Upper gastrointestinal disease and disorders of the small bowel

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7 Upper gastrointestinal disease and disorders of the small bowel

Oesophagus – dysphagia

Many conditions of the oesophagus present with dysphagia. If chronic there is nearly always associated weight loss. Dysphagia may be progressive, suggesting a malignant growth or stricture, or non-progressive, suggesting a disorder of function. Conditions of the oesophagus may be divided into causes in the lumen, in the wall or outside the lumen. In addition, some neurological conditions may also cause dysphagia (Box 7.1).

Box 7.1 Causes of dysphagia

In the lumen

Foreign body

In the wall

Carcinoma
Stricture (inflammatory)
Achalasia
Scleroderma
Plummer–Vinson
Atresia (congenital)
Post radiotherapy

Outside the wall

Bronchial carcinoma
Mediastinal lymphadenopathy

Rolling hiatus hernia

Retrosternal goitre

Thoracic aortic aneurysm

Pharyngeal pouch

Vascular ring (dysphagia lusoria)

Neurological

Myasthenia gravis
Bulbar palsy

Polio

Psychological

Foreign body

This condition usually presents in young children accidentally (e.g. coins, buttons) or occasionally deliberately in the mentally disturbed (e.g. razor blades, spoons). Impaction usually occurs at the narrowest point (the commencement or the crossing of the left main bronchus or at the diaphragm). In general, once a foreign body has passed below the diaphragm, it will pass through the rest of the GI tract without causing problems.

Small smooth objects often pass into the stomach and may safely be left to pass through the GI tract. Serial radiography is not indicated for young children. Irregular and sharp objects may impact or perforate and need to be retrieved.

Clinical features

There is usually a short history of painful dysphagia. Psychiatric patients may give a history of previous episodes.

Investigations

• CXR is a useful investigation to determine whether the object is stuck in the mediastinum, and whether perforation has occurred

• Barium swallow is rarely needed, and may result in aspiration

• Oesophago-gastro-duodenoscopy (OGD).

Treatment

Most foreign bodies can be retrieved endoscopically with grasping forceps. Laparoscopic thoracotomy or open thoracotomy is indicated for perforation.

Oesophageal perforation

Causes include:

• iatrogenic following therapeutic dilatation

• foreign body

• corrosive liquids

• penetrating injury

• Boerhaave’s syndrome (perforation due to violent vomiting).

Clinical features

These include sudden/gradual onset of chest, neck and upper abdominal pain, pyrexia, shock, surgical emphysema (in neck or suprasternal notch). Mediastinitis has a high mortality in the elderly.

Investigations

Urgent chest X-ray (CXR) is required looking for air in the mediastinum or neck, and pleural effusion. Confirm with water-soluble contrast swallow to delineate site of perforation.

Treatment

• Resuscitate if shocked

• Broad-spectrum antibiotics

• Nothing by mouth

• Small leaks may be conservatively treated

• Do not pass a nasogastric tube

• Large leaks can be repaired by thoracotomy or laparoscopic thoracotomy with drainage

• Stents occasionally used.

Corrosive oesophagitis

Common substances ingested either accidentally or intentionally include caustic soda, sulphuric acid and household bleach. Severe damage (bleeding/perforation) is caused not only to the oesophagus, but to the mouth, pharynx, larynx and stomach. Aspiration of corrosive liquid can also occur, giving rise to severe respiratory problems. In the longer term, stricture may occur.

Clinical features

• History of ingestion

• Severe pain from mouth to stomach

• Signs of shock, pyrexia, respiratory distress

• Oedema of lips, mouth, pharynx, lung.

Treatment

Immediate

• If the ingestant is known, immediately give a buffering solution, e.g. milk

• Do not induce emesis; this may rupture the oesophagus.

Urgent

• Endoscopy to assess extent of damage (may need general anaesthetic)

• Broad-spectrum antibiotics/steroids/total parenteral nutrition.

Long-term

• Dilatation of early strictures

• Surgery required for severe strictures

• ENT/respiratory support may also be needed.

Long-term results depend on the degree of stricture formation. Prompt early treatment gives better outcome.

