by Hannah Farrell
Our expert witnesses in upper gastrointestinal (GI) surgery specialise in treating disorders of the oesophagus, stomach, and duodenum (first part of the bowel). They are experts in providing both medical and surgical management, such as proton pump inhibitors and PEG tube feeding, in addition to performing investigations such as gastroscopy and oesophago-gastric-duodenoscopy (OGD).
Our experts in upper GI surgery have a profound knowledge of managing conditions such as Barratts oesophagus, gastric ulcers, duodenal ulcers, duodenitis, dumping syndrome, duodenitis, gastritis, and oesophageal webs. Further, their extensive experience in the operating theatre means they can review operation notes and assess the practical nature of the surgical procedures performed.
With a strong understanding of appropriate standards of care and NICE Guidelines, in addition to a thorough knowledge of treatment pathways, our expert witnesses in upper GI surgery can advise on causation, breach of duty, current condition, and prognosis in individuals with upper gastrointestinal disorders.
See below for a brief overview on upper gastrointestinal surgery. Alternatively, contact an expert witness in upper GI surgery to see how they can help.
What is the Upper Gastrointestinal System?
Basic Anatomy & Physiology
The upper gastrointestinal (GI) system is comprised of the oesophagus, stomach, and duodenum (first part of the small intestine). The primary function of the upper GI system is to allow the ingestion and digestion of food and water.
The stomach can be divided into four main sections:
- Cardia – surrounding where the oesophagus enters the stomach;
- Fundus – most superior aspect;
- Body – central portion; and
- Pylorus – the lowest portion, which leads into the duodenum via the pyloric sphincter.
Reflux Disease
As we consume food and water, it passes from our mouth down the long muscular tube of the oesophagus. The oesophagus contracts to aid movement into the stomach through the oesophageal hiatus (opening into the stomach). At rest, this opening is held closed by the lower oesophageal sphincter, preventing reflux of stomach contents into the oesophagus. If this sphincter malfunctions and the acidic stomach contents are allowed to enter the oesophagus, people develop what is known as gastro-oesophageal reflux disease (GORD). This can be managed with a change in diet, prescription of proton-pump inhibitors, or in more severe cases, a Nissen fundoplication (surgery to strengthen the lower oesophageal sphincter). Some individuals may also develop a hiatus hernia; this is when part of the stomach protrude through the oesophageal sphincter.
Oesophageal Cancer
Chronic exposure of the oesophagus to the acid stomach contents can cause the cells lining the lower oesophagus to change and become pre-malignant; this is known as Barrett’s oesophagus and can develop into adenocarcinoma. Squamous cell carcinoma may also develop elsewhere along the oesophagus. Oesophageal cancer presents often with dysphagia (difficulty swallowing) and weight loss. People with oesophageal cancer may undergo surgical removal of the tumour via an oesophagectomy.
Oesophageal Varices
The oesophageal blood supply drains into the systemic and portal blood circulation. In people with portal hypertension (such as those with chronic liver disease), the pressure in the circulation increases and leads to the development of oesophageal varices (abnormally dilated veins). These varices are susceptible to bleeding and may present with haematemesis (vomiting blood) or melaena (passing dark, tarry stools of digested blood). Oesophageal varices can be treated using band ligation or sclerotherapy.
Peptic Ulcers
The stomach secretes peptic acid which digests the majority of what we consume and prevents infection by destroying bacteria. The stomach also produces a mucus layer which helps protect the stomach lining from the stomach acid. Excessive peptic acid secretion (e.g., Zollinger-Ellison syndrome), or a breach in the mucus layer, can lead to the development of peptic ulcers (gastric ulcers) which may bleed. The mucus layer may be breached through infection with Helicobacter pylori (H. pylori) infection or by nonsteroidal anti-inflammatory drugs (NSAIDs). If there is insufficient peptic acid produced (achlorhydria) then individuals are susceptible to salmonella and cholera infection.
Duodeneal Ulcers
From the stomach pylorus, the gastric contents enter the first part of the small intestine, the duodenum. Here, bile is secreted from the gallbladder and liver, through the sphincter of Oddi. As the duodenum is exposed to the highly acidic contents of the stomach, the bile is used to neutralise this and protect the surface of the duodenum; whilst bile is very successful at preventing harm to the duodenum, duodenal ulcers may still develop, with the individual experiencing an upper GI bleed and presenting with melaena and haematemesis.
Endoscopic Upper GI Investigation
An oesophageo-gastro-duodenoscopy (OGD) is an endoscopic procedure performed to view the upper GI tract. It is also used to take biopsies and diagnose conditions such as oesophageal cancer and gastric cancer.