Les maladies du tractus gastro-intestinal (GI) supérieur touchent l'œsophage, l'estomac et le duodénum — des organes essentiels à la digestion et à l'absorption nutritionnelle. Les pathologies vont des plus courantes (le RGO touche environ 40 % des adultes dans le monde) aux plus complexes (l'œsophage de Barrett, la maladie ulcéreuse peptique et les sténoses œsophagiennes). Le diagnostic repose principalement sur l'endoscopie digestive haute (gastroscopie / OGD), qui offre une visualisation directe de la muqueuse, la possibilité de biopsies et l'accès à des interventions thérapeutiques comme la dilatation par ballonnet, l'hémostase et l'ablation. Ce guide couvre les principales pathologies du tractus GI supérieur, les procédures endoscopiques et les stratégies thérapeutiques conformes aux recommandations de la BSG, de l'ESGE et des directives mondiales de gastroentérologie.
Overview of Upper GI Diseases
The upper gastrointestinal (GI) tract includes the oesophagus, stomach, and the first part of the small intestine (duodenum). Diseases affecting these organs are among the most common medical conditions worldwide, ranging from reflux and ulcers to more serious conditions like Barrett's oesophagus and oesophageal cancer.
Many upper GI conditions are manageable with lifestyle changes and medication, but some require endoscopic or surgical intervention. Early diagnosis is key — a gastroenterologist uses a thin flexible camera (endoscope) passed through the mouth to visualise the lining of the oesophagus, stomach, and duodenum.
When to see a doctor
Persistent heartburn, difficulty swallowing, unexplained weight loss, vomiting blood, or dark tarry stools are all symptoms that require prompt medical evaluation.
Upper GI pathology spans a spectrum from functional disorders (functional dyspepsia, non-erosive reflux disease) to structural and neoplastic disease. Accurate classification drives appropriate investigation and therapy selection. The Rome IV criteria guide functional GI disorder diagnosis. Upper GI endoscopy (oesophagogastroduodenoscopy, OGD) remains the gold standard for direct mucosal visualisation, biopsy, and therapeutic intervention.
| Condition | Category | Primary Investigation | Endoscopy Role |
|---|---|---|---|
| GERD / NERD | Functional / Structural | 24h pH-impedance, OGD | Diagnostic (LA classification), surveillance |
| Peptic Ulcer Disease | Structural | OGD + H. pylori testing | Diagnosis, biopsy, haemostasis |
| Barrett's Oesophagus | Pre-neoplastic | OGD + biopsy (Prague criteria) | Surveillance, RFA, EMR, ESD |
| Oesophageal Stricture | Structural | OGD, barium swallow | Dilation (balloon / bougie), stenting |
| Oesophageal Cancer | Neoplastic | OGD + biopsy, CT staging | Diagnosis, EUS, stenting, palliation |
| Gastric Cancer | Neoplastic | OGD + biopsy, CT/PET | Diagnosis, ESD, palliation |
Anatomy of the Upper GI Tract
Oesophagus
A muscular tube (~25 cm) connecting the throat to the stomach. Lined by squamous epithelium; propels food by peristalsis. The lower oesophageal sphincter (LOS) prevents acid reflux.
Stomach
Stores and partially digests food using hydrochloric acid and pepsin. Lined by gastric mucosa; the antrum produces gastrin. Capacity ~1 litre when full.
Pylorus
The gateway between stomach and duodenum. Controls the rate of gastric emptying. Pyloric stenosis (narrowing) can cause persistent vomiting.
Duodenum
The first 25–30 cm of the small intestine. Receives bile and pancreatic enzymes; the most common site of peptic ulcers. The ampulla of Vater opens here.
Clinical Note — Gastro-oesophageal Junction (GOJ)
The GOJ (Z-line / squamocolumnar junction) is the critical landmark in upper GI endoscopy. Its precise identification using the Prague C&M criteria is essential for Barrett's staging. The lower oesophageal sphincter (LOS) and the diaphragmatic hiatus normally coincide; in hiatus hernia they separate, impairing the anti-reflux barrier. The Hill grade and BRAVO pH capsule placement both reference this landmark. During OGD, retroflexion in the stomach allows inspection of the gastric cardia and fundus — areas missed on forward view.
