and Zolvis with the esophagus and stomach. Okay, perfect. All right, thank you, everybody. I'm gonna be walking you through GI tract and disease, specifically focused on the esophagus and stomach. Those of you that know me, know that I could probably talk about the esophagus for the entire time. So please keep me on track, Dr. Yoon, to make sure that I don't go over because there are a lot of slides here about the stomach as well. So I wanna do it justice. You've seen this slide before. We're gonna be focusing more on the esophagus and the stomach. What I'm gonna try and do with my time is I'll review with you a little bit of what you've already heard about in terms of the esophageal anatomy, structure and function. We'll talk about structural disorders. Are you seeing my slide up there? Yeah, okay. Structural disorders, specifically hiatal hernias, esophageal rings, webs, and diverticuli, and how they relate to esophageal symptoms. We'll talk about clinical disorders, including reflux disease. EOE will be focused tomorrow. We'll then go into motility disorders and talk about some miscellaneous disorders of the esophagus. And are you all still seeing my screen? Okay. So if so, you've seen these slides before. I just wanna highlight a little bit about the anatomy of the esophagus as it pertains to some symptoms. So what you've heard about is that the esophagus is this long muscular tube here. It has a sphincter muscle at the top, the cricopharynges, a sphincter muscle at the bottom, that lower esophageal sphincter, and it's sandwiched between the trachea and the spine for a while, and then again, sandwiched between the trachea, the spine, and the aorta in that middle portion. Proper esophageal functioning allows food and saliva to go into the stomach and prevents food and contents from coming back up into the esophagus. So when that functioning doesn't work properly, patients have esophageal symptoms. So let's just go over a quick glossary of symptoms on what patients may be reporting to us as gastroenterologists. They talk about heartburn. That's the most common esophageal symptom. This is a discomfort or burning sensation behind the sternum. Regurgitation is this effortless return of food or fluid into the pharynx without nausea or retching, so very different than vomiting. Dysphagia is that feeling of food sticking or even lodging in the chest. Odynophagia is pain caused by or exacerbated by swallowing. Globus is a perception of a lump or fullness in the throat felt even without swallowing, and it's a symptom of reflux. And water brash is excessive salivation, tons of saliva in the mouth, which is a compensatory response to reflux. So esophageal symptoms can be transit-related, antigrade, going down with food impactions or dysphagia, or retrograde, going up, regurgitation, or even aspiration. They can be perception-related, meaning discomfort like chest pain, pressure, or heartburn. Now, etiologies of esophageal symptoms include structural abnormalities, which are picked up on endoscopy, and structural abnormalities typically cause dysphagia, dysphagia to solid food. And those structural abnormalities can be esophageal rings, strictures, EOE, which we'll talk about tomorrow, infections, pilosophagitis, and many of the things. Esophageal symptoms can also be due to propulsive disorders or motility disorders, and the hallmark here is that that dysphagia occurs with both solids and liquids, and that is picked up with functional esophageal tests, and things like a peristalsis, weak peristalsis, esophageal spasms, and achalasia, which you heard about briefly earlier today. There can also be sensory abnormalities of the esophagus, where patients will have symptoms with, again, both solids and liquids, and this is typically thought to be functional esophageal disorders, or nonspecific esophageal motility disorders. And what's even more confusing is that there can be a significant overlap with propulsive disorders, reflux, and even some of these structural abnormalities. So let's move on to the structural disorders. The first one I'll talk about is a hiatal hernia. Now, this is normal anatomy with the esophagus meeting the stomach. This is your diaphragm muscle, and here, all the stomach is below the diaphragm. That's what should happen. But if there is a weakness in this diaphragm, some of the stomach pooches up into the chest, and that's called a hiatal hernia. This is a type I, or sliding hiatal hernia, which is the most common type of hernia. And as you can imagine, because this junction is no longer intact, this is gonna predispose patients to having reflux disease. Now, there are also other types of hernias that I just wanna show you, and how this will relate to esophageal symptoms. So that type I hernia is in this picture here. Type II is where part of the stomach comes up into the chest. Type III is a combination of these two, both a type II and a type I. And type IV is where there's tons of gastric contents and lower contents up in the chest. And what you can imagine is that if you have a ton of these intragastric contents up into the chest, that patient is gonna have significant dysphagia, chest pain, reflux, regurgitation. What about these other structural disorders? We think about structural disorders as being like speed bumps in the esophagus. So these are esophageal rings and webs, and they look exactly like that. A little speed bump here, and you can see this on the barium esophagram here. So the most common is a Schottky ring, which is a lower esophageal mucosal ring. It happens in about 15% of patients, and usually is asymptomatic