Pouches in the walls of the structures in the digestive system that occur wherever weak spots exist between adjacent muscle layers are called diverticula. In the upper esophagus, diverticula may occur in the area where the striated constrictor muscles of the pharynx merge with the smooth muscle of the esophagus just below the larynx. Some males over 50 years of age show protrusion of a small sac of pharyngeal mucous membrane through the space between these muscles. As aging continues, or if there is motor disturbance in the area, this sac may become distended and may fill with food or saliva. It usually projects to the left of the midline, and its presence may become known by the bubbling and crunching sounds produced during eating. Often the patient can feel it in the left side of the neck as a lump, which can be reduced by pressure of the finger. Sometimes the sac may get so large that it compresses the esophagus adjacent to it, producing a true obstruction. Treatment is by surgery. Small diverticula just above the diaphragm sometimes are found after the introduction of surgical instruments into the esophagus.
Boerhaave syndrome is a rare spontaneous rupture to the esophagus. It can occur in patients who have been vomiting or retching and in debilitated elderly persons with chronic lung disease. Emergency surgical repair of the perforation is required. A rupture of this type confined to the mucosa only at the junction of the linings of the esophagus and stomach is called a Mallory-Weiss lesion. At this site, the mucosa is firmly tethered to the underlying structures and, when repeated retching occurs, this part of the lining is unable to slide and suffers a tear. The tear leads to immediate pain beneath the lower end of the sternum and bleeding that is often severe enough to require a transfusion. The circumstances preceding the event are commonly the consumption of a large quantity of alcohol followed by eating and then vomiting. The largest group of individuals affected are alcoholic men. Diagnosis is determined with an endoscope. Most tears spontaneously stop bleeding and heal over the course of some days without treatment. If transfusion does not correct blood loss, surgical suture of the tear may be necessary. An alternative to surgery is the use of the drug vasopressin, which shuts down the blood vessels that supply the mucosa in the region of the tear.
Cancer
Esophageal tumours may be benign or malignant. Generally, benign tumours originate in the submucosal tissues and principally are leiomyomas (tumours composed of smooth muscle tissue) or lipomas (tumours composed of adipose, or fat, tissues). Malignant tumours are either epidermal cancers, made up of unorganized aggregates of cells, or adenocarcinomas, in which there are glandlike formations. Cancers arising from squamous tissues are found at all levels of the esophagus, whereas adenocarcinomas are more common at the lower end where a number of glands of gastric origin are normally present. Tumours produce difficulty in swallowing, particularly of solid foods; they are much more common in men than in women, and they seem to vary greatly in their worldwide distribution. In North China, for example, the incidence of esophageal cancer in men is 30 times that of white men in the United States and 8 times that of black men. The exact causes of esophageal cancer are not known. Risk factors may include age, sex, smoking, excessive consumption of alcohol, Barrett esophagus, and a personal history of cancer.
In women, cancer of the upper esophagus is more common than in men, and women may be predisposed by long-standing iron deficiency, or Plummer-Vinson (Paterson-Kelly) syndrome. Dysphagia is the first and most prominent symptom. Later swallowing becomes painful as surrounding structures are involved. Hoarseness indicates that the nerve to the larynx is affected. The diagnosis is suggested by X ray and proved by endoscopy with multiple biopsies from the area of abnormality. Diagnosis can be reinforced by removing quantities of cells with a nylon brush for examination under a microscope (exfoliative cytology). The prognosis is poor because the tumour has usually been growing for one or two years before symptoms are apparent. The channel of the esophagus is encroached upon and can be almost entirely obstructed. Esophageal cancer is usually accompanied by considerable weight loss, but nutrition may be restored by nutritional supplements. In advanced cases, a tube may be inserted into the esophagus to keep it open. Where the channel is greatly narrowed, the size of the tumour can be reduced by destroying the tissue with lasers. Radiotherapy is used for malignancies of the upper esophagus and as treatment for those at the lower end. A combination of radiotherapy followed by surgical excision may also be used. The five-year survival rate for esophageal cancer remains very low. Lessening the effects of the disease, with restoration of eating ability, is very important, because otherwise the inability to swallow even saliva is distressing and starvation may result.
Stomach
Indigestion
Indigestion, also called dyspepsia, is any or all of the unpleasant symptoms that are associated with the malfunctioning of the digestive system. Indigestion may be caused by a disease, but it primarily occurs because of stress or improper eating habits, smoking, drinking excessive quantities of coffee or alcohol, or hypersensitivity to particular foods. Any disorder that affects the coordination of the stomach muscles is capable of producing symptoms ranging from those that are mildly unpleasant to others that are life-threatening. Symptoms include abdominal discomfort, belching, flatulence, anorexia, nausea, vomiting, diarrhea, constipation, and heartburn. Anorexia and nausea seem to be mediated through the central nervous system, with reflex input from nerve endings in the stomach and duodenum. Sometimes the entire duration of a nausea-vomiting episode is so short that it appears to be vomiting alone, obscuring the presence of nausea. This is characteristically noted in persons with primary diseases of the brain, especially those with tumours or meningitis in which the cerebrospinal fluid is under increased pressure. In many diseases, vomiting may not be preceded by nausea at all, and in others there may be a long time lag between the two. Seasickness is the best-known example of this relationship.
The intrinsic muscles of the stomach are innervated by branches of the vagus nerves, which travel along the esophagus from their point of emergence in the brain stem. Gastric retention may result from the degeneration of these nerves that can result from diabetes mellitus. Obstruction due to scarring in the area of the gastric outlet, or to tumours encroaching on the lumen, causes the stomach to fill up with its own secretions as well as with partially digested food. In these circumstances, vomiting leads to dehydration and to electrolyte losses, which threaten life if not corrected. The ingestion of soluble alkali in this situation may aggravate the disturbance in the acid-base balance of the body. Bulimia, a nervous disorder characterized by compulsive eating followed by vomiting and purging, can cause severe dehydration and even a ruptured stomach, and it can prove fatal.
