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Upper GI Disorders and Management

Examples of functional GI and motility disorders which affect the upper GI tract, from the esophagus to the stomach, include:

Achalasia

Achalasia is a motility disorder in which the esophagus (food tube) empties slowly. The delay results from poor opening of the lower esophageal sphincter (valve) in association with the loss of the normal, orderly muscle activity (peristalsis) that propels foods and liquids along the esophagus into the stomach.

Achalasia results from the nerves in the esophagus and lower esophageal valve being damaged or destroyed. Most cases are idiopathic, meaning the cause is unknown. The origin may possibly be viral or autoimmune, and rarely it may be due to a cancer.

Symptoms of Achalasia

The symptoms of achalasia most often occur during and after a meal. All individuals experience the sensation of solids, and usually liquids, hanging up and passing slowly into the stomach. This may occur several times a week or at every meal.

Effortless regurgitation of bland, undigested food or whitish foam (saliva) is common and may be associated with coughing and choking at night. Some people experience chest pain, and heartburn is common. This heartburn is not related to acid reflux into the esophagus, but rather due to retained acidic food or the fermentation of food in the esophagus.

Treatment of Achalasia

The goal of treating achalasia is to disrupt and open the lower esophageal valve to improve esophageal emptying and relieve symptoms. Unfortunately, no treatment is available to promote the return of peristalsis.

The best treatments for healthy patients are pneumatic dilatation or laparoscopic Heller myotomy. Frail or elderly patients may do well with botulinum toxin (Botox) injections.

Treatment markedly relieves symptoms, but is rarely curative. Overall, the success of both the pneumatic dilation and heller myotomy procedures is 80%-90% and dependent on the skills of the operator. Retreatment may be required and alternative treatments may be needed.

  • Pneumatic dilatation – This procedure involves upper GI endoscopy with the passage of various size balloons to tear the esophagus from within, opening the valve. The procedure is done with conscious sedation and takes about 30 minutes, with a loss of one day of activity. The major complication, esophageal perforation (hole in the esophagus), is rare (less than 5%), but will require major surgery.
  • Heller myotomy – Surgery for achalasia involves cutting the muscle (myotomy) from the outside via small laparoscopic sites on the abdomen. The procedure requires general anesthesia, hospitalization for up to two days, and limited activity for two weeks. The major side effect is cutting the muscle too much, causing bad acid reflux.
  • Botulinum toxin – Botox can be injected into the esophagus and lower esophageal valve, via a needle passed through an upper endoscope. The toxin relaxes the sphincter, and thereby relieves symptoms. In young patients, symptoms relief is generally for only 3-6 months, while older patients may have relief for one year or longer. Adverse events are rare.

Medications may also be tried to relax the lower esophageal sphincter when surgery or pneumatic dilation is not an option, or Botox therapy has failed. Calcium channel blockers and long-acting nitrates are commonly used.

Cyclic Vomiting Syndrome (CVS)

Cyclic vomiting syndrome (CVS) is a disorder with repeated episodes of severe nausea and vomiting that alternate with symptom free periods. It occurs in children and adults.

What are the signs and symptoms of CVS?

The symptom episodes tend to follow the same pattern in each person with CVS over time. There are typically four phases:

  • The first phase is relatively symptom-free. It occurs between vomiting episodes and usually lasts weeks to months.
  • During the second phase the coming on of an episode is felt. There is nausea, but oral medicines may still be taken. This phase lasts minutes to hours.
  • In the third phase there is intense nausea and vomiting, and an inability to eat, drink, or take medicines without vomiting. Other symptoms may include belly pain, hot sweats, cold chills, headache, sensitivity to light and sounds, and diarrhea. The person may be drowsy and withdrawn. This phase lasts from hours to days.
  • In the fourth phase, recovery begins with the settling down of symptoms and ends with going back to a normal diet and a return to the relatively symptom-free period.

