1DDX: LECTURE 26 – JANUARY 12TH 2007

GASTROINTESTINAL DISORDERS: ESOPHAGUS, STOMACH AND DUODENUM

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ESOPHAGEAL WEBS, RINGS AND STRICTURES

Can only differentiate these conditions through biopsy. Legal obligation for biopsy to be taken when lesion observed in esophagus.

Ring: consists of all 3 layers of tissue (includes muscle), whereas web is muscosa and sub-mucosa only.
Stricture: can be 1, 2, or 3 layers. The lumen of the esophagus is REDUCED in this case. Web and ring will not necessarily produce a stricture.
These are often due to scarring from acid reflux. Patients may be asymptomatic at beginning (could be many years), or may be minor (ear, throat, chest
pain).

Many congenital disorders can produce comparable symptoms.

Plummer vinson syndrome: result of iron deficiency anemia, not acid reflux
Mediastinal irradiation: result of cancer treatment.

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To DDX from cancer, have to do a CAT scan. Even if a biopsy is taken, the area involved may not be sampled. May not get cancerous area. You can
see what is happening OUTSIDE of the esophagus with a CAT scan and see if there is involvement of other structures.
R/o = “rule out”

PLUMMER VINSON SYNDROME

Iron deficiency anemia (most of the time): sometimes associated with AI conditions.
With AI condition: have to do full work-up as symptoms can occur anywhere.

SCHATZKI’S RING
Unknown etiology. Correlated with GERD primarily. Possibly same etiology, link with acid reflux?
Non-progressive, intermittent condition. Depends on size of stricture.
Treatment: avoid large meals. May attempt dilation of ring, by inserting metal rods. Can help, but problem may come back. Will have to break ring for
more permanent solution. Surgical solution.
Benign problem, but causes a lot of problems. Invasive treatment options.

PEPTIC ESOPHAGEAL STRICTURE

Progressive inflammation, ulcer formation.
Makes body deposit collagen in areas, producing strictures.
Same treatments as above.

CARCINOMA OF THE ESOPHAGUS

Increase over past 15-20 years, related to increased use of antacids.
2 most common types are squamous cell carcinoma and adenocarcinoma
Related to smoking, alcohol, vitamin deficiency, Barrett’s esophagus in 50% of cases, nitrosamines (cured meats)
Patients may not have symptoms, they may not feel “well”, minor symptoms. May be allowed to progress, palliated with antacids.
enlarged supraclavicular node

Precancerous lesions of the esophagus: these conditions may lead to cancer: have to monitor. Important for us to know that these conditions are
precancerous: we can help with lifestyle choices that reduce their risk: dietary changes (anti-cancer diet), smoking cessation, have to make sure they
don’t have any food allergies/sensitivities (IgG test for food sensitivities). They should avoid foods that cause inflammation: cancers are influenced by
chronic inflammation. We can do IgG tests, but if an allergist orders them, OHIP pays.

Barrett’s esophagus, Lye stricture, Tylosis, Plummer-Vinson syndrome, Celiac sprue, Zenker’s diverticulum, Achalasia, Chagas disease.

Naturopathic intervention may provide more options than conventional treatments. Hard work, requires commitment of patient.

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ACHALASIA
Patients lack inhibitory cells therefore LES is spastic. Food will sit in the esophagus for days.
“Bird’s beak” appearance of lower esophagus (know this for exam: characteristic feature)
This occurs over time, individual progression depending on lifestyle factors.
Weight loss: food is not being absorbed. Constant state of malnutrition.
Regurgitation of old food.
Treatments are supportive measures. Can’t replace the missing plexus. More recent treatment with botulinum toxin, cutting muscle of sphincter to keep
it open.

DIFFUSE ESOPHAGEAL SPASM

Food isn’t propelled downwards. There is a spasm, but it doesn’t do anything to the food. Produces pain and irritation.
Intermittent dysphagia for both solids and liquids. Strong spasm will stop passage of water.

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ESOPHAGEAL VARICES
Problem secondary to portal hypertention: normally don’t have primary esophageal varices.
Increased risk of bleeding due to rupture, flow chart of how portal hypertension produces varices.

DDX LECTURE 26, JANUARY 12TH, 2007 – PAGE 1

ESOPHAGEAL TEARS
Longitudinal tears that can occur in esophagus d/t sudden increase pressure in LES (violent or chronic vomiting, extreme cough). Something that
happens very forcefully.
Most cases are due to intense vomiting (for many different reasons)
Only solution is surgical. Tears can progress if not sutures, can lead to transmural rupture of the esophagus.
Need to know WHY this happened: what lead to tear? Why are they vomiting? Get to source of problem. Can be observed in bulimics.

BOERHAAVE’S SYNDROME
Transmural tear. There is probably some kind of weakness at esophageal level, maybe other places too, could be due to vitamin deficiency. If the wall
is weak, even pressure from normal vomiting will cause rupture.
Medical emergency! Acid, food etc., entering the body will cause infection, damage. Bleeding.