Ulcerative diseases
Ulcers are produced when external factors reduce the ability of the mucosal lining to resist the acidic effects of gastric juice (a mixture of digestive enzymes and hydrochloric acid). The area of the stomach in which acid and pepsin are secreted has the highest resistance to peptic ulcer. The mucosa elsewhere is less well protected, and its breakdown may lead to ulceration. If the lesion is confined to the superficial layers of the mucosa, it is called an erosion; if it extends through the intrinsic layer of muscle of the mucosa into the tissues below, it is known as an ulcer. Erosions and ulcers can be acute or chronic according to how readily they heal. Infection with the bacterium Helicobacter pylori and long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs) are the two major causes of ulcers. In special circumstances such as the state of shock produced by large burns, intracranial surgery, coronary occlusion, and septicemia, acute and rapidly penetrating ulcers may occur.
In the Western world duodenal ulcer is much more common than gastric ulcer, occurs more often in men than in women, and is aggravated by stress. In Japan gastric ulcer is more common than duodenal ulcer and is thought to be related to the raw fish and acetic acid pickles of the traditional diet. Duodenal ulcer is most common between 25 and 35 years of age, while gastric ulcer is uncommon before 40 years and has a peak frequency between 55 and 65 years. Genetic factors are also involved in the development of ulcers. Inheriting blood group O may render a person more likely to develop duodenal ulceration. There are families in whom the secretion of pepsinogen I is excessive and renders them prone to duodenal ulcer since excess acid secretion is linked to excess secretion of this hormone.
Pain is the major symptom of duodenal ulcers. The pain is a burning or gnawing sensation felt in the midupper abdomen. In gastric ulcer it comes on soon after eating, whereas in duodenal ulcer it comes on when the stomach is empty, one and a half to two hours after meals and during the night hours. In the early stages of the disease, the pain is easily and immediately relieved by antacids and, in duodenal ulcer, by light food.
Gastric ulcers almost always recur in the same site within the stomach, but duodenal ulcers are often multiple, and recurrence may be anywhere in the duodenal bulb. Furthermore, duodenal ulcers are usually accompanied by an inflammation affecting the whole bulb (duodenitis). Multiple erosions varying in size between 0.5 and 5 millimetres are frequently scattered over the mucosa. With gastric ulcers the inflammation is usually confined to the immediate vicinity of the crater and, as a rule, is not accompanied by erosions. The exceptions are gastric ulcers in the antrum and prepyloric area associated with the use and abuse of analgesics and NSAIDs for arthritic disorders, in which multiple erosions are commonly present.
The most common site of gastric ulcers is halfway up the inner curvature of the stomach at the junction of the lower one-third with the upper two-thirds of the organ. This may be because blood flow to this site is more easily reduced than elsewhere. Chronic gastric ulcers at this site are strongly associated with obstructive disease of the airways (chronic bronchitis and emphysema). Smoking impairs the healing of both gastric and duodenal ulcers.
Infection with H. pylori is the most common bacterial infection in humans; it is pervasive in the Third World, and in the United States it affects about a third of the population. Among those who suffer from peptic ulcers, as many as 90 percent of those with duodenal ulcers and 70 percent with gastric ulcers are believed to be infected with H. pylori. This bacterium converts the abundant waste product urea into carbon dioxide and ammonia. The process causes the mucosal lining to break down. In its weakened condition the lining cannot withstand the corrosive effects of gastric acid, and an ulcer can form.
The complications of peptic ulcers are hemorrhage, perforation, and obstruction of the outlet of the stomach (pyloric stenosis) by scarring of the duodenal bulb or of the pyloric channel. Scarring often leads to bouts of vomiting and accompanying malnutrition and requires surgery. Bleeding may be obscured because of oozing from the floor of the ulcer and detectable only by laboratory testing of the feces, or bleeding may be brisk, leading to the passage of tar-coloured stools (melena). Occasionally, when the ulcer erodes into a large vessel, bleeding is excessive and life-threatening. The mortality associated with bleeding is high in the elderly because of chronic changes in the lungs, heart, and blood vessels, which reduces cardiorespiratory reserves. This is further aggravated by smoking. Brisk bleeding is usually accompanied by the vomiting of blood (hematemesis), which requires treatment by blood transfusion. In the elderly, hardening of the arteries (atherosclerosis) prevents the vessel from closing down around the lesion. If bleeding persists or recurs, surgery is necessary. Ulcers that penetrate the back wall of the stomach or duodenum erode into the pancreas, and back pain becomes prominent. If the ulcer penetrates the anterior wall, free perforation into the abdominal cavity may occur. This causes immediate, intense pain and shock, and the abdominal wall becomes rigid. In most instances this requires emergency surgery with drainage of the abdomen.
Surgery for chronic ulceration is used less frequently since the introduction of drugs that stop the secretion of stomach acid. Histamine-receptor antagonists, such as cimetidine, ranitidine, and famotidine, block the action of histamine on the acid-secreting parietal cells of the stomach. Proton pump inhibitors, such as omeprazole, lansoprazole, and rabeprozale, inhibit the ATPase enzyme inside the parietal cell and prevent acid secretion. Most peptic ulcers not caused by H. pylori infection result from the ingestion of large quantities of NSAIDs. Withdrawal of NSAID treatment usually allows the ulcer to heal. Treatment for H. pylori–induced ulcers are antibiotics and a proton pump inhibitor.
