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Disorders of upper gastrointestinal tract

Description

The gastrointestinal tract (GI) extends from the mouth to the anus. It is divided into upper and lower GI tracts. The upper gastrointestinal tract encompasses the mouth, oesophagus, stomach and duodenum, the first part of the small intestine. There are many diseases of the upper digestive tract; some of which include hiatal hernia, gastritis, ulcers, gastro-oesophageal reflux disease (GORD), Barrett’s oesophagus, and mouth, oesophageal, gastric and small intestinal cancers.

Causes

Some of the causes of upper gastrointestinal disease include inflammation, smoking and alcohol consumption, long-term use of medications, bacterial infections and excess secretion of digestive fluids.

Impact

Disorders of the upper gastrointestinal tract can significantly impact your health. The symptoms can substantially affect your quality-of-life and psychological wellbeing. Conditions such as GORD can severely interfere with your life as it can hinder a good night’s sleep, thereby affecting alertness and productivity the next day. Common symptoms such as heartburn and nausea can significantly interrupt your life.

Anatomy

The gastrointestinal system is a long tube with specialised sections that are capable of digesting and extracting useful components entering the mouth and expelling waste products from the anus. The upper gastrointestinal region of the body encompasses the mouth, oesophagus, stomach and duodenum. Food is chewed and mixed with saliva in the mouth and swallowed. It then enters the oesophagus (food pipe), a long, narrow tube. The food pipe is lined by muscles that expand and contract, pushing food into the stomach. The stomach secretes acid and other digestive enzymes for digestion and stores food before it enters into the intestine. The duodenum is the first part of the small intestine attached to the stomach which helps in digestion.

Symptoms

Symptoms of upper gastrointestinal diseases vary depending upon the condition. Some of the symptoms include difficulty swallowing, nausea, vomiting, heartburn, difficulty in the passage of food, belching, bloating, regurgitation of food and loss of appetite.

Diagnosis

Your doctor may order some of the following tests to diagnose upper gastrointestinal diseases:
  • Upper GI endoscopy or esophagogastroduodenoscopy: examination of the upper digestive tract using an endoscope, a thin tube with a camera on the end. The endoscope is inserted down your throat and into your oesophagus, stomach or small intestine to detect the problem.
  • Upper GI series: involves swallowing a barium preparation, which can be detected through X-rays.
  • Twenty four-hour pH monitoring: involves inserting a tube with a sensor through your nose and extending it till the lower oesophageal sphincter (muscles present at the junction of the oesophagus and stomach) to measure the pH of its contents. The tube is left there for 24 hours to detect level of acids, which can indicate reflux of stomach’s acids into the oesophagus (GORD).
  • Impedance study: requires two probes; one is placed in the stomach and the other just above it. The dual sensor helps to detect both acidic and alkaline reflux.
  • Biopsy: sample of tissue removed through endoscopy to further examine in the lab.
  • Imaging tests such as PET (positron emission tomography), CT (computed tomography), MRI (magnetic resonance imaging) and ultrasound.

Treatments

Treatment depends on the condition and its progression. Several treatment options are available, some of which are mentioned below.
  • Medication: prescription and over-the-counter medicines including antacids provide relief to heartburn and indigestion by neutralizing the acids in the stomach. Antibiotics are prescribed to treat infections.
  • Lifestyle changes: change in diet, eating smaller and more frequent meals, avoiding smoking and excess intake of alcohol.
  • Endoscopic resection: cancerous tissue removal with the help of an endoscope, which is inserted through the mouth and extended to the concerned area. Surgical tools passed through it help in cutting and excising the cancerous tissue. When lesions or cancer involves only the top layer of the oesophagus, the lining is lifted by injecting a solution under it or by suction, and cut by a procedure called endoscopic mucosal resection. Endoscopic resection is non-invasive and does not involve any incisions on the body.
  • Balloon dilation of the oesophagus: A deflated balloon is passed through an endoscope and inflated at the constriction in the oesophagus to allow the free flow of food.

Prognosis

The outcome of treatment varies from person to person. Some may experience mild symptoms while others may have a complete cure. Lifestyle changes and medications can drastically improve your symptoms and your quality of life. Surgical intervention is also associated with optimal results and success in relieving symptoms.

