2 - Diseases of Upper GI

Canker Sores

• Official name

• What is it

• Cause

• Treatment

• Aphthous ulcer

• A superficial ulcer in the mouth with thin layer of exudate and an erythematous rim

• Unknown cause but associated with things like celiac disease, inflammatory bowel disease, so maybe observe if a patient keeps on getting these sores

• Heals on their own

Irritation Fibroma vs Pyogenic Granuloma

• What is it

• Cause

• Location

• Treatment

• Irritation fibroma:

  • Soft tissue proliferation that looks like a pink mass, formed in response to repeated trauma, found at the กระพุ้งแกม(buccal mucosa) and removed by surgery

• Pyogenic granuloma:

  • Not a real granuloma(These are macrophages walling something off). Instead, this is a vascular proliferation that looks like a red/purple mass, formed in response to low-grade irritation, found at the gums, sometimes due to pregnancy, and removed by surgical excision

    • Another name is lobular capillary hemangioma

HSV-1 primary infection results

1. Most people: Asymptomatic

2. A subset(10-20%): Acute herpetic gingivostomatitis; vesciles and ulcers across gums/mouth with fever and lymphadenopathy

Herpes reactivation cause and result

• A trigger causes the dormant virus, hiding in ganglions, to wake up and cause an outbreak along the trigeminal nerve fibers(around the lips), forming small vesciles

Oral thrush

• What is it

• Cause

• Distinguishing feature

• A condition where C. albicans overgrow leading to throat/mouth pain and white patchy spots all over

• Immunocompromised patient or patient on broad spectrum antibiotics affecting normal flora

• The white is a pseudomembrane, able to be scraped off

Oral Hairy Leukoplakia

• What is it

• Cause

• Distinguishing feature

• White/fluff patches found often on the lateral side of the tongues

• Caused by epstein-barr virus in immunocompromised patient(Age, cancer treatment, AIDS)

• White patches non-scrapable

Mallory-Weiss Tears

• What is it?

• Cause

• Symptoms

• Treatment

• A tear down the Y-axis at the gastroesophageal junction

• Caused by prolonged/forceful vomiting, often in alcoholic patients

• Hematemesis

• Usually self-resolves rapidly

Chemical esophagitis

• What is it

• Cause

• Symptoms

• Damage to the squamous mucosa of the epithelium

• Caused by many possible things, such as hot fluids often, smoking, alcohol, or medicinal pills getting lodged and dissolving at strictures

• Odynophagia always, bleeding can happen too

HSV, CMV, Candida esophagitis key info

• HSV esophagitis can occur in healthy/immunocompromised patients, shows up as punched out ulcers

• CMV esophagitis has larger wounds due to the virus targeting blood vessels + Owl’s eye inclusion

• Candida esophagitis: Extension of what we alr learned

Esophageal varices

• What is it

• Cause

• Symptoms

• Dilation and การคดเคี้ยว of esophageal veins

• As a result of portal hypertension, like cirrhosis, where the pressure is so high that blood needs to find other ways back to the heart

• Hematemesis/melena if a hemorrhage happens, and it can be fatal

Reflux esophagitis

• What is it

• Cause

• Symptoms

• Gross findings

• A part of GERD, or กรดไหลย้อน, where acid refluxes from stomach and into the esophagus

• Due to relaxed LES tone, and if chronic, it can cause metaplasia of the squamous cells into columnar goblet cells in a condition called Barrett’s esophagus, and due to the increased division, this can lead to esophageal adenocarcinoma

• Chest pain, dysphagia, heartburn, postprandial regurgitation(เรอเปรี้ยว)

• Red, กำมะหยี่ cells up past the gastroesophageal junction

Acute gastritis

• Cause

• Mechanism(Simple)

• Symptoms(2)

• Anything sudden/severe like burns, trauma, alcohol binges

• Damage > defense rapidly

• Pain, bleeding/anemia

H, pylori

• What is it

• Stages

  • Timeline

  • Mechanism

  • Symptoms

• A gram negative bacteria that survives by producing urease and living at the epithelial surface

• Stage one: Antral-predominant

  • D-cells are targeted, gastrin inhibition lifted, too much acid is produced

  • Peptic ulcers can form as a result(Can cause peptic ulcer disease) and can cause MALT lymphoma from the inflammation

  • Often asymptomatic aside from ulcers that happen

• Stage two: Multifocal atrophic gastritis

  • Spreads more, but in a patchy pattern to the body/fundus, causing hypochlorhydria due to damage of parietal cells, and can also cause gastric adenocarcinoma via intestinal metaplasia

  • Symptoms actually resolve due to less acid, but found once the cancer gets advanced

Autoimmune gastritis

• What is it

• Mechanism/symptoms

• An autoimmune disease with anti-parietal and anti-intrinsic factor antibodies

• This leads to loss of HCl due to destruction of parietal cells, and also loss of intrinsic factor → B12 deficiency

  • G-cells increased(Hypergastremia) as negative feedback

  • Megaloblastic anemia

Why do NSAIDs cause peptic ulcer disease?

