mallory weiss syndrome

MALLORY-WEISS SYNDROMEMALLORY-WEISS SYNDROME

Vigorous vomiting-vert split in the gastric Vigorous vomiting-vert split in the gastric mucosa (below sc jn at the cardia)- 90%mucosa (below sc jn at the cardia)- 90%

Tear in the oesophagus-10%Tear in the oesophagus-10% Presents with hematemesisPresents with hematemesis endoscopic injection therapy requird 4 severe endoscopic injection therapy requird 4 severe

casescases

CORROSIVE INJURYCORROSIVE INJURY

Corrosive-sod hydroxide,sulphuric acidCorrosive-sod hydroxide,sulphuric acid Accidental ingestion-damage Accidental ingestion-damage

2nouth,pharynx,larynx,oeso,stomach2nouth,pharynx,larynx,oeso,stomach Alkalies causeliquifaction,saponification of Alkalies causeliquifaction,saponification of

fat,dehydration and thrombosis of bv- fibrous fat,dehydration and thrombosis of bv- fibrous scarringscarring

Acids-coagulative necrosis with eschar formationAcids-coagulative necrosis with eschar formation -causes intense pylorospasm with pooling -causes intense pylorospasm with pooling

in the antrum(more gastric damage) in the antrum(more gastric damage)

Investigaion- endoscopy

-deep ulcers n black eschars-greatest risk of perforation

Managemnt-minor injury- pt safely fed

sev injury-feeding jejunostomy

Complication-stricture formation-50% (oeso resection)

GORD GORD

Loss of competence of LOSLoss of competence of LOS Competence affected-obesity,smoking n Competence affected-obesity,smoking n

excissive eatingexcissive eating Gastric acid reflux- extensive inflammmation of Gastric acid reflux- extensive inflammmation of

lower oeso- oesophagitislower oeso- oesophagitis Types-a/c – alcohol,burns,stressTypes-a/c – alcohol,burns,stress c/c – hitus hernia,oesophagojejunostomyc/c – hitus hernia,oesophagojejunostomy

PRECIPITATING FACTORS- 1.structurally defective LOS

2.short length of oesophagus

3.ineffective oesophageal pump(influenced by gravity,oeso motility,salivation)

4.increased gastric pressure

overeating/ingestion of irritants

gasrtic distension

unfolding of sphincter

terminal s epi of oeso exposed to acid

erosion,ulceration,fibrosis,metaplasia

barret”s oeso

AdenoCa

AetiopathogenesisAetiopathogenesis

Acid reflux to LOS – diffuse inflmn with Acid reflux to LOS – diffuse inflmn with multiple ulcers multiple ulcers

Symptoms worse when patient lies downSymptoms worse when patient lies down Vicious cycleVicious cycle vagal hypersensitivity – oesophagitis – vagal hypersensitivity – oesophagitis –

long muscle spasm – displacement of long muscle spasm – displacement of oesophagus – increased regurgitationoesophagus – increased regurgitation

CLINICAL FEATURESCLINICAL FEATURES

Retrosternal painRetrosternal pain Epigastric painEpigastric pain RegurgitationRegurgitation Occult blood in stoolsOccult blood in stools Anaemia & weaknessAnaemia & weakness Dysphagia(sricture)Dysphagia(sricture) Atypical symp – Angina like chest pain , pulm or Atypical symp – Angina like chest pain , pulm or

laryngeal symplaryngeal symp

DIAGNOSISDIAGNOSIS

Assume rather than prevent – Rx is Assume rather than prevent – Rx is empericalemperical

Investigations – when patient does not Investigations – when patient does not respond to ppirespond to ppi

24 hr ph recording – gold std24 hr ph recording – gold std TLOSR – manometric findingTLOSR – manometric finding Ba swallow( in trendelenburg position)Ba swallow( in trendelenburg position) OesophagoscopyOesophagoscopy

MEDICAL MANAGEMENT MEDICAL MANAGEMENT

Alcohol minimisedAlcohol minimised Loose weightLoose weight Coffee & tea minimisedCoffee & tea minimised Oeso mucosal protecters(Antacids,H2 blockers)Oeso mucosal protecters(Antacids,H2 blockers) Head up tiltHead up tilt Oily& spicy food avoidedOily& spicy food avoided Large meal avoided at nightLarge meal avoided at night PPI most effective drug Rx (8 wks)PPI most effective drug Rx (8 wks)

SURGERYSURGERY

Endoscopic treatmentsEndoscopic treatments Surgical treatments – Surgical treatments – uncomplicated gord –pt”s choiceuncomplicated gord –pt”s choice Symptomatic on PPI(volume reflux , Symptomatic on PPI(volume reflux ,

hermit lifestyle , poor compliance)hermit lifestyle , poor compliance)Laproscopic fundoplicationLaproscopic fundoplication

COMPLICATIONSCOMPLICATIONS

Barret”s oesophagusBarret”s oesophagus

StrictureStricture

Oesophageal shorteningOesophageal shortening

HIATUS HERNIA HIATUS HERNIA

Abnormal protrusion of abdominal viscus Abnormal protrusion of abdominal viscus through oesophageal hiatus into chest.through oesophageal hiatus into chest.

