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Recurrent reflux Alcohol abuse Heavy smoking Corrosive agents Prolonged gastric intubation Candidiasis, Herpes virus infection External radiation to chest Chemotherapeutic agents Uremia Reflux Esophagitis Esophageal mucosal injury (acid peptic action) y Efficacy of esophageal anti-reflux y Presence of sliding hiatal hernia y Inadequate, slowed esophageal clearance of refluxed material Delayed gastric emptying, Gastric volume y Barrett Esophagus Complication of long standing gastroesophageal reflux Replaced mucosa y From distal squamous mucosa y To metaplastic columnar epithelium May lead to development of adenocarcinomas
Webs, Rings Mucosal webs Upper esophagus web Lower esophagus ring Radiological diagnosis Women ( common), >40 y/o Patterson-Brown-Kelly/ Plummer-Vinson Syndrome Lesions Associated With Motor Dysfunction Achalasia Degenerative changes to neural innervations y 20-40 y/o, M=F y Progressive dysphagia y Aperistalsis y Partial, incomplete relaxation of LES y Resting tone of LES Secondary Trypanosoma cruzi (destruction of myenteric plexus) Hiatus Hernia Sliding Hernia
Rolling Hernia Carcinoma of Esophagus Commonest tumour > 50 y/o, Male ( common) Present late remains silent until well advanced Types Squamous cell carcinoma (90% cases) y y Adenocarcinoma Squamous Cell Carcinoma (SCC) Predisposing factors y Betel chewing y Heavy smoking y Alcohol y Long standing esophagitis y Achalasia y Webs Plummer-Vinson syndrome
Epinephric Diverticulum
Mallory-Weiss Syndrome Alcoholics Excessive vomiting, refluxing of gastric contents Laceration of mucosa 10% of upper GI bleed
Grading well, moderate, poorly differentiated Spread mediatinum (most), lymph nodes, distal (lung, brain, bone)
Stomach Anatomy Chronic Gastritis Chronic inflammatory changes y Mucosal atrophy, metaplastic change Dysplasia, development of malignancy y Common forms Type A (Autoimmune gastritis) < 10% of chronic gastritis Auto-antibodies to y Parietal cells y Intrinsic factor Gland destruction, mucosal atrophy y Loss of specialized cell (esp. in fundus) y Loss of epithelial cells y Chronic inflammatory infiltrate y Intestinal metaplasia y Anaemia (megaloblastic, pernicious) Symptoms y Lack of acid secretion (gradual achlorhydria) y Predisposing cause of gastric carcinoma Associated with y Hashimoto s thyroiditis y Addison s disease
Type B (H. Pylori associated) 90% of chronic gastritis Causes y H. pylori y Alcohol ingestion Cigarette smoking y Motor, mechanical obstruction y Radiation y Amyloid Graft-vs-host reaction
Pathogenesis
Acute Gastritis Acute mucosal inflammatory process (usually of a transient nature) Endoscopic visualisation Biopsy, Histological determination Neutrophils, haemorrhage into mucosa Causes NSAIDs (eg. aspirin) Excessive alcohol consumption Heavy smoking Chemotherapeutic drugs Uremia Systemic infections (eg. salmonellosis) Severe stress (trauma, burns, surgery) Ischemia, shock Gastric irradiation Mechanical trauma (eg. nasogastric tube) After distal gastrectomy Acids, alkali Idiopathic Presentation Epigastric pain, nausea, vomiting Massive hemetemesis, malaena
Peptic Ulcer Disease Chronic, Solitary Lesions occur in any portion of GIT Exposed to aggressive action of acid peptic juices Breach in mucosa of alimentary tract Extends through muscularis mucosa to submucosa or beyond Common sites y Lower esophagus y Stomach st y 1 part of duodenum y Gastrojejunostomy margin (if duodenum removed) y Meckel s diverticulum, ectopic gastric tissue Pathogenesis Imbalance between gastroduodenal y Mucosal defense mechanisms y Damaging forces
Tumours of Stomach Types y Gastric carcinoma y Gastric polyp y Gastric adenoma y Gastric lymphomas y Carcinoid tumour y Mesenchymal tumours o Leiomyomas o Leiomyosarcomas o Gastrointestinal stromal tumour Gastric Polyps Nodule, mass that projects above level of surrounding mass Non-neoplastic (inflammatory, hyperplastic) Mixture of y Hyperplastic glands y Intervening edematous stroma (few inflammatory cells, scanty smooth muscle fibers) Gastric Adenoma True neoplasm May be pedunculated, sessile 10-15% of polypoidal lesions Malignant potential Proliferative dysplastic epithelium Gastric Carcinoma Epidemiology y Socio-economic group y Intestinal type 55 y/o, M:F = 2:1 y Diffuse type 45 y/o, M:F = 1:1 Pathogenesis Environmental Host Factors Genetic Diet y Chronic gastritis y Blood group A y Nitrites from y Infection by y Family history of nitrates H. pylori gastric cancer y Smoked, salted y Partial gastrectomy y Hereditary nonfood, pickled polyposis colon y Gastric adenomas vegetables cancer syndrome lead to intestinal y Lack of fresh fruit, type vegetable y Barrett esophagus Socio-economic Cigarette smoking Site y Pylorus, antrum 50-60% y Cardia 25% y Body, fundus 15-25% Lesser curvature ( common than greater curvature) Classification Growth pattern, Depth of invasion, Histology Early/ Advanced Early Advanced
Gastric carcinoma
Gastric carcinoma (diffuse type) Signet ring cells Rugae flattened Wall-thickened Clinical Features Insidious onset Weight Abdominal pain Anorexia Vomiting Altered bowel habit Dysphagia, anaemic symptoms, haemorrhage Virchow s node Krukenberg tumour Prognosis Early Gastric Cancer Advanced Gastric Cancer 90-95% < 15% 5 year survival
Lesion confined to y Mucosa y Submucosa Regardless of perigastric lymph node metastasis (not synonymous with carcinoma in situ)