until it gets small. And when it gets under 13 millimeters across, and you heard from lectures earlier today, a normal esophageal diameter is about 20 millimeters across. So once it gets less than 13, patients will have problems and symptoms of difficulty swallowing. Usually happens over the age of 40, thought to be an acquired condition. And as you can imagine, because there's a speed bump here, it's treated with dilation, getting rid of the speed bump. Other esophageal rings and webs are the cervical webs. And the cervical webs, we're relating to the cervical esophagus, which is up in the neck. And these are very high up in the esophagus. They're sometimes missed on a regular endoscopy. These can be congenital or inflammatory in origin. It happens in about 10% of patients. They're usually circumferential, so all the way around. And this relates to and causes intermittent dysphagia. And patients usually relate it to upper in the neck. They'll point to up here when they're saying things are sticking. This is treated with a dilation. And if you have this combination of a middle-aged female, the cervical web high up in the neck and iron deficiency, this is called Plummer-Vinson syndrome. What about esophageal diverticuli? So similar to the colon, where you have these pouches in the colon, you can also have them in the esophagus. And one of the more common ones is this called Zanker's diverticulum. It's a sac-like outpouching in the upper portion of the neck. So here you see this pouch. It's a weakening in the muscles here, and so you have this little sac. It's not very common. Happens in about two per 100,000 patients. It's more common in men than women. And it's typically a problem of older age. Now, this is what it looks like on a bariomesophagram. You can see all this contrast pooling in this pouch. And if you can imagine, there's a ton of food and saliva that sticks in here. So symptoms can be bad breath, regurgitation, neck fullness, gurgling in the throat, and even since it's so close to the airway here, some aspiration. And one of the things that we always talk to our medical school students about is when you're doing a good physical exam, sometimes you'll actually feel some crunching in one side of the neck or the other, and that's that diverticulum. You can have other esophageal diverticuli, meaning these traction diverticuli in the middle portion of the esophagus, and epiphrenic diverticulum close to that diaphragm muscle. These are usually above the lower esophageal sphincter and usually associated with motility disorders like achalasia. Now you can imagine here, if you have a big pouch in your esophagus, symptoms can be difficulty swallowing, feeling like things are sticky, or even regurgitation, because a lot of stuff is just pooling in here and coming back up. Moving on to reflux disease, gastroesophageal reflux disease, or GERD. This is reflux of stomach contents into the esophagus or mouth, and you've seen the anatomy. Here's your esophagus. That's squamo-columnar junction, the junction of the esophagus and the stomach, that lower esophageal sphincter, the diaphragm muscle, and your stomach. So normally, your lower esophageal sphincter stays closed and it relaxes throughout the day. When it's closed, it prevents this reflux of gastric contents from going into the esophagus. However, if it relaxes or stays relaxed, that's when more of this stomach content is gonna go up into the chest. What are the causes of reflux? One of the most common causes of reflux, I'm just gonna go back one second, oops, hold on. One of the most common causes of reflux is what we call transient gastric reflux, transient lower esophageal sphincter relaxation. So this sphincter is just relaxing way too frequently and allowing more of these contents to come up into the chest. So normal physiology can cause reflux. It's normal to have some degree of reflux. Once you have too much of it, that's when people have that pathologic reflux. You can have reflux in response to food bolus, so when you have a lot of food or gastric distension, that can give you reflux. And like abnormality, like those hiatal hernias, certain foods such as alcohol or coffee and caffeine can trigger those transient lower esophageal sphincter relaxations, and even certain medications can cause that LES pressure to relax. What are those symptoms of reflux? Most common are heartburn and acid regurgitation. Less common symptoms include dysphagia, a chronic cough, laryngitis, like sore throat, and even worsening asthma. Treatment includes lifestyle modification, elevating the head of the bed, weight loss, avoiding some of those foods. If that doesn't work, and diet and lifestyle modification, including getting closer to your ideal body mass index, if that doesn't work, we step up to medical management with medications like proton pump inhibitors. And if that doesn't work, then in some cases an anti-reflux surgery, such as a Nissen fundoplication, would be warranted. When reflux is not well controlled, you get complications like esophagitis, and esophagitis just means inflammation of the esophagus. Those symptoms can be dysphagia, chest pain, heartburn, or even odynophagia, painful swallowing, that can be caused by that bad reflux. Infection medication, radiation can cause esophagitis, caustic injection, if someone drinks something caustic, that can cause some irritation, and of course, EOE. And what you're seeing here on this picture are these breaks in the lining of the esophagus here, and that signifies that esophagitis. Here is what we see on endoscopy when we're looking at reflux