Gastro-oesophageal Reflux Disease (GERD)
GERD occurs when stomach acid repeatedly flows back into the oesophagus, irritating its lining. It is one of the most common digestive disorders globally, affecting approximately 1 in 5 adults in Western countries.
Occasional heartburn is normal. GERD is diagnosed when symptoms are frequent (more than twice per week), persistent, or when they cause complications such as erosions, strictures, or Barrett's oesophagus.
Symptoms
Typical Symptoms
- Heartburn — burning sensation behind the breastbone
- Regurgitation of acid or food into the mouth
- Chest discomfort, especially after eating
- Difficulty swallowing (dysphagia)
- Sensation of a lump in the throat (globus)
Atypical / Extra-oesophageal Symptoms
- Chronic cough or throat clearing
- Hoarseness / laryngitis
- Asthma exacerbation
- Dental erosion from acid
- Non-cardiac chest pain
Risk Factors
LA Classification of Oesophagitis (OGD Grading)
| Grade | Endoscopic Findings | Management |
|---|---|---|
| A | One or more mucosal breaks ≤5 mm, not extending between mucosal folds | PPI 4–8 weeks; lifestyle modification |
| B | One or more mucosal breaks >5 mm, not continuous between folds | PPI 8 weeks; consider maintenance |
| C | Mucosal breaks continuous between ≥2 folds but <75% circumference | PPI maintenance; Barrett's surveillance |
| D | Mucosal breaks involving ≥75% of oesophageal circumference | High-dose PPI; urgent Barrett's surveillance; surgical referral |
Peptic Ulcer Disease (PUD)
A peptic ulcer is an open sore that develops on the inner lining of the stomach (gastric ulcer) or the upper part of the small intestine (duodenal ulcer). They form when the protective mucus layer is disrupted, allowing acid to damage the tissue underneath.
The two main causes are infection with Helicobacter pylori bacteria and long-term use of non-steroidal anti-inflammatory drugs (NSAIDs). Contrary to popular belief, stress and spicy food do not cause ulcers, though they can worsen symptoms.
H. pylori accounts for 70–90% of duodenal ulcers and ~70% of gastric ulcers in non-NSAID users. NSAIDs inhibit COX-1-mediated prostaglandin synthesis, reducing mucus secretion and mucosal blood flow. Diagnosis requires OGD with biopsy (CLO test / histology), urea breath test, or stool antigen test. Gastric ulcers mandate repeat OGD at 6–8 weeks to confirm healing and exclude malignancy.
Common Symptoms
- Burning or gnawing epigastric pain
- Pain relieved by eating (duodenal) or worsened by food (gastric)
- Nausea and bloating
- Loss of appetite and weight loss
- Dark or tarry stools (if bleeding)
Complications ⚠️
- Bleeding — most common; may require endoscopic haemostasis
- Perforation — surgical emergency; sudden severe abdominal pain
- Pyloric stenosis — scarring causing gastric outlet obstruction
- Malignant transformation — gastric ulcers require biopsy
Barrett's Oesophagus
Barrett's oesophagus is a condition where the normal squamous lining of the lower oesophagus is replaced by specialised columnar epithelium (intestinal metaplasia), as a result of chronic acid exposure from GERD. It is considered a pre-cancerous condition.
Most people with Barrett's oesophagus do not develop oesophageal cancer, but regular endoscopic surveillance is important to detect any progression to dysplasia (abnormal cells) at an early, treatable stage.
Barrett's is defined by ≥1 cm of columnar-lined oesophagus with confirmed intestinal metaplasia on biopsy (4-quadrant biopsies every 2 cm — Seattle protocol). Risk of progression to oesophageal adenocarcinoma: non-dysplastic ~0.3%/year; low-grade dysplasia ~0.5%/year; high-grade dysplasia ~7%/year. Endoscopic eradication therapy (RFA, cryotherapy, EMR, ESD) is indicated for confirmed dysplasia.
