1. Upper gastrointestinal tract
Dr.Ishara Maduka M.B.B.S. (Colombo)

2. Surgical conditions affecting upper GI tract
Oral cancer
Dysphagia and Oeasophageal cancer
Dyspepsia and GORD
Peptic ulcer
Gastric carcinoma
Upper GI bleeding

3. Oral cancers Oral cancer is the commonest cancer in males in Sri Lanka
Accounts for 2-4 % of all malignant tumours in the western world
Particularly common in some parts of Asia where betel chewing is common.
Associated with other tumours of the aerodigestive tract
In particular carcinoma of the :
Larynx
Bronchus
Oesophagus
85% are squamous cell carcinomas

4. Risk factors Betel chewing Smoking Alcohol excess Syphilitic glossitis
Sideropenic dysphagia

5. What is a premalignant lesion
A Premalignant lesions is a morphologically altered tissue that has a greater risk than normal tissue for a malignancy to occur.

6. What are the premalignant lesions in the oral cavity
Leucoplakia
Erythroplakia
Chronic hyperplastic candidiasis

7. Leucoplakia Erythroplakia

8. Clinical features of oral cancer
Oral cancer produces symptoms early
This allows the potential for early diagnosis and treatment
Diagnosis is usually clinical
Commonest sites with the mouth are
Tongue
Floor of the mouth
Gingiva and alveolar ridge
Buccal mucosa
Hard palate
Most tongue cancers occur on the lateral margin of the middle third of the tongue

9. Clinical features Contd…
Tumours in the floor of the mouth often have early bone involvement
Present as exophytic growths or ulcers
Pain is a late symptom

11. Investigation
Diagnosis can be confirmed by a biopsy under local anaesthetic
FNA of palpable nodes is useful to confirm lymphatic spread
CT is useful for assessing extent of nodal disease

12. Management
Resection
Reconstruction
Radiotherapy
Chemotherapy

13. Physiotherapists role
Establish communication with the patient
Preoperative assessment
Post operative care
Chest clearance exercises
Shoulder and neck exercises
Donor flap site exercise
Mobility

14. Dysphagia

15. What’s meant by dyspahgia?
Dysphagia means difficulty in swallowing.
Orynophagia means pain when swallowing.
Phagophobia means fear of swallowing.

16. What causes dysphagia
Causes can be divided anatomically into mechanical and non mechanical causes
Mechanical causes
Non mechanical causes
Oesophageal carcinoma
Achalasia cardia
Corrosive strictures
Oesophageal spasms
Mediastinal tumours compressing oesophagus
Foreign bodies

17. Clinically categorized according to presentation
Progressive dysphagia
Non progressive dysphagia
Oesophageal carcinoma
Achalsia cardia
Corrosive stricture
Foreign body
Mediastinal tumour compressing oesophagus
Oesophageal spasms

18. Oesophageal carcinoma
2nd commonest cancer in males in Sri Lanka
90% are squamous cell carcinomas
Occur in the upper or middle third of the oesophagus
8% are adenocarcinomas
Occur in the lower third of the oesophagus
Overall 5 year survival is very poor and is at best 20%

19. Risk factors Squamous cell carcinoma Adenocarcinoma Alcohol / tobacco
Diet high in nitrosamines
Trace element deficiency - molybdenum
Vitamin deficiencies - vitamins A & C
Achalasia
Coeliac Disease
Genetic - Tylosis
High incidence in areas of Northern China and the Caspian region
Adenocarcinoma
15% associated with Barrett's Oesophagus

20. Premalignant lesions in the oes.
Barrett's oesophagus
Consists of columnar-lined distal oesophagus
Due intestinal metaplasia of distal oesophageal mucosa
Can progress to dysplasia and adenocarcinoma
Its is an acquired condition due to gastro-oesophageal reflux
Bile reflux appears to be an important aetiological factor
10% of patients with GORD develop Barrett's oesophagus
Approximately 1% of patients with Barrett's oesophagus per year progress to carcinoma
Barrett's oesophagus increase the risk of cancer by x30

21. Clinical features Progressive dysphagia
Respiratory symptoms due to overspill or occasionally a trachea-oesophageal fistula
Weight loss

22. Investigations Diagnosis confirmed by:
Endoscopy plus biopsy / cytology
Barium swallow

23. Treatment
Surgical
Resection and anastomosis

24. Dyspepsia and GORD

25. What is dyspepsia
characterized by chronic or recurrent pain in the upper abdomen, upper abdominal fullness and feeling full earlier than expected when eating. It can be accompanied by bloating, belching, nausea, or heartburn.