Gastro-oesophageal reflux (GORD)

Gastric acid may reflux through an incompetent gastro-oesophageal sphincter. The most common cause is a sliding hiatus hernia. Rarer causes include previous surgery (e.g. for achalasia, Ivor Lewis oesophago-gastrectomy, prolonged nasogastric intubation).

Not all patients with sliding hiatus hernia have reflux and vice versa. Oesophageal pH monitoring and manometry is vital to confirm significant reflux if surgery is being considered after medical treatment has failed. Significant reflux is confirmed when the pH is <4 for >4% of the 24-hour period.

Long-standing reflux may lead to Barrett’s oesophagus – a precursor of malignancy or stricture. Barrett’s oesophagus is inflamed ‘salmon pink’ epithelium in the distal oesophagus which has undergone gastric metaplasia in response to chronic reflux. Complications include bleeding, stricture, ulceration and malignancy. Once Barrett’s oesophagus has been identified, regular endoscopic surveillance, and biopsy is required if dysplasia. Development of severe dysplasia indicates a high risk of malignancy and oesophagectomy may be required.

Hiatus hernia

Two types of hiatus hernia are described: sliding (90%) and rolling (para-oesophageal). In the latter, the gastrooesophageal sphincter remains intact and reflux does not occur (Fig. 7.1). The common sliding hiatus hernia disrupts and changes the oesophago-gastric junction, giving rise to reflux.

image

Figure 7.1 (a) The oesophago-gastric anatomy in a sliding hiatus hernia. (b) The anatomy in a para-oesophageal hernia.

Long-term complications include ulceration, Barrett’s oesophagus, bleeding and stricture.

Clinical features

Retrosternal burning pain, worse on lying, bending or stooping (‘heartburn’), relieved by antacids. Waterbrash (reflux of fluid up into the mouth). Many cases present to ENT departments with a hoarse voice.

Investigations

• OGD to assess degrees of inflammation and exclude malignancy by biopsy

• Barium swallow

• pH monitoring.

Treatment

• Weight loss in the obese

• Elevate head of the bed to avoid nocturnal reflux

• Alginate antacids

• Reduce gastric acidity with either H2 receptor antagonists or proton pump inhibitors (PPIs).

Surgery is indicated if conservative measures fail and reflux is considerable. Nissan’s fundoplication is now performed laparoscopically. Rolling hiatus hernias should be repaired due to risk of incarceration, strangulation (high mortality) and gastric volvulus.

Achalasia

The cause is unknown but the result is a failure of the lower sphincter to relax in response to oesophageal contraction. This leads to retention of the bolus and ultimate dilatation and elongation of the whole oesophagus. Aspiration pneumonia may result. There is an increased risk of malignancy due to chronic inflammation of the mucosa. Pathologically there is loss of ganglion cells in Auerbach’s plexus.

Clinical features

There is intermittent dysphagia in the 30–40-year age group. This gets progressively worse (for liquids rather than solids) and there is a slowing down of ingestion of food – the patient gets left behind at meals.

Investigation

Barium swallow shows ‘rat’s tail’ stricture in chronic cases. OGD is essential in the elderly to exclude malignancy and other causes of stricture.

Treatment

Medical treatment with anti-spasmodics is unrewarding. Balloon dilatation is successful in 80%. Heller’s operation (longitudinal myotomy) via laparoscope in the abdomen or chest is very effective. Injection with botulinum toxin is increasingly being used.

Carcinoma of the oesophagus

The incidence in Europe is 2–8 cases/100 000. It is much higher in the Far East (100–150/100 000). Males are more commonly affected. The aetiology of oesophageal cancer is summarised in Figure 7.2.

image

Figure 7.2 The aetiology of oesophageal cancer. GORD, gastro-oesophageal reflux disease.

Pathology

Cancers of the upper two-thirds of the oesophagus are usually squamous, the lower third adenocarcinoma. Both spread by local invasion, lymphatic and blood-borne metastases.

Clinical features

The main symptom is progressive dysphagia to solids then liquids. Other features are regurgitation, weight loss, anorexia, anaemia, painful cough, hoarse voice (recurrent laryngeal nerve palsy), supraclavicular lymph nodes and palpable liver metastases.

Investigation

• Barium swallow – demonstrates stricture and provides a road map for surgery

• CXR

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