esophagitis. It's graded by this LA gradation. So you see a grade A here, which is very mild breaks, grade B, greater than five millimeters in length here, grade C, mucosal breaks that extend between the tops of more than two mucosal folds, and grade D is horrible here, more than 75% of that circumference. So when you look at endoscopy reports, and people are talking about esophagitis, it's typically graded in this fashion. And reflux esophagitis in these grades are very specific for acid reflux. When we talk about EOE tomorrow, there's lots of discussion about that overlap between reflux and EOE, but when people have this erosive esophagitis, we know that it's related to reflux disease. Now, what happens with uncontrolled reflux over a long period of time? You get an increased risk of this condition called Barrett's esophagus. Barrett's esophagus is replacement of the normal lining of the esophagus with a lining similar to that of the small intestine. So what you saw in earlier pictures from this morning is the squamous columnar junction, the esophagus mucosa is white, it hits the stomach mucosa, which is pink. But what you're seeing here is intestinal epithelium coming up into the esophagus. It is thought to be a precancerous condition and an increased risk of developing esophageal adenocarcinoma. And oftentimes there's no symptoms, so the patients may not have any symptoms of Barrett's esophagus. So there is a progression of disease and this cartoon depicts that. So what you see here is that junction of the esophagus, this is normal, the squamous columnar junction, white meeting pink. Then you start to see evidence of Barrett's here, this pink coming up into the white, and you see that here in the histogram and histology cartoon. You then start to get low-grade dysplasia, which is increased inflammation, high-grade dysplasia, and of course, the dreaded complication of esophageal cancer. So one thing I should mention is if someone is diagnosed with Barrett's esophagus, they do go through specific surveillance protocols on periodic endoscopies to monitor and follow. And that risk, while this looks really scary, this risk of progression is really quite low. So typically surveillance intervals are anywhere from three to five years. You can treat it when there is dysplasia, there is treatment with something called radiofrequency ablation. So at the time of endoscopy here, there's a little device here with a balloon that gives radiofrequency ablation waves across the mucosa and essentially burns off the esophageal tissue. And you can see here, this is what happens on the right side after that radiofrequency ablation, it's actually burning off this tissue and allowing the normal tissue underneath to heal. It can also be treated with something called endoscopic mucosal resection. Dr. Snyder might have mentioned this earlier when she was talking about different tools, but essentially with endoscopic mucosal resection, you have that little scleral needle here. It's injecting saline. It's lifting up the spot of that lesion here. It's being drawn into a cap and then suctioned out and cauterized, and that lesion is removed by that technique. We'll then move on to esophageal motility disorders. And esophageal motility disorders are characterized by abnormal motility of the esophagus. So problems with peristalsis. Peristalsis is that coordinated contraction going through that esophagus, essentially going through the entire bed, but we're focusing on the esophagus today. Symptoms of abnormal motility can be dysphagia, odynophagia, chest pain, and heartburn. How do we pick up on motility disorders? One of the tools is a manometry catheter. And what you can see here, it's this long, skinny catheter, and along this catheter has over 30 pressure sensors, and basically it goes into the patient's nose and down into their esophagus, into the stomach. Those pressure sensors create this nice, pretty, colorful grid here on the monitor to show peristalsis or normal contractions or abnormal contractions, and that's how we pick up on motility disorders. Common motility disorders include achalasia, not correct for esophagus, esophageal spasm, or scleroderma. We'll talk a little bit about some of these. So achalasia is based on the Greek term, does not relax. And the hallmark of achalasia is that that lower esophageal sphincter has lost that signal to relax. So it's constantly staying tight, and when it constantly stays tight here, the upstream effects on your esophagus is that esophagus is going to dilate or stretch out. So the hallmarks are loss of peristalsis, failure of that lower esophageal sphincter relaxation, and that essentially leads to this functional obstruction of that lower esophagus. It can be treated in different ways. So if we think about the main problem being the sphincter muscle here not relaxing, we have to figure out how we can make the sphincter muscle relax. One of the techniques and the least invasive techniques is with Botox or botulinum injection into this lower part of the esophagus. So through the esophagus, there's that scleronatal here that directly injects this Botox into different quadrants, four different quadrants, directly into the lower esophageal sphincter to allow that sphincter muscle to relax. The next treatment is a more aggressive treatment called a pneumatic dilation. So this is one of the types of dilators, and this is different than what we use in EOE, and we'll talk about that tomorrow. So pneumatic dilation is not what's done in EOE. This is for achalasia. There's a wire-guided balloon device that comes across this lower