Untreated

If upper gastrointestinal diseases are left untreated, it can lead to serious complications such as severe loss of blood, ulcers, inflammation of the upper digestive tract, pulmonary aspiration, cutting off the blood supply to the stomach, narrowing of the oesophagus and may increase the risk of developing stomach cancer. Some people develop Barrett’s oesophagus, a condition characterised by changes in the oesophageal lining, which can lead to oesophageal cancer.

The Treatment

Surgery

When non-invasive methods fail, surgery is recommended. Surgeries are performed on an outpatient basis under general anaesthesia. Surgeries can be performed through open, laparoscopic or robotic methods. While open surgery involves a large incision on the chest or abdominal wall (depending on the region of disease), laparoscopy and robotic surgery are minimally invasive techniques performed through tiny incisions through which a long tube with a camera and other surgical instruments are inserted. The robotic method is performed with the help of robotic arms controlled by your surgeon on a console, to ensure precision and accuracy during a procedure.

Procedure

Laparoscopic Nissen fundoplication (LNF) During the procedure, your surgeon wraps the upper part of the stomach, the fundus, around the lower oesophagus to create a valve, suturing it in place. It prevents stomach acid and food from flowing back into the oesophagus and is indicated for GORD and hiatal hernia. The incisions are closed and covered with small bandages.

Cancer resection Cancers of the upper gastrointestinal tract may be treated with surgical removal of the cancer and a surrounding margin of healthy tissue. Some of the common surgeries involved are gastrectomy for stomach cancer, oesophagectomy for oesophageal cancer, and transoral surgery for outh or throat cancer. The surgery aims at treating cancer by surgically removing the whole or part of the organ affected along with a margin of healthy tissue. Most often, affected adjoining tissues, organs and lymph nodes are also resected to ensure complete elimination of the cancer and to prevent spread to the rest of the body.

Hiatal hernia repair In this procedure, the hiatal hernia, stomach bulging though the hiatus (hole in the diaphragm, which allows the oesophagus to open out into the stomach) is pushed back to its correct position and the opening of the hiatus narrowed.

Heller myotomy Heller myotomy is a surgical procedure performed to open tight sphincter muscles by cutting the thick outer muscle from the oesophagus to the stomach. This is usually followed by a partial fundoplication to prevent reflux following the surgery. The surgery allows food to pass easily into the stomach.

Post–operative information

After surgery, you should keep the incision area clean and dry, and not shower or bathe until your doctor tells you. You may feel soreness around the incision areas. Your surgeon will prescribe pain medicine or non-steroidal anti-inflammatory drugs (NSAIDs) for the first few days to keep you comfortable. If the abdomen was distended with gas, you may experience discomfort in the abdomen, chest, or shoulder area for a couple of days while the excess gas is being absorbed. Contact your doctor immediately if you have a fever, vomiting, chills, increased pain, bleeding or fluid leakage from the incisions, chest pain, shortness of breath, leg pain or dizziness.

Benefits of this approach

Surgical management of upper gastrointestinal conditions can provide considerable relief from symptoms and improve your quality of life.

Preparation

Before upper gastrointestinal surgery, you will be given specific instructions as to your diet. You may be instructed not to eat or drink anything or to be on a liquid diet prior to the procedure. Your surgeon will also tell you what medications you can take and which ones to avoid.

Outcome

Most often, upper gastrointestinal surgery results in positive outcomes where you obtain complete relief from your symptoms. However, as with any surgery, they may involve certain risks and complications which include fever, infection, injury to adjacent nerves, blood vessels and organs, swallowing difficulties, gas embolism, adhesions (extensive scar tissue formation in the surgical area) and recurrence.

Post-op stages of recovery and care plan

After some of the procedures you will be given specific instructions with regard to your diet. You are recommended to start with soft food and slowly progress into your regular diet. You are advised not to lift heavy objects for 8 to 12 weeks after the surgery. Avoid driving for a few days after surgery. You are encouraged to start walking as early as possible to reduce the risks of blood clots and pneumonia. Your recovery after surgery will depend on the procedure and the care that you take in following your surgeon’s care plan.

Downtime - lifestyle or off work duration

Most surgeries will allow you to resume your regular activities within a week after the procedure. However, complete recovery takes around two to three weeks.

Costs

Any costs involved will be discussed with you prior to your surgery.