Gastroenterology Core

Curriculum

Introduction

Bushra Ibnauf, MD MS ABIM

Consultant, Gastroenterology & Hepatology

Assistant Professor
Department of Medicine
Faculty of Medicine , University of Khartoum
Symptoms of GI/Liver Disease
• Dysphagia • Hematemesis
• Odynophagia • Coffee ground emesis
• Chest pain • Rectal bleeding
• Heartburn • Melena
• Nausea/Vomiting • Jaundice
• Regurgitation
• Abdominal pain
• Abdominal swelling
Gastroenterology Core
Curriculum

ESOPHAGUS

Bushra Ibnauf, MD MS ABIM

Consultant, Gastroenterology & Hepatology

Assistant Professor
Department of Medicine
Faculty of Medicine , University of Khartoum
 Esophagus
• GasrtoEsophageal Reflux Disease (GERD)
• Barrett’s Esophagus
• Esophageal Cancer
• Esophageal Varices
• Miscellaneous esophageal disorders
 Approach
• Symptoms: • Diseases:

- Dysphagia - Gastroesophageal Reflux

- Hematemesis - Esophageal Cancer
- Odynophgia - Esophageal Spasm
- Chest pain - Achalsia
- Heartburn - Benign strictures/webs
- Nausea/vomitting - Esophageal Ulcers
- Varices
 SYMPTOMS-Definitions
• Dysphagia: Difficulty in swallowing
• Odynophagia: Pain on swallowing
• Hematemesis: vomiting of blood
• Vomiting: FORCEFULL return of gastric contents
• Regurgitation: UNFORCED return of gastric
contents
 Diagnostic Tools
• Upper GI endoscopy
• Barium studies
• CT scan
• Esophageal manometry
• 24 hour pH studies
 GasrtoEsophageal Reflux
Disease (GERD)

• Definition:
Reflux of gastric contents back into the
esophagus
 GERD-symptoms
• Heartburn – 75%
• Acid regurgitation
• Belching
• Dysphagia
• Odynophagia
• Chest pain
• Globus sensation
• Chronic cough
• Asthma
 GERD-Pathophysiology
• External Factors: High fat diet, spicy foods, late eaters,
obesity
• Transient Lower Esophageal Sphincter Relaxation
- Physiologic
• The AntiReflux Barrier: LES , diaghragm
• Esophageal Dysmotility
• Gastric acid secretion
• Gastric dysmotility
• Genetic factors: twin studies
 GERD-Diagnosis
• Symptoms !!
Diagnostic evaluation is NOT needed in most cases of
GERD and treatment is started empirically.
• Endosocpy: low sensitivity, highest yield in complicated
GERD
• Barium studies
• 24-hour pH monitoring
GERD-Endoscopy
 GERD-Management
LIFESTYLE MEDICATIONS

• Type of foods • Antacids

• Bed elevation • H2 Blockers
• Small frequent meals • PPI (Proton pump
• Weight loss inhibitors
 Barrett’s Metaplasia
• Definition:
- Prolonged lower esophageal acid exposure
leads to replacement of the lower esophageal
squamous epithelium by columnar epithelium
- Premalignant Condition
 GERD

Reflux Esophagitis

Intestinal metaplasia
(Barrett’s esophagus)

Dysplasia

Adenocarcinoma
Barrett’s Esophagus: Gross
Appearance
Barrett’s Esophagus
 Esophageal Cancer-
Epidemiology
Squamous Adeno

Male-to-female ratio 3:1 7:1

Black-to-white ratio 6:1 1:4
Major risk factors smoking Barrett’s
Alcohol esophagus
Socioeconomic class lower high
Geography SE Asia western /
Africa industrial
Iran
 Esophageal AdenoCarcinoma
Risk Factors
• Barrett’s mucosa: most significant (40 fold)
• GERD

• AC is largely a disease of Caucasians and males

• Obesity has been associated with AC but not SCC
• Smoking probably increases the risk of AC
– Development of HGD in Barrett’s
• Alcohol is probably not an important risk factor
Esophageal Squamous Cell Ca
Risk Factors

• Diet: • Associated diseases:

– N-nitroso compounds – Head & neck cancer
– Alcohol – Achalasia
– Hot tea – Plummer-Vinson
• Tobacco syndrome
• HPV 16 – Tylosis
• Lye induced strictures – Celiac disease
• Chronic esophagitis – Gastrectomy
– Radiation therapy
 Esophageal Cancer
Clinical Presentation
• Dysphagia:
– Most common
– Initially intermittent
– Solids then liquids
• History of GERD (AdenoCa):
– Esophagitis / Barrett’s in 50% on presentation
• Food intolerance, anorexia and wt. Loss
• Odynophagia and back pain:
– Mediastinal involvement
• Hoarseness
• Esophago-pulmonary fistula
• Liver / diaphragm / airway mets
 Esophageal Cancer
Diagnosis
• Endoscopy:
– Location: Distal vs. proximal
– Associated Barrett’s
– Appearance: Flat vs. polypoid

• Endoscopic biopsy:
– Most valuable
– Sensitivity of 6-8 bxies: 98%
– Sensitivity of cytology and bx: 100%

• Radiology:
– Esophagogram: Filling defect
– CAT scan: Thickening
Esophageal Cancer
Diagnosis
 Esophageal Cancer
Survival
STAGE 5-Year Survival
• Stage 0: 75%
• Stage I: 50%
• Stage IIA: 40%
• Stage IIB: 20%
• Stage III: 15%
• Stage IV: < 5%
 Esophageal Cancer
Staging Classification-TNM
• T: Primary tumor
– Tis: Carcinoma in situ / high grade dysplasia
– T1: Mucosa and submucosa
– T2: Muscularis propria
– T3: Transmural / periesophageal

• N: Regional lymph nodes

– N0: No adenopathy
– N1: Regional nodal metastasis

• M: Distant metastasis
– M0 vs. M1
 Esophageal Cancer
Staging Tools
• Endoscopic Ultrasound (EUS)
– Best modality for locoregional staging
– Limited role in distant metastasis

• CAT scan:
– T staging: no role
– Nodal staging: very low sensitivity
– Detection of metastasis

• PET scan:
– Whole body survey
– Helpful in diagnosing metastatic disease
– Limited role in T / local staging
 Mucosa
Submucosa
Scope

Lumen Muscularis propria

Serosa
Treatment: Early Disease

• Stages: Tis, I and IIA

• Surgery:
– Mainstay of treatment
– Surgery alone
– Best outcome:
• Tis & HGD: cure rate of 100%
• Stages I & IIA: cure rate ~ 80%
Treatment: Locally advanced
Disease
• Stages IIB and III
• Difficult and controvercial
• Surgery alone: 10% cure!
• Neoadjuvant chemo or XRT: No difference
• Neoadjuvant chemo and radiation:
– Greatest chance for prolonged survival
– Cisplatin and 5-Fluorouracil
• Patient and Dr.’s decision!!!
Treatment: Metastatic Disease
• Palliative
• Chemotherapy +/- XRT:
– Potential prolongation of life?
– Fit and willing patient
 Endoscopic Therapy

• Limited role
• Endoscopic Mucosal resection
• Coagulation therapy (Barrett’s HGD):
• Photodynamic therapy
• Bipolar / heat coagulation
• Laser
 Palliative Treatment
• XRT
• Chemotherapy
• Endoscopic dilation
• Endoscopic stenting
• Photodynamic therapy
• Endoscopic laser therapy
• Access for nutritional support
 Screening & Prevention
• Aggressive treatment of GERD
– Medical
– Surgical
• Screening of target population :
– Barrett’s metaplasia
– High incidence areas
• Tools:
– Endoscopy
– Balloon cytology
– Endoscopic ultrasound
– Biomarkers
 Achalasia
• Most common Esophageal Dysmotility Disorder
• Hypertensive Lower Esophageal sphinncter
• Clinical presentation: dysphagia, regurgitation
• Diagnosis:
- Endoscopy: dilated lower esophagus
- Barium: “bird beak” appearance
- Manometry: atonic esophagus, High LES
• Treatment: Endoscopic dilation, surgery (Heller myotomy)
Other Esophageal Dysmotility
Disorders
• Pseudoachalsia
- Secondary achalasia (tumors)
• Diffuse esophageal spasm
- Chest pain
- “corkscrew” esophagus
• Progressive Systemic sclerosis