux and who does it affect?

The sphincter at the bottom of the oesophagus normally prevents acid reflux. Problems occur if the sphincter does not work very well. This is common, but in most cases it is not known why it does not work so well. In some cases the pressure in the stomach rises higher than the sphincter can withstand. For example, during pregnancy, after a large meal, or when bending forward. If you have a hiatus hernia (when part of the stomach protrudes into the chest through the diaphragm), you have an increased chance of developing reflux. Most people have heartburn at some time, perhaps after a large meal. However, about 1 in 3 adults have some heartburn every few days, and nearly 1 in 10 adults have heartburn at least once a day. In many cases it is mild and soon passes. However, it is quite common for symptoms to be frequent or severe enough to affect quality of life. Regular heartburn is more common in smokers, pregnant women, heavy drinkers, the overweight, and those aged between 35 and 64.

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What are the treatments for acid reflux and oesophagitis?

Antacids: These are alkali liquids or tablets that neutralise the acid. A dose usually gives quick relief.

Acid-suppressing drugs: Two groups of acid-suppressing drugs are available - proton pump inhibitors (PPIs) and histamine receptor blockers (H2 blockers). They work in different ways but both reduce (suppress) the amount of acid that the stomach makes. Proton pump inhibitors include: omeprazole, lansoprazole, pantoprazole, rabeprazole, and esomeprazole. H2 blockers include: cimetidine, famotidine, nizatidine, and ranitidine.

Prokinetic drugs: These are drugs that speed up the passage of food through the stomach. They include domperidone and metoclopramide. They are not commonly used but help in some cases, particularly if you have marked bloating or belching symptoms.

Surgery: An operation can 'tighten' the lower oesophagus to prevent acid leaking up from the stomach. It can be done by 'keyhole' surgery. In general, the success of surgery is no better than acid-suppressing medication. However, surgery may be an option for some people whose quality of life remains significantly affected by their condition and where drug treatment is not working well or not wanted long-term.

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Are there any complications from oesophagit is?

• Stricture. If you have severe and long-standing inflammation it can cause scarring and narrowing (a stricture) of the lower oesophagus. This is uncommon.

• Barrett's oesophagus. In this condition the cells that line the lower oesophagus become changed. The changed cells are more prone than usual to become cancerous. (About 1 or 2 people in 100 with Barrett's oesophagus develop cancer of the oesophagus.)

• Cancer. The risk of developing cancer of the oesophagus is slightly increased compared to the normal risk if there is long-term acid reflux.

Note: It has to be stressed that most people with reflux do not

develop any of these complications. When there is pain or difficulty (food 'sticking') when swallowing , it may be the first symptom of a complication.

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What is cancer of the oesophagus? • Cancer of the oesophagus or gullet develops as a result of

cell changes in the lining of the oesophagus.• There are two main types of cancer of the oesophagus:

squamous carcinoma, which is more common at the upper end of the gullet, and adenocarcinoma, which is more common at the lower end, particularly around the junction between the gullet and the stomach.

• There has been a recent increase in the proportion of tumours arising close to the junction of the stomach and gullet, but the reasons for this are not yet known.

• In a condition called Barrett's oesophagus, the lining of the gullet becomes more like the lining of the stomach. Patients with Barrett's oesophagus are at an increased risk of developing cancer of the oesophagus and may benefit from regular follow-up and supervision by a doctor.

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What causes cancer of the oesophagus? • It’s thought that smoking and alcohol, among other things, can

contribute to cancer of the oesophagus. (There’s some evidence that spirits are the most dangerous type of alcohol to drink in connection with this particular type of cancer.) This could account for the marked regional variation within Europe. For example, cancer of the oesophagus is twice as common in eastern Scotland as it is in the south of England.

• There is also a particularly high rate in Normandy in France which has been blamed on drinking Calvados, an apple brandy. It’s also 10 times more common in southern China than in the UK. These differences are probably related to diet as people in southern China eat a lot of heavily smoked and salted fish.

• In the UK, iron deficiency used to be a common cause of cancers in the upper gullet, particularly in women. But with better diet and better medical care during pregnancy, this problem has now been virtually eliminated.

• The disease is three times more common in men than in women and is more common in people over the age of 60.

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What are the symptoms of cancer of the oesophagus?

• The first symptom of the disease is almost always difficulty in swallowing. There is the feeling that food is getting stuck, often behind the lower end of the breastbone. At first the problem is only with solid food but later even semi-solids and liquids can cause problems.

• Pain felt between the shoulder blades can also be troublesome. This discomfort is sometimes triggered by eating.

• Another characteristic symptom is regurgitating unaltered food a few minutes after having difficulty swallowing the food. The patient often tries to handle these problems by eating less and avoiding solid food. This causes weight loss and fatigue.

• Later on, heartburn, vomiting and vomiting of blood may become the dominant symptoms. The early symptoms are relatively minor and tend to creep up on patients. This means it is often several months before they consult their doctors.

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How is cancer of the oesophagus diagnosed?

• It can be diagnosed by using X-rays using special dye. Before the X-ray picture is taken, the patient will be asked to swallow a beaker of a whitish fluid called barium. X-ray pictures are taken as the barium travels down the gullet and into the stomach.

• The definitive diagnosis is made through direct vision using a camera attached to a flexible tube (an endoscope), which makes it possible to take a tissue sample (biopsy). The endoscopy (sometimes called a gastroscopy) is carried out while the patient is under sedation.

• A sample will be taken from any abnormal or suspicious areas. After processing, these samples will be examined by a pathologist who will decide whether or not there are any cancer cells present. It usually takes 7 to 10 days after the test before the pathologist's report is ready.

• A CT scan is often performed to assess whether or not the disease has spread either locally or to the liver. This is a particularly important investigation if surgery is being considered.

