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Gastroenterology Notes

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Medicine & Surgery Gastrointestinal Pharynx & Oesophagus Structure & Function
~20cm long connecting the pharynx to the stomach Upper 2/3 = striated muscle Lower 1/3 = smooth muscle (including LOS) Vagal nerve controls the smooth muscle and LOS Swallowing Between swallowing, the oesophagus is relaxed apart from the sphincters The UOS contracts once the bolus has passed The primary peristaltic wave is coordinated by the swallowing centre via the vagal nerve The circular muscle contracts and raises pressure on the oral side of the bolus and pushes it into an area of low pressure The longitudinal muscle contracts and pulls the oesophagus over the food bolus This sequence of events repeats in the distal direction towards the stomach As food approaches the Lower Oesophageal Sphincter (LOS), it relaxes due to action from the vagus nerve Peristalsis moves at a rate of 2-5cm/second and takes about 10 seconds to reach the LOS A secondary peristaltic wave may occur if not all the food has left the oesophagus and may be induced by reflux of the gastric contents into the oesophagus

Symptoms of oesophageal disorders Dysphagia Sensation of obstruction during the passage of liquid Odynophagia Pain during the act of swallowing Caused by reflux, infection, chemical oesophagitis due to drugs Substernal discomfort (Heartburn) Reflux of gastric contents Retrosternal burning that can radiate to the neck or across the chest, worse when lying flat Regurgitation Effortless reflux of gastric contents in mouth

Signs Weight loss due to reduced food intake

Investigations Barium swallow Oesophagoscopy Manometry - use of a catheter to measure pressures in the oesophagus pH monitoring - pH probe is placed in the lower oesophagus to identify reflux episodes

Gastro-Oesophageal Reflux Disease (GORD)

Small amounts are normal - rises in intra-abdominal or intra-gastric pressure Normally cleared off by secondary peristalsis, gravity or salivary bicarbonate GORD occurs when these mechanisms fail and gastric contents make prolonged contact with mucosa

After meals the sphincters relax transiently independently of a swallow (Transient Lower oEsophageal Sphincter Relaxation [TLESR]) - 2/3 GORD patients

Clinical features Heartburn, waterbrash (excessive salivation), odynophagia Aggrevated by bending, stooping or lying down promoting acid exposure Relieved by oral antacids Pain on drinking hot liquids or alcohol Differential diagnosis Oesophagitis, infection, DU, gastric ulcers or cancer Investigations Doesn't normally need investigations if isolated incident Endoscopy if there is oesophagitis/Barrett's Monitor pH - excessive reflux = pH<4 4% of the time

Treatment Lifestyle Weight loss Smoking cessation Raise the bed head Small regular meals Avoid: hot drinks, chocolate, citrus fruits, spicy foods

Drugs Antacids - magnesium tricilicate mixture Gaviscon PPI - omeprazole

Surgery Only if Sx are severe No medical help

Complications Peptic stricture - >60, intermittent dysphagia for solids, progressively getting worse Barrett's oesophagus - squamous epithelium is replaced by metaplastic columnar mucosa to form a segment of columnar lined oesophagus (CLO). Almost always a hiatus hernia, diagnosed by endoscopy


Oesophageal aperistalsis and impaired relaxation of LOS 1:100,000 incidence M=F Clinical features Dysphagia, regurgitation particularly at night ? aspiration pneumonia, spontaneous chest pain (oesophageal spasm) Investigations Barium swallow - lack of peristalsis & swan-neck deformity due to failure of LOS to relax Treatment All palliative Endoscopic balloon dilatation under x-ray control - weakens the LOS 80% success Intrasphincteric botulinum toxin A injection - wears off after months Surgical intervention - Heller's operation divides the LOS

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