TYPESTYPES 1.Sliding hernia(oesophageo gastric 1.Sliding hernia(oesophageo gastric

hernia) – 80%hernia) – 80% 2.Rolling or paraoesophageal hernia 2.Rolling or paraoesophageal hernia 3.Mixed hernia3.Mixed hernia 4.Massive herniation4.Massive herniation

Common symptoms Common symptoms

1.Symptoms due to reflux(reflux &heart 1.Symptoms due to reflux(reflux &heart burn)burn)

2.Symptoms due to 2.Symptoms due to complications(dysphagia, complications(dysphagia, odynophagia,hematemesis, melaena) odynophagia,hematemesis, melaena)

3.Nonoesophageal synp(asthma & chest 3.Nonoesophageal synp(asthma & chest pain )pain )

SLIDING HERNIASLIDING HERNIA

Anatomical factors which prevent sliding Anatomical factors which prevent sliding herniahernia

1.Presence of 2 cm of intraabd 1.Presence of 2 cm of intraabd oesophagusoesophagus

2.The angle of His2.The angle of His 3.Mucosal folds at oesophageocardial jn3.Mucosal folds at oesophageocardial jn 4.+ intraabd pressure4.+ intraabd pressure 5.LOS5.LOS

Causes Causes

1.The position of fatty tissue in the hiatus1.The position of fatty tissue in the hiatus 2.Advancing age – mus degeneration2.Advancing age – mus degeneration 3.Lower abd trs , preg – raised intraabd 3.Lower abd trs , preg – raised intraabd

pressurepressure 4.Saint”s triad- Gallstone , diverticulosis, 4.Saint”s triad- Gallstone , diverticulosis,

hiatus herniahiatus hernia

CF

like reflux oesophagitis

commom in women,obese

INVESTIATIONS

Oesophagoscopy- reflux of the gastric acd – most valuable sign.

Ba meal- gord in trendelemburg

TREATMENT 1.Conservative treatment

Principles:

1.Lifestyle changes

-decrease in wt

-Diet cntrol

-decreasd alcohol n tobecco consumption

2.Oesophageal mucosa protection

-Antacids

-H2 blockers

-PPI

3.Reflux prevention

Surgery Surgery

IndicationsIndications -Intractable pain-Intractable pain -Complication –hge or stricture-Complication –hge or strictureTypes of surgeryTypes of surgery1.Nissen”s total fundoplication1.Nissen”s total fundoplication2.Partial fundplication(Tupet)2.Partial fundplication(Tupet)3.Belsey mark IV operation3.Belsey mark IV operation4.Hill”s repair4.Hill”s repair

ROLLING HERNIAROLLING HERNIA

Cardio –oeso jn is normal.Cardio –oeso jn is normal. Greater curvature of stomach ascends into Greater curvature of stomach ascends into

a preformed sac in mediastinum.a preformed sac in mediastinum. Compression of heart & lung.Compression of heart & lung.

Clinical FeaturesClinical Features

No retrosternal burning painNo retrosternal burning pain Discomfort after a small mealDiscomfort after a small meal Feeling of fullness after meal or dysphagiaFeeling of fullness after meal or dysphagia PalpitationsPalpitations RTI or hiccough (phrenic nerve irritation)RTI or hiccough (phrenic nerve irritation)

InvestigationInvestigation

Ba mealBa mealRxRx Reduction of sac &repair of hiatusReduction of sac &repair of hiatus MIXED HERNIAMIXED HERNIABoth rolling & sliding hernia +Both rolling & sliding hernia +Symptoms & Rx - mixedSymptoms & Rx - mixed

BARRET”S OESOPHAGUSBARRET”S OESOPHAGUS

When columnar mucosa extends at least 3 When columnar mucosa extends at least 3 cm into oesophaguscm into oesophagus

Intestinal metaplasia Intestinal metaplasia PathogenesisPathogenesis Rptd reflux –Shifting of oesogastric jn Rptd reflux –Shifting of oesogastric jn

upwards – Further increase in reflux – upwards – Further increase in reflux – Intestinal metaplasia of middle & lower Intestinal metaplasia of middle & lower oesooeso

PATHOLOGICAL TYPESPATHOLOGICAL TYPES

1.Gastric type – Chief & parietal cells1.Gastric type – Chief & parietal cells 2.Intestinal type – Goblet cells2.Intestinal type – Goblet cells 3. junctional type – Mucous glands3. junctional type – Mucous glands CLINICAL TYPESCLINICAL TYPES-Long segment : Metaplastic changes more -Long segment : Metaplastic changes more

than 3cmthan 3cm-Short segment:Changes less than 3 cm-Short segment:Changes less than 3 cm

Incidence of malignancyIncidence of malignancy

Lower &Midle oeso more prone to develop Lower &Midle oeso more prone to develop CACA

CA will be invasive & more proximalCA will be invasive & more proximal

TYPES OF DYSPLASIATYPES OF DYSPLASIA-Low grade : negligible risk for ca-Low grade : negligible risk for ca-High grade :very high risk for ca-High grade :very high risk for ca

RxRx Laser photodynamic therapyLaser photodynamic therapy Argon beam plasma coaulationArgon beam plasma coaulation Lap antireflux surgeryLap antireflux surgery High dose PPIHigh dose PPI Oesophagectomy(High grade dysplasia)Oesophagectomy(High grade dysplasia)

ComplicationsComplications 1. Oesophageal ulcers1. Oesophageal ulcers 2.Oesophageal strictures2.Oesophageal strictures 3.Dysplasia & adenoca3.Dysplasia & adenoca