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Ok. Ok. Hi guys. We'll just give um, a few more minutes if anyone else wants to join, uh, just give it two more minutes. Ok, I'll get started then. Um, so welcome to today's session um, on upper Gi and Gi Cancers. So I'll just spend the 1st 45 minutes or so going over upper gi and then you will go through Gi cancers. So the structure of the session, uh, is similar to the previous ones. We go through the conditions and presentations relating to upper gi starting with the etiology, history, presentation, investigations and management. Um, so these are the conditions that we'll cover. Achalasia Barret's Esophagus, Mallory, Weiss, Hair boar's esophagus, go, uh, peptic ulcer disease, gastritis and hiatus hernia. So, starting off with SBA one, a 29 year old female presents with a two year history of difficulty swallowing solids and liquids. She has remarked that her clothes no longer fit her as they are all too big for her. All examinations are unremarkable. What is the first line investigation? So I'll give you around 30 seconds, um, feel free to type it in the chat, um, or you can think about it in your head, whichever you prefer. Yeah, we have an answer. Um upper gi endoscopy and that is correct. Um So this patient from the questions done presents with achalasia and the first line investigation is upper gi endoscopy. Um So we'll just go through the condition of achalasia briefly. So, the etiology involves the ganglion cells which are located in the esophageal region um which are degenerated often by an unknown course. Um This then leads to impaired production of nitrous oxide and vasoactive intestinal peptide, which are both neurotransmitters that um play a role in relaxing the lower esophageal sphincter. Um So, therefore, impaired production of these neurotransmitters results in a failure or incomplete relaxation of the lower esophageal sphincter. Um and risk factors and causes um most um presentations of achalasia have a fairly unknown cause. Um but a notable cause is Chagas Chagas disease or Chagas disease, um which is a parasitic disease. So, a patient will present with the following symptoms. So they'll have dysplasia for both solids and liquids. Um which is a key thing you'll often spot in question stems. Um, regurgitation. This is due to food trapped in the esophagus, gradual weight loss due to lack of food ingestion and on physical examination, they may have signs of complications such as aspiration, pneumonia, malnutrition and weight loss. In terms of investigations. Uh you want to think about doing a high resolution esophageal manometry used to assess the pressure at the lower esophageal sphincter. So obviously, if there's failure to relax, then there'll be an elevated uh resting, lower esophageal pressure. Um And there'll be incomplete um low esophageal relaxation, there'll also be an absence of Peric in the smooth muscle portion of the esophagus. Um Another notable um investigation you'll see is a barium swallow. So you'll see a dilated esophagus which smoothly tapers down. Um uh You can see in the image on the right here. Um That first line investigation as correctly identified as a first line upper gi endoscopy. This is because a lot of the signs and symptoms overlap with malignancy. So you want to be doing an upper gi endoscopy to exclude this in terms of management. The treatment is to reduce the symptoms of dysphasia. Um Unfortunately, for these patients swallowing will actually never return to normal. Um The gold standard for treatment is pneumatic dilation, which is essentially inserting a balloon um into the esophagus and inflating it which stretches the esophageal esophagus. Um Other options if the patient is surgically fit is to do either a laparoscopic or an endoscopic myotomy. Um And this involves cutting the lower esophageal sphincter muscle fibers. Um This therefore allows food to pass into the stomach. Um However, myotomies can also lead to acid reflux. So, a hela myotomy is often combined with fundoplication when treating achalasia surgically. Um If the patient is not surgically fit, we then move on to pharmacological therapy. Um So this could be calcium channel blockers, nitrates or Botox. Um and all of these medications aim to relax the lower esophageal sphincter muscle. So this is just a summary slide um of the condition um moving on to SBA two. This is a.