esophageal sphincter. It is under fluoroscopy insufflated or stretched out. The balloon then opens up the sphincter, and you can see here an opening of the sphincter. It's actually trying to tear open some of those muscle fibers. There is a surgical myotomy, which you heard about earlier. So through surgery, and it can be done laparoscopically, we're cutting. This is myotomy means cutting the muscle, cutting that muscle of that lower esophageal sphincter to help prevent that obstruction. This can now also be done endoscopically with something called a peroral endoscopic myotomy or POEM, and what happens is through the camera here, there is an incision into that submucosal space, and then there's a creation of a little tunnel here, and then through that tunnel, that's where they actually cut the muscle. So it's a less invasive way to do that myotomy. Moving now on to other esophageal conditions, we'll start with infectious esophagitis. So these are the most common infectious causes of esophagitis. Candida esophagitis is the most common. It causes painful swallowing as well as difficulty swallowing dysphagia. You see these white plaques in the esophagus, and someone might look at this and say, hey, that looks like AOE, and it kind of does look like AOE, except for in this case, this is actually candida. It is treatment with antifungal medications such as oral fluconazole for 14 days. Next thing is herpetic esophagitis, which is caused by herpes simplex virus 1 or 2, and these, you'll see these punched out lesions throughout the esophagus. Treatment is often self-limited. It gets better on its own, but in severe cases, you can have, be treated with acyclovir or valcyclovir. NCMV, cytomegalovirus esophagitis, is seen here at the bottom panel. This is typically in immunocompromised patients. We see these serpiginous or snake-like ulcerations throughout the esophagus, and it is also treated with a medication called ganciclovir. So infections can also cause inflammation, just like acid reflux can. What about pill esophagitis? This is another very common thing we see as gastroenterologists, and I want to just bring you back to that anatomy because this is why this is important. So the esophagus is sitting here, the trachea is pushing on it, as well as that aorta, kind of in that middle portion of the esophagus. And so pill esophagitis occurs when a swallowed pill lodges in that esophagus. That mid-portion of the esophagus is the most common location because that's where the aorta crosses, as well as the carinae of the trachea. Implicated medications are listed here, things like doxycycline or tetracycline, and many other things, including iron pills or even non-steroidal medications can do this. The hallmark that patients will tell us about is the sudden-onset chest pain or painful swallowing, and a common clinical scenario is a young patient went to the dermatologist, got medications like tetracycline for their acne, they started taking that, and five days into this they come in to us saying, oh my gosh, my chest hurts so bad, I cannot swallow, I'm having so much pain, and it's because of this pill esophagitis. This is usually self-limited, although you can treat it with proton pump inhibitors and something called sucrofate, which coats that esophagus. Now moving on to the stomach, I have to leave the esophagus eventually, so for the rest of the time we'll focus on some of these gastric disorders. We'll talk about peptic ulcer disease, and these are ulcers or mucosal breaks in the GI tract. The most common locations are the stomach or the duodenum, and you can see here a stomach ulcer, a break in that mucosa, and a duodenal ulcer here. The most common causes are helicobacter pylori or H. pylori, and this is a stomach biopsy stain for these organisms, which you can see here highlighted in brown, and the next most common cause is non-steroidal medications, NSAIDs, similar to ibuprofen. So people taking too much of those, you can develop ulcers of the stomach or the small bowel. Symptoms include abdominal pain, discomfort, GI bleeding, gastric outlet obstruction, and perforation, and perforation typically one of the hallmarks of severe acute abdominal pain and even rigidity, firmness of that abdominal wall. How do we diagnose these ulcers? Well, with the upper endoscopy, we'll go in with the camera, and then we'll see this mucosal break, and you see this in this endoscopic image. The treatment, if someone is positive for H. pylori, is to eradicate that H. pylori with antibiotics. If they don't have H. pylori, then it's treating with proton pump inhibitors, and I should say, even if they do have H. pylori, if there's a big ulcer there, you're going to treat with that proton pump inhibitor to reduce that gastric acid to help heal that mucosal lining. Moving on to upper GI bleeding, that is bleeding from the gastrointestinal tract located before the ligament of trite, so that's really in the second, third portion of the duodenum, so up in here is what we consider sources of upper GI bleeding. Blood in the GI tract can be emesis, so vomiting up of that blood. We refer to this as hematemesis, that's bright red bloody emesis or vomit, or coffee ground emesis, which is basically what it sounds like, looks like coffee grounds, this dark black colored emesis that suggests some old blood that's in the stomach. You can also see bleeding in the stools with what's called hematochesia, that's bright red blood from your bottom, or melana, which is black, tarry-colored stools that also signifies older blood or older bleeding. So what are the causes of bleeding? You've heard some of this mentioned earlier today, but these big veins in the esophagus, there's esophageal varices here, usually in the setting of very bad liver disease or portal hypertension. You can see ulcers or erosions in the stomach, gastropathy is listed here, a large duodenal ulcer, a Mallory-Weiss tear, this is a tear in the lower part of the esophagus that happens from repeated vomiting, gave or gastric anterovascular ectasia here, looks like a watermelon stomach, these are superficial vessels here that can bleed, these large kind of grape-like gastric varices, so again, dilated veins in the stomach, and these superficial angioectasias here can bleed. So all these can cause bleeding. How do we manage a situation with GA bleeding? This is one of the common reasons why gastroenterologists get called in in the middle of the night is GI bleeding from one of these various sources. The first thing is volume resuscitation, giving patients a lot of fluid through that IV to bring back up that blood pressure. Of course, if we're thinking about ulcers, we want to do management with medications, either proton pump inhibitors intravenously or orally. Treatment includes endoscopic hemostasis, meaning we have to get this to stop bleeding. That could be putting epinephrine through this scleroneedle directly into the ulcer, and the goal is to kind of tamponade or close off some of these lesions. Then we do thermal therapy, you saw this catheter before, where basically you're just touching the mucosa with this thermal device and it's kind of heat zapping that and making it stop bleeding. Hemoclips are clipping that ulcer closed, and band ligation, putting that rubber band over that esophageal varix. Moving on to gastric outlet obstruction. So this is an obstruction where your stomach meets your duodenum. There's a pylorus muscle here, and if there's an obstruction in this area, it doesn't allow for all of that stuff that's being churned in the stomach to get into that small intestine. It's a mechanical obstruction that prevents the emptying of the stomach into that small intestine. Causes can be benign, like peptic ulcer disease or pancreatitis, or it can be malignant gastric cancer or pancreatic cancer. Our goal is not to really talk about eosinophilic GI disease below the esophagus, but EGID, eosinophilic gastritis or duodenitis, can also cause this picture. Symptoms include nausea or vomiting, abdominal pain, early satiety, which just means that people are feeling fuller more quickly. They can't finish a plate of food. They feel full after just a few bites. Abdominal distension, and even weight loss because they can't eat. Diagnosis can be with x-rays. So x-rays showing you a very dilated stomach here. CT scan, a very dilated stomach. Or endoscopy, where you're seeing the significant narrowing of that pylorus. Treatment is to, if you have a very big and dilated stomach here, it's to decompress the stomach, putting in a tube, a nasogastric tube, to get rid of these contents. And then ultimately you want to do something to help open up that passage again. And one thing that you can do for this gastric outlet obstruction is putting in a stent. And here you see the radiologic image of the stent. You can also do surgery. That's called a Bilroth II because there's such a significant obstruction. You can take out the area of the obstruction and connect your stomach to that small intestine. That's called a gastrojejunostomy, your gastric connected to the jejunum. Gastroparesis is another GI symptom, problem I should say. This is a delayed emptying of the stomach in the absence of a mechanical obstruction. We think about this being a motility problem of the stomach. Causes include diabetes, after surgery, post-infection, and idiopathic. Symptoms include nausea, vomiting, again, that early satiety or early fullness, abdominal pain, bloating, and weight loss. And this is picked up on a nuclear medicine scan called a gastric emptying study, where patients swallow radiolithic foods. And they take pictures of their stomach over time to see how much of that food is still left over. And what you can see here is an abnormal patient. There's very little tracer left in the stomach. Abnormal patient with gastroparesis, tons of tracer left in the stomach still. Treatment for this is small, frequent meals. Prokinetics, meaning medications that help squish the stomach, like erythromycin and metoflopramide. Anti-emetic, which is a ton of vomiting, so helping them with that symptom. And in some cases, even a gastric pacemaker to help recreate that motility of the stomach. Subepithelial masses here, you can see these. Whoops. Subepithelial lesions here are masses or bulges seen in the GI tract. They can be intramural, arising within the layer of the GI tract or outside. They can be benign, leiomyomas or pancreatic rest or even lipomas. They can be malignant, such as these areas here, the gist or carcinoid. Someone asked about endoscopic ultrasound. This is a really good tool to use to figure out what these lesions are. It's the most accurate test for evaluating subepithelial lesions. It helps to understand the layer of origin, the echogenicity, meaning is this fat or is this something more significant, the size, and you can actually put a needle through that to get tissue. All right. I think I did justice. So hopefully I've gotten through everything. I am at time, so please let me know if there are any questions with anything I went through.

gastrointestinal diseases

esophageal disorders

GERD

peptic ulcer disease

upper GI bleeding

gastroparesis

endoscopic diagnosis