Small groups: Create picture of patient with condition from notes

GERD gastro esophageal reflux disorder (signs and symptoms)

Heartburn radiating up/down thorax, (ddx angina)
Occurs within 1.5 hours after meal.
Chest pain, substernal radiate to back neck, jaw
Dysphagia for solids
Regurgitation
Full feeling in throat
Non-productive cough
Hoarseness.
Solids

A 37 year-old male comes in complaining of intermittent pain, radiating up and down the chest and to the left arm and jaw. He has had a chronic
cough for the last year. This is his first visit to a doctor to address this problem.

Physical exam findings: 6’2”, 340lbs. BP: 140/100

His daily diet consists of the following:

Breakfast: Fried eggs and bacon with onions, toast and butter with coffee (total of 6 cups per day).
Lunch: McDonald’s Big Mac with fries.
Dinner: 2 beers and a bottle of wine with spaghetti and meatballs.

You observe that the patient clears his throat throughout your visit with him.

What condition would you suspect? GERD

What would be on your DDX list? Angina, MI.

Class cases:

#1
10 years old, at 6 months, difficultly breast feeding, started vomiting breast milk. When he started eating solids, would vomit too. Still has same problem
with food: vomits after every meal, 1-5 times. Seems to be coming from esophagus. Patient is underweight and malnourished.
Tests: has had barium swallow.
Diagnosis? Achalasia.
This is a congenital problem, starts in infancy.

#2
25 year old female, Italian descent. GI problems, pain swallowing. Pain in throat, distension after eating her mother’s lasagna. She is vegan, her skin is
pale, hair is brittle, she has scanty periods, her energy is 6/10. She has lost 20lbs in the past year. She experiences palpitations during your cardio
exam. Blood pressure is 120/60, 16 breaths per minute.
Diagnosis: Plummer Vinson syndrome from iron deficiency anemia.
Confounding etiology? Celiac disease.

#3
Visit with grandmother in nursing home over Christmas. At dinner, she couldn’t swallow most of the turkey, and you remember that had same problem at
Thanksgiving. She says the condition hasn’t gotten worse.
You remember that growing up, she was always the first to finish eating, and would jump up from the table to make dessert.
Takes antacids while talking. Dentures don’t fit her
Not chewing food properly?
Reassure her it is benign.
Thickening area of ring around esophagus. Shatski’s ring.

#4
Sexually active female. Epigastric pain during vomiting. 7 days. Poor diet.
Esophageal tear.

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STOMACH PHYSIOLOGY
Review: see notes.
DDX LECTURE 26, JANUARY 12TH, 2007 – PAGE 2
Mucous cells are the first to be disrupted. Provide protection.
Gastric ulcer and carcinoma are tightly linked.

*Hypoacidity will produce the same symptoms as hyperacidity: produces same disruption to protective barrier.

If you have normal pH, H. pylori will not be able to exist (pH 1-2). H. pylori infection can only be due to hypoacidity. This will allow the bacteria to burrow
into mucosa, produces urease, cytotoxic substances. Creates halo of less resistance around bacteria. Will lead to ulcers, gastritis, cancer.
H. pylori has also been associated with skin rashes such as rosacea, sclerosis, lots of others (see notes)
You may not realize that the skin conditions are associated with an H. pylori infection.
With low HCl, there is dysbiosis (disruption in the normal concentration of the bacteria of GI) along the GI tract. This will lead to many other problems:
leaky gut syndrome, inflammation of SI, LI.
Damage to mucosa may lead to passage of contents to the rest of the body  allergic reaction, systemic inflammation, which can lead to vascular
problems, (ischemic heart disease, primary raynaud’s phenomenon, primary headache, alopecia areata)
Others are autoimmune: Sjogren’s syndrom, autoimmune thyroiditis, authoimmune thrombocytopenia, schoenlein-Henoch purpura
Others: Liver cirrhosis, growth retardation, chronic idiopathic sideropenia, sudden infant death syndrome (passed from mother d/t antibiotic treatment,
direct contact), diabetes mellitus.

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Another important association with H. pylori is with chronic bronchitis, TB, bronchiectasis, lung cancer, bronchial asthma
H. pylori can lead to development of bronchiectasis: pockets of dilation in bronchioles, poor air transfer, mucous accumulation, bouts of coughing with
lots of sputum.

H. pylori infection can be a reason for failure to thrive, especially in boys (unknown reason)
Systemic effects of H. pylori: release of pro-inflammatory cytokines (IL-1, TNF-alpha), inflammation everywhere in the body.
Allopathic treatment is 2 antibiotics: amoxicillin and omeprazole and a proton-pump inhibitor for 7 days. This will possibly kill the H. pylori, but it will
come back if the underlying cause is not addressed.

What can we do naturopathically for these patients?

Re-establish HCl: stimulate parietal cells (could use bitters), use demulcents (slippery elm, marshmallow)
Garlic, turmeric, capsicum, oregano oil.

DDX LECTURE 26, JANUARY 12TH, 2007 – PAGE 3