~10%
of chronic GERD patients develop Barrett's
5–10 yr
typical surveillance interval for non-dysplastic Barrett's
~95%
eradication success rate with radiofrequency ablation (RFA)
Oesophageal Strictures
An oesophageal stricture is a narrowing of the oesophagus that makes swallowing difficult or painful. Strictures can be benign (peptic, post-surgical, radiation-induced, eosinophilic oesophagitis) or malignant (oesophageal cancer).
The most common treatment is endoscopic balloon dilation or bougie dilation, which stretches the narrowed segment. Malignant strictures may require metal stent placement to maintain the lumen and allow the patient to eat.
Endoscopic Balloon Dilation — Clinical Considerations
Through-the-scope (TTS) balloon dilation uses controlled radial force to dilate oesophageal strictures under direct endoscopic vision. Balloon diameter is titrated based on stricture severity — the "rule of three" (no more than 3 mm increase per session) applies to bougie dilation. High-pressure through-the-scope balloons are particularly effective in tight peptic and anastomotic strictures. Success rates for benign strictures: ~80% at 1 year, though refractory strictures (requiring >5 dilation sessions) may need steroid injection, incision therapy (electrocautery / laser), or surgical resection. Radiation-induced strictures carry higher perforation risk and require particular care.
Benign Causes
- • Peptic stricture from chronic GERD
- • Post-surgical anastomotic narrowing
- • Radiation-induced fibrosis
- • Eosinophilic oesophagitis (EoE)
- • Chemical / caustic ingestion
- • Schatzki ring
Malignant Causes
- • Oesophageal squamous cell carcinoma
- • Oesophageal adenocarcinoma (Barrett's-related)
- • Gastric cardia tumour with proximal extension
- • Extrinsic compression (lung, mediastinal nodes)
Diagnosis & Endoscopy
Upper GI endoscopy (gastroscopy) is the definitive investigation. A thin, flexible tube with a camera on the end is passed through the mouth into the oesophagus, stomach, and duodenum. It allows the doctor to directly inspect the lining, take biopsies, and perform treatments — all in a single procedure.
Upper GI Endoscopy (OGD)
Direct visualisation, biopsy, and therapeutic access
H. pylori Testing
Urea breath test, stool antigen, CLO test, serology
Imaging & pH Studies
Barium swallow, CT, 24h pH-impedance, EUS
Endoscopic Interventions in Upper GI Disease
| Technique | Indication | Key Points |
|---|---|---|
| Balloon Dilation (TTS) | Benign strictures, anastomotic stenosis, achalasia (pneumatic) | Radial force; fluoroscopy guidance optional; high-pressure balloons for resistant strictures |
| EMR (Endoscopic Mucosal Resection) | Barrett's HGD, early cancer ≤20 mm | En-bloc preferred; inject-and-cut or cap technique |
| ESD (Endoscopic Submucosal Dissection) | Early oesophageal/gastric cancer >20 mm | En-bloc resection; technically demanding; risk of perforation |
| RFA (Radiofrequency Ablation) | Barrett's with dysplasia | HALO system; ~95% complete eradication |
| SEMS (Metal Stenting) | Malignant oesophageal obstruction | Palliative; restores swallowing; covered vs uncovered choice |
| Endoscopic Haemostasis | Bleeding peptic ulcer (Forrest Ia–IIb) | Dual therapy: adrenaline + thermal/clip; PPI infusion post-procedure |
Traitement du GI supérieur : IPP, éradication d'H. pylori, dilatation par ballonnet et procédures endoscopiques
Treatment depends on the specific condition, but most upper GI diseases respond well to a combination of lifestyle changes, medication, and when necessary, endoscopic or surgical procedures.
Lifestyle Modification
Elevate head of bed, lose weight, avoid trigger foods (caffeine, alcohol, fatty meals, citrus), stop smoking, eat smaller more frequent meals, avoid lying down within 3 hours of eating.
Acid Suppression Therapy
Proton pump inhibitors (PPIs — omeprazole, lansoprazole, pantoprazole) are the cornerstone of GERD and PUD treatment. H2-receptor antagonists (famotidine) are used as alternatives or add-on therapy. Antacids for symptomatic relief.
H. pylori Eradication
Standard triple therapy (PPI + clarithromycin + amoxicillin, 7–14 days) or bismuth-based quadruple therapy in areas with high clarithromycin resistance. Confirm eradication with urea breath test 4 weeks after completing treatment.