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How is cancer of the oesophagus treated?

• Treatment may consist of surgery, radiotherapy, chemotherapy or a combination of these.

• The best chance of cure is with surgery. Patients who are in good general condition and who have small tumours have more than a 25 per cent chance of cure with surgery.

• In fit patients with more advanced disease, the combination of chemotherapy and radiotherapy may be used - this can produce cure rates of around 20 per cent. The combination is sometimes used to shrink tumours in order to make subsequent surgery easier and more effective.

• Unfortunately the majority of patients are not fit for intensive treatment of this type. In their case treatment will be aimed simply at relieving symptoms.

• This can sometimes be done most easily using a stent. A stent is simply a kind of tube that is inserted inside the gullet to help keep it open and allow the passage of fluid and food. There are various kinds available, ranging from a simple plastic tube to a device made of metal mesh that expands once it has been put in place.

• Stents can be put in place as a simple procedure at the same time as an endoscopy is carried out.

• Radiotherapy can also be used to try and shrink the tumour and keep the gullet open for longer.

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What is the prognosis?

• Overall, the outlook is very poor. The five-year survival rate for cancer of the oesophagus is less than 10 per cent. Survival rates are higher in younger patients who are fit enough for intensive treatment, with cure rates of 20 per cent or more.

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Stomach Diseases (Gastropathy )

• Common Stomach Diseases and Problems

• Causes of Stomach Diseases• Symptoms of Stomach Diseases• Stomach Diseases Treatment• Stomach Diseases Self-treatment

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Common Stomach Diseases and Problems

Different stomach diseases and problems affect millions of people throughout the world most commonly during their most active period of life. Stomach diseases are relatively common, while the most frequent stomach diseases are:

1. Dyspepsia is the most common stomach disease which affects 40-60% of world's population at least once in a lifetime and is characterized by persistent or occasional pain in upper abdomen or in lower chest but can also result regurgitation (reflux of stomach content back into esophagus and mouth), bloating, nausea and vomiting.

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2. Heartburn or pyrosis is a burning ache in the esophagus below the breastbone which affect about 10% of world's population, while every second person experiences heartburn at least once in a year. Heartburn affects men more often than women and can besides burning sensation in the esophagus also result bad breath, regurgitation, sour or bitter taste in the mouth, vomiting and mouth ulcer.

3. Gastroesophageal reflux disease (GERD) is a chronic disease which results abnormal gastric reflux from stomach to esophagus and might damage the esophagus. GERD is often accompanied by heartburn, difficult swallowing and regurgitation especially after substantial meal and at night if eating minutes before bedtime.

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4. Peptic ulcer is an sore in mucous membrane of the stomach although it develops more often in the duodenum. Peptic ulcer is more common in men and causes perpetual abdominal pain, burning ache, bloating and abdominal fullness, loss of appetite and unintentional weight loss.

5. Helicobacter pylori infection is the world's leading bacterial infection and according to some estimation about one half of world's population is infected with bacteria known as Helicobacter pylori although about 20% of infected people have no health problems. However, Helicobacter pylori infection causes chronic low-level inflammation of the stomach lining and is believed to be the leading cause of peptic ulcers, gastritis and stomach cancer.

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6. Gastritis is an inflammation of the stomach lining and most frequently results pain in the upper abdomen.

7. Stomach cancer is a type of cancer which is characterized by growth of abnormal cells in any part of the stomach and might spread to other organs via circulatory or lymphatic systems. Stomach cancer affects men more often than women, while its symptoms usually include abdominal pain, unintentional wight loss, poor digestion, nausea, vomiting, difficult swallowing and black stools.

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Causes of Stomach Diseases

Causes of stomach diseases and problems greatly vary although many stomach diseases are associated with infections, especially Helicobater pylori infection. Causes of stomach diseases can be generally divided on:

1. Internal factors such as too high (hyperchlorhydia) or too low levels (hypochlorhydria) of gastric acid and too slow emptying of the stomach.

2. External factors which are in most cases responsible for stomach disease - stress, unhealthy diet, excessive consumption of coffee, alcohol and tea, smoking, certain medications especially non-steroidal anti-inflammatory drugs, and infection with Helicobacter pylori.

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Causes of stomach diseases also greatly depend from the types of diseases

1. Dyspepsia can be caused by virtually all mentioned internal and external factors but it can be also a symptom of another disease such as peptic ulcer, gastritis and stomach cancer.

2. Heartburn can be a result of esophagus motility disorder, regurgitation, and esophagus irritation, while in some people heartburn is also caused by certain foods such as onion, garlic, caffeine containing drinks, tomato, vine and other alcoholic drinks, etc. which greatly depend from person to person.

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3. Gastroesophageal reflux disease (GERD) is in the first place caused by abnormal gastric reflux from stomach to esophagus which is most frequently caused by deficiency of strength of lower esophageal sphincter.

4. Peptic ulcer is in most of patient caused by Helicobacter pylori infection or use of non-steroidal anti-inflammatory drugs. Other factor which increase the risk of peptic ulcer are aging (in greater risk are men after age of 60 years), history of stomach diseases and problems, stress and use of corticosteroids and anti-platelet drugs.

5. Helicobacter pylori infection is very widespread and according to some estimations over one half of world's population is infected with bacterium Helicobacter pylori but the way of transmission is unknown.

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6. Gastritis, inflammation of the stomach lining has many causes : Helicobacter pylori infection, autoimmune disorders, stress, non-steroidal anti-inflammatory drugs, excessive alcohol consumption and is often also associated with some medical conditions such as liver or kidney failure and connective tissue disorders.

7. Stomach cancer like any other cancer type might develop for no particular cause (at least not know yet) but it is widely believed that the greatest risk factors are Helicobacter pylori infection, gastritis and salty diet.