Treatment

In general, treatment includes avoiding potential triggering factors, taking medicines to prevent episodes or reduce symptoms, and getting supportive care during episodes.

Triggering factors like stress, anxiety, or certain foods will vary between persons. Try to identify and avoid triggers.

Drug treatments may be divided into short-term treatment of the vomiting episodes and long-term treatment to try to prevent the episodes. In the short term, antiemetic agents can reduce nausea and vomiting. Antianxiety and antimigraine medications may also help. Long term, antidepressant can help prevent nausea and vomiting. Other medicines may also be used as preventive therapies.

Continual vomiting can cause other problems, which need to be treated as well. Examples include loss of fluids (dehydration), electrolyte imbalance, and irritation of the esophagus (food tube).

Dyspepsia

Dyspepsia, also called indigestion, may include symptoms like upper abdominal pain, upper abdominal burning or heat and the stomach feeling full during, or painfully full after, eating.

While dyspeptic symptoms may develop due to diseases such as peptic ulcer or gastritis, the vast majority of people who see doctors for dyspeptic symptoms are ultimately diagnosed as having functional dyspepsia.

Functional dyspepsia (FD) is a heterogeneous disorder; in other words a variety of causes can lead to similar symptoms. Some studies suggest that FD is a chronic condition for many people, with approximately 50% of patients still experiencing symptoms over a 5-year follow-up period.

Treatment Options

Treatment options for functional dyspepsia generally include one or a combination of:

  • Diet
  • Eradication of H. pylori
  • Acid-lowering medications
  • Prokinetic and antiemetic agents
  • Centrally acting therapies

Diet – Most patients with FD have symptoms associated with the ingestion of food. As such, a variety of dietary recommendations are often made, although no clinical trials have formally evaluated specific dietary interventions for the treatment of FD. There are limited data to suggest that dietary fat may induce or exacerbate symptoms and patients often report improvement by eating low-fat meals, and more frequent, smaller meals.

Eradication of H. pylori – Although testing and treating H. pylori infection is recommended and often employed, the eradication of H. pylori infection generally does not improve symptoms outside of those associated with peptic ulcer disease.

Acid-lowering Medications – H2 blockers are the initial agent used by many primary care providers, and are marginally better than placebo at improving upper-center abdominal (epigastric) pain, although they do not improve other dyspeptic symptoms.

If H2 blockers fail to improve symptoms, most doctors then use a proton pump inhibitor (PPI) Short-term risks of this strategy are low, and this may provide relief of symptoms in a small number of people, many of whom may have had silent acid reflux. As a group, PPIs are approximately 10% better than placebo at improving dyspeptic symptoms.

Centrally Acting Therapies – Much of the control of digestive function and sensation is under central nervous system guidance; therapies that target central control mechanisms may have value in relieving symptoms. Tricyclic antidepressants, used in doses lower than required to treat depression, may improve symptoms of dyspepsia in patients who have failed to benefit from treatment with H2 blockers or prokinetics.

Hypnotherapy may improve dyspeptic symptoms in some patients, and a recent study found that hypnotherapy was better than medical therapy and supportive therapy at improving quality of life and symptom scores. Although not well studied, psychological therapies, including cognitive behavioral therapy, may also relieve symptoms of dyspepsia.

Gastroparesis

Gastroparesis is a disorder characterized by symptoms and in which the stomach takes too long to empty its contents. No obstruction or blockage is evident.

In most people diagnosed with gastroparesis, the cause is unknown (idiopathic). Diabetes is the most common known cause of gastroparesis. The condition can also result as a complication from some surgical procedures, from taking certain medications, and from certain other illnesses.

Gastroparesis Treatment

The treatment for gastroparesis in an individual depends on the severity of symptoms. Treatments are aimed at managing symptoms over a long-term.

Treatment approaches may involve one or a combination of:

  • Dietary and lifestyle measures,
  • Medications, and/or
  • procedures that may include surgery, such as
  • Enteral nutrition,
  • Parenteral nutrition,
  • Gastric electrical stimulation (Enterra), or
  • Other surgical procedures

Some people with gastroparesis have mild symptoms that come and go, which can be managed with dietary and lifestyle measures.

