Dr. Ajmal Hasan

Stomach Esophagus

Gastric cancer

Peptic ulcer disease

H pylori infection

GIST and lymphoma

Gastroesophageal reflux

Achalasia

Esophageal stricture & web

Esophageal cancer

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Gastric cancer

Gastric cancer is the most common malignant tumor of the stomach
Risk factors of gastric cancer are

  • H pylori infection with chronic atrophic gastritis/metaplasia/dysplasia
  • Gastric adenoma
  • Smoking
  • Hereditary non polyposis colorectal cancer
  • Juvenile polyposis
  • Peutz jegher’s Syndrome
  •  Obesity
  • Cigarette smoking

Clinical symptoms

  • Vomiting
  • Hemetemesis
  • Pain abdomen
  • Post prandial fullness
  • Anorexia
  • Weight loss

Diagnosis and staging

  • Endoscopy is the investigation of choice for diagnosis of gastric cancer. Findings on endoscopy are gastric ulcer with raised margins, growth in the stomach
  • CECT abdomen is done in every patient for assessment of resectibility
  • PET scan plays a limited role in these patients

Treatment

  • In patients with resectable tumor, surgery is the treatment of choice
  • In patients with advanced disease, chemotherapy can result in palliation of symptoms, prolong the survival and downstage the tumor, so that surgery can be done

Peptic ulcer disease

Peptic ulcer is the discontinuity in the mucosa GI tract due to excessive gastric acid secretion. Most common site for peptic ulcers are stomach and duodenum.
Common causes of peptic ulcers are:
  • H pylori infection
  • NSAID use
  • Cigarette smoking
  • Hypersecretory conditions like gastrinoma
  • Hypercalcemia
  • Cirrhosis
  • Renal failure
  • Chronic obstructive pulmonary disease
Symptoms
  • Upper abdominal pain related to meals
  • Radiation of pain to the back
  • Vomiting of blood or black stool in case of bleeding from the ulcer
  • Severe pain abdomen in case of ulcer perforation
Diagnosis
  • Peptic ulcers are easily diagnosed on upper GI endoscopy
  • Biopsy is taken from gastric antrum for H pylori
Treatment
  • Proton Pump Inhibitors(PPI)
  • H pylori eradication

H pylori infection

H pylori is bacteria causing chronic infection of the stomach.
More than 50% of Indian population is suffering from H pylori infection.
Most of the individuals with the infection remains asymptomatic, however few may develop complications such as:
  • Duodenal and gastric ulcer
  • Gastric lymphoma
  • Gastric adenocarcinoma

Diagnosis

  • UGI is done, biopsy is done from gastric antrum for Rapid Urease Test

Treatment

  • Proton pump inhibitors and antibiotics such as amoxicillin, clarithromycin, metronidazole and tinidazole

GIST and lymphoma

GIST (Gastrointestinal stromal tumor)

Stomach is the most common site for the GIST, other sites include small intestine, rectum, and esophagus
Clinical presentation

  • Asymptomatic lesion detected during endoscopy or CT scan
  • GI bleed in the from of hemetemesis and black colored stools
  • Abdominal pain
  • Obstructive features such as dysphagia, recurrent vomiting, abdominal distension, and severe pain abdomen

Diagnosis
Following test are required for diagnosis and management  

  • Endoscopy and endoscopic ultrasound
  • CECT abdomen
  • PET scan to rule out distant metastasis

Treatment   

  • Small GIST can be followed up
  • Large tumor without metastasis should be operated
  • Unresectable tumors, and in patients where surgery is not feasible, are best treated by chemotherapy with imatinib and sunitinib

Gastric Lymphoma
Gastric lymphoma constitute 3-5 % of all gastric tumors. Stomach is the most common extranodal site of lymphoma.

Marginal zone B cell lymphoma of stomach
Marginal zone B cell lymphoma, also known as MALT lymphoma is the most common lymphoma of stomach, chronic H pylori infection leading to chronic gastritis is the underlying cause.