26. Conditions causing dyspepsia
GORD (gastro-oeasophageal reflux disease)
Peptic ulcer
Carcinoma of the stomach
Gall bladder stones

27. GORD (gastro-oeasophageal reflux disease)
Occurs due to reflux of gastric contents in to oesophagus causing symptoms of dyspepsia.
Risk factors – High fat diet, obesity, pregnancy, increased acid secretion, alcohol, smoking.
Treatment – Advice to remain seated after eating, reduced amount of fatty food, weight control, antacid drugs.

28. Peptic ulcer

29. Peptic ulcer Occur due to increased acid secretion by parietal cells.
Risk factors – NSAIDS, H. Pylori infection
Sites of peptic ulceration
Stomach
Duodenum

31. Symptoms Dyspeptic symptoms Upper GI bleeding
Symptoms due to complications

32. Complications Bleeding Gastric carcinoma Duodenal rupture
Gastric ulcer
Duodenal ulcer
Bleeding
Gastric carcinoma
Duodenal rupture
Gastric outlet obstruction
Duodenal stricture

33. Helicobacter pylori
H. pylori is gram-negative spiral flagellated bacterium
Produces urease
Important in the aetiology of peptic ulcers and gastric cancer
Found in:
90% patients with duodenal ulceration
70% patients with gastric ulceration
60% patients with gastric cancer

34. Treatment of peptic ulcer
Avoid NSAIDS as much as possible
Eradicate H. pylori by antibiotics and proton pump inhibitors.
Truncal vagotomy and highly selective vagotomy done in the past to reduce acid secretion
Gastrectomy in untreatable gastric carcinoma
Treat complications

35. Carcinoma of the stomach
Risk factors
Diet low in Vitamin C
Blood group A
Pernicious anaemia
Hypogammaglobulinaemia
Post gastrectomy
Precursor states
Helicobacter pylori infection
Atrophic gastritis
Intestinal metaplasia
Gastric dysplasia
Gastric polyps

37. Clinical features Dyspeptic symptoms Upper GI bleeding
Loss of appetite
Wasting/ cachexia

38. Management
Surgical – gastrectomy
Radiotherapy
Chemotherapy

39. Gall stones and biliary conditions

40. Gall bladder stones Gallstones are found in 12% men and 24% women
Prevalence increases with advancing age
10-20% become symptomatic
Pathophysiology
Three types of stones are recognised
Cholesterol stones (15%)
Mixed stones (80%)
Pigment stones (5%)

41. Clinical presentation of gall stones
Acute cholecystitis
Biliary colic
Dyspepsia
Obstructive jaundice
Pancreatitis

42. Acute cholecystitis
90% cases result from obstruction to the cystic duct by a stone
Increased pressure within the gallbladder results in an acute inflammatory response
Secondary bacterial infections occurs in 20% of cases of acute cholecystitis
Most common organisms are E. coli, Klebsiella and strep. faecalis

43. Clinical features
Constant pain (usually greater than 12 hours duration) in right upper quadrant
Fever, tachycardia
Tenderness in right upper quadrant

44. Investigations
Ultrasound scan
Serum bilirubin
Serum amylase

46. Management Initial management is usually conservative
Patient is fasted, given intravenous fluids and opiate analgesia
Intravenous antibiotics (e.g. second generation cephalosporin) should be given to prevent secondary infection
80% patients improve with conservative treatment
Surgical treatment of choice is delayed cholecystectomy

47. Cholecystectomy
Open or closed

48. Laparoscopic cholecystectomy is the gold standard

49. Thank You!
Questions?