GERD

GERD, or gastroesophageal reflux disease, develops when the back-flow (reflux) of stomach contents causes troublesome symptoms and/or complications. Serious health problems can result if it is not treated properly.

The most frequent symptoms of GERD, heartburn and acid regurgitation, are so common that they may not be associated with a disease. Self-diagnosis can lead to mistreatment. Consultation with a physician is essential to proper diagnosis and treatment of GERD.

Treatment for GERD includes:

  • Lifestyle and dietary changes
  • Medication
  • Endoscopic therapy
  • Surgery

Lifestyle and Dietary Changes

Dietary and lifestyle changes are the first step in treating GERD. Certain foods make the reflux worse. Suggestions to help alleviate symptoms include:

  • Lose weight if you are overweight — of all of the lifestyle changes you can make, this one is the most effective.
  • Avoid foods that increase the level of acid in your stomach, including caffeinated beverages.
  • Avoid foods that decrease the pressure in the lower esophagus, such as fatty foods, alcohol and peppermint.
  • Avoid foods that affect peristalsis (the muscle movements in your digestive tract), such as coffee, alcohol and acidic liquids.
  • Avoid foods that slow gastric emptying, including fatty foods.
  • Avoid large meals.
  • Quit smoking.
  • Do not lie down immediately after a meal.
  • Elevate the level of your head when you lie down.

Globus

Globus (Latin for globe or ball) is the sensation of a lump or ball in the throat, typically felt in the throat at the level of the Adam’s apple. It is commonly experienced with an intense emotional experience. The “globus response” is a common human experience. Globus seems equally prevalent in men and women.

Causes of Globus

As with all the functional gastrointestinal disorders, the cause of the globus sensation is unknown. Hypersensitivity of the upper esophagus is suspected. One observer suggested that nervousness leads to a dry mouth, repeated swallowing, and enhanced awareness of the throat.

Distinguishing Globus from Other Conditions

From a medical point of view, it is important to distinguish the globus sensation from dysphagia, or difficulty swallowing. Unlike globus, dysphagia usually indicates a demonstrable cause, and mandates investigation of the esophagus. Heartburn commonly occurs with globus, as it does in people generally. However, the two conditions do not appear to be causally related, and treatment of heartburn does not reliably benefit the globus.

Globus uniquely occurs between meals, and is somewhat relieved by swallowing something, often a glass of water. On the other hand, dysphagia occurs during the swallowing of food or sometimes liquids. It gives the sensation that something is stuck in the gullet – often below the throat. An attempt to swallow in this situation seems to make things worse.

“Red Flag” Signs and Symptoms that may indicate a More Serious Disorder

  • Neck or throat pain
  • Bleeding from the mouth or throat
  • Weight loss
  • Pain or difficulty on swallowing
  • Muscle weakness
  • Mass in the throat or mouth confirmed by a doctor’s examination
  • Progressive worsening of the symptom

Treatment of Globus

By itself, globus seldom indicates a structural disease, that is a disease where damage to the body can be demonstrated. Nevertheless, any accompanying symptom must be investigated as indicated. There is no specific treatment for globus beyond the assurance that it isn’t the sign of a serious disease.

Should you require additional information or would like to make an appointment with our Consultant General surgeon, Dr. Majid Bassuni ,please call us or e-mail us at info@westminsterclinic.ae

Reference:

  • Iffgd.org – International Foundation for Gastrointestinal Disorders
  • hopkinsmedicine.org
  • National Institute of Diabetes and Digestive and Kidney Diseases
  • gastro.org: American Gastroenterological Association

Disclaimer: All contents on this site are for general information and in no circumstances information be substituted for professional advice from the relevant healthcare professional, Writer does not take responsibility of any damage done by the misuse or use of the information.

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