Clinical features

  • Dyspepsia
  • Epigastric pain
  • Nausea, vomiting and early satiety
  • GI bleeding
  • Fever, vomiting and weight loss

Diagnosis
Lesions are usually diagnosed by endoscopy, endoscopic findings are

  • Erythema
  • Erosions
  • Ulcers
  • Growth.
  • Biopsy is taken from the suspicious areas
  • CT and EUS are the investigations required for evaluation of extent of diseases and  metastasis

Treatment

  • Early state disease can be treated by eradication of H Pylori
  • Advanced disease is treated by chemotherapy

Diffuse large B cell lymphoma
The role of H pylori in the pathogenesis is not very clear
Clinical symptoms

  • Epigastric pain and dyspepsia
  • Large tumor may cause obstruction
  • Ulcerated lesion may bleed

Diagnosis

  • Upper GI endoscopy and biopsy are required for the diagnosis
  • Endoscopic findings are large tumor and ulcer
  • Body and antrum are common sites
  • CT/PET and EUS are done for staging

Treatment

  • Chemotherapy with or without radiotherapy is mainstay of treatment

Gastroesophageal reflux

Gastroesophageal reflux (GERD) is consequence of failure of the normal antireflux barrier of the lower esophageal sphincter system Hiatus hernia impairs the function of lower esophageal sphincter and has been implicated as causative factor in patients with severe GERD. Spectrum of GERD varies from mild heartburn with normal endoscopic findings and no esophageal mucosal disease to esophageal ulcerations, bleeding, stricture and dysphagia. Prolonged GERD can lead to Barrett’s esophagus which is risk factor for esophageal dysplasia and cancer
Symptoms of GERD are
  • Retrosternal burning pain
  • Dysphagia-difficulty in eating
  • Odynophagia- pain during eating
  • Upper GI bleed
Diagnosis
  • In patients with classical GERD symptoms, diagnosis is straight forward, and no further testing is required. In patients with severe symptoms such as dysphagia and bleeding, endoscopy is required to establish the diagnosis and rule out other causes
  • Barium swallow, 25 hour pH testing, maonometry are the other tests which are helpful in diagnosis
Treatment
  • Lifestyle modification
  • Stopping smoking and alcohol
  • Avoiding tight cloths
  • Raising head end of bed
  • Weight reduction
  • Avoiding bed time snacks
  • Avoiding Tea/coffee/cola/citrus fruits
Medications
  • PPI and prokinetic agents are effective medications for control of symptoms
Surgery
  • Fundoplication is the procedure which corrects the physiological processes causing GERD
Indication of surgery
  • Patents doing better on PPI, but want to avoid long term use of medications
  • Young patients with recurrent stricture

Achalasia

Achalasia is motor disorder of esophagus characterized by impaired relaxation of lower esophageal sphincter

Symptoms of achalasia are

  • Dysphagia
  • Odynophagia
  • Chest pain
  • Weight loss
  • Aspiration pneumonia

Diagnosis
Following tests are performed for the diagnosis of achalasia

  • Upper GI endoscopy to rule out obstructing lesion
  • Barium swallow
  • Esophageal manometry

Treatment
Following are the treatment options

  • Surgery
  • Endoscopic pneumatic balloon dilatation
  • Oral nifedepine and nitroglycerine
  • Botulinum injection

Surgery and endoscopic dilatation are mainstay of treatment

Esophageal stricture & web

Esophageal stricture
Esophageal stricture are narrowing of esophageal lumen resulting in dysphagia

Causes of esophageal stricture are

  • Ingestion of acid or alkali
  • Post surgery
  • Gastroesophageal reflux disease
  • Drug induced
  • Tuberculosis
  • Esophageal cancer
  • Dysphagia and weight loss

Symptoms

  • Dysphagia for solids is the predominant symptom

Diagnosis

  • Diagnosis is established by endoscopy and biopsy

Treatment

  • Treatment is endoscopic dilatation, surgery and medical therapy depending upon the underlying cause.

 

Esophageal webs
Esophageal webs are membranes in the esophageal lumen, and are mostly seen in upper esophagus

Symptoms

  • Webs may be asymptomatic or may lead to dysphagia

Treatment

  • Treatment is endoscopic dilatation

Esophageal cancer

Esophageal cancer is the most common tumor of esophagus
Risk factors are

  • More common in male
  • Alcohol
  • Smoking
  • Gastroesophageal reflux and Barrett’s esophagus
  • Obesity

Symptoms

  • Dysphagia  (more for solid than liquids)
  • Weight loss

Diagnosis

  • Diagnosis is confirmed by endoscopy and biopsy

Staging

  • CECT, PET, EUS with or without FNA are essential tests for the staging of esophageal cancer

Treatment

  • Surgery is the best treatment for early esophageal cancer
  • Advanced cancers are treated by chemotherapy and radiotherapy and surgery
  • For metastatic disease, esophageal stent can be placed for palliation of dysphagia