NSAIDs inhibit COX, COX produces prostaglandin(PGE2) that makes mucus/bicarbonate

What happens if PUD gets to the point of perforation?

• Sign

• Result

• Air under diaphragm(Will be able to see diaphragm line then black under it due to the perforation

• Can be fatal!

What type of metaplasia does chronic gastritis cause?

Intestinal

Most common benign esophageal tumor

Leiomyoma(Smooth muscle benign tumor)

How long does a Barrett’s esophagus have to be for it to have high risk of dysplasia?

>3cm

Esophageal adenocarcinoma

• Cause

• What do these cells produce

• Symptoms

• From Barret esophagus, even more so due to obesity-related GERD

• Produces mucin, because they are now glandular epithelium(columnar/intestinal-type)

• Can be asymptomatic and found on workup, but if symptomatic, can cause progressive dysphagia and vomiting(a mass in the lumen), weight loss(patients eating less, tumor releasing cytokines), hematemesis(tumor tissues have poorly formed blood vessels, often leak), chest pain/pain(tumor necrosis, invasion into sensitive areas)

Squamous Cell Carcinoma

• What is it/cause

• Demographic

• Symptoms

• A cancer that occurs typically in the middle 1/3 of the esophagus, arising from the squamous cells, due to things like alcohol, tobacco, hot beverages, basically damage in general

• More common in Asian populations

• Very similar to adenocarcinoma

Which lymph nodes do cancer from the esophagus metastasis to?

1. Upper

2. Middle

3. Lower

1. Upper = cervical

2. Middle = mediastinal, paratracheal, tracheobronchial

3. Lower: Celiac, gastric

Treatment difference of adenocarcinoma and squamous cell carcinoma

AC: Not radiosensitive, focus on chemo then surgery

SCC: Radiosensitive, surgery can still be done

Gastric Adenocarcinoma

• Cancer of the stomach’s glandular epithelium split into two types, intestinal and diffuse

  • Intestinal: Due to H. pylori, forms bulky masses

  • Diffuse: No precursor, doesn’t form bulky mass because of loss of E-cadherin, so cells don’t stick together

Gastric cancer is more common at the ___ curvature

Lesser

Gastric adenocarcinomas are hard to ___, which means that they are often discovered when symptoms are ___

Hard to distinguish from PUD, which means that they are often discovered late when symptoms like weight loss, anorexia, early satiety show up

Gastric Lymphoma

• Alternative name

• What is it, cause, and nuance

• Fast or slow

• Also called a MALToma

• It’s a cancer of lymphoid tissue that happens due to sustained chronic inflammation, a main trigger being H. pylori, which means they can be resolved if the H. pylori is eradicated

  • However, they can also mutate into things like DLBL and be no longer H. pylori dependent

• Indolent

Well-Differentiated Neuroendocrine Tumor

• What is it

• Causes

• Secretions

• A tumor from neuroendocrine cells(like G cells)

• Can be caused by conditions like autoimmune chronic atrophic gastritis(aka the autoimmune disease we talked about earlier) because it stimulates G cells to produce more gastrin since we have less gastric acid due to the parietal cells being killed

  • Zollinger-Ellison syndrome(Gastrin secreting tumor), MEN-1

• Can secrete gastrin(In Zollinger-Ellison for example), or serotonin

Gastrointestinal Stromal Tumor(GIST)

• What cell is it coming from?

• What is it, cause, and symptoms

• Treatment

• From interstitial cells of Cajal, the pacemaker cells of the GI

• Mesenchymal tumor arising from mutations in receptor tyrosine kinase called KIT(or rarer, PDGFRA) which causes proliferation, causing bleeding(due to the tumor itself) presenting as IDA or melena or hematemesis, and things due to the mass itself like abdominal pain, early satiety, a palpable mass, weight loss/fatigue, but some are asymptomatic

• Treated by imatinib(If KIT/PDGFRA