Endoscopic Intervention
Balloon dilation for strictures, haemostasis for bleeding ulcers, endoscopic mucosal resection (EMR) or radiofrequency ablation (RFA) for Barrett's with dysplasia, and stenting for malignant obstruction.
Surgery
Laparoscopic Nissen fundoplication for refractory GERD. Oesophagectomy or gastrectomy for cancers not amenable to endoscopic resection. Perforated or obstructed ulcers typically require emergency laparoscopic or open surgery.
Clinical Insights & Current Guidelines
BSG / ESGE 2023 Key Updates
- • Non-dysplastic Barrett's (<3 cm): surveillance OGD every 3–5 years; ≥3 cm every 2–3 years (BSG 2023).
- • Confirmed low-grade dysplasia: endoscopic eradication preferred over surveillance; RFA first-line.
- • ESGE recommends potassium-competitive acid blockers (P-CABs, e.g. vonoprazan) as an emerging alternative to PPIs in H. pylori eradication and erosive oesophagitis.
- • For suspected upper GI bleeding: OGD within 24h; <12h if haemodynamically unstable after resuscitation (ESGE 2021).
- • Risk stratification using Glasgow-Blatchford Score (GBS) pre-endoscopy; Rockall score post-endoscopy for re-bleeding risk.
Endoscope Hygiene & Single-Use Technology
Flexible endoscope reprocessing failures have been documented as vectors for H. pylori, multidrug-resistant organisms, and viral transmission. Single-use flexible endoscopes eliminate cross-contamination risk and maintain consistent optical performance — particularly relevant in immunocompromised patients and high-risk diagnostic procedures. Envaste's single-use scope portfolio aligns with the growing movement toward disposable endoscopy platforms in GI and pulmonology.
Balloon Dilation in Upper GI Strictures
Through-the-scope (TTS) balloon dilators — such as the Amara 3-Stage Balloon Dilator and the Amara Wire-Guided Balloon Dilator — are the standard of care for benign oesophageal, pyloric, and anastomotic strictures. Key technical principles: balloon placement under direct vision, fluoroscopic guidance for complex anatomy, and incremental dilation (no more than 3 Fr per session in fibrotic strictures). High-pressure balloons with radiopaque markers allow real-time waist obliteration confirmation. Intralesional corticosteroid injection at time of dilation reduces recurrence in refractory peptic strictures.
Questions fréquentes : Maladies du tractus GI supérieur
Quels sont les symptômes de la maladie de reflux gastro-œsophagien (RGO) ?
Le RGO provoque des brûlures d'estomac (sensation de brûlure derrière le sternum), des régurgitations acides, des difficultés à avaler (dysphagie) et une gêne thoracique après les repas. Les symptômes atypiques incluent une toux chronique, une voix rauque et des douleurs thoraciques non cardiaques. Le RGO est diagnostiqué lorsque les symptômes surviennent plus de deux fois par semaine ou entraînent des complications telles que des érosions œsophagiennes, des sténoses ou un œsophage de Barrett.
Qu'est-ce que l'œsophage de Barrett et est-ce dangereux ?
L'œsophage de Barrett survient lorsque la muqueuse normale de l'œsophage inférieur est remplacée par une métaplasie intestinale due au reflux acide chronique (RGO). Il s'agit d'une affection précancéreuse. Environ 10 % des patients souffrant de RGO chronique développent un œsophage de Barrett. La surveillance endoscopique régulière détecte les dysplasies précocement, et l'ablation par radiofréquence (RFA) éradique les dysplasies de Barrett dans environ 95 % des cas.
Quelles sont les causes des ulcères peptiques et comment sont-ils traités ?
Les ulcères peptiques sont des lésions de la muqueuse de l'estomac ou du duodénum causées principalement par une infection à Helicobacter pylori (H. pylori) ou par une utilisation prolongée d'AINS. H. pylori est responsable de 70 à 90 % des ulcères duodénaux. Le traitement comprend une thérapie par inhibiteurs de la pompe à protons (IPP) et l'éradication d'H. pylori par triple ou quadruple antibiothérapie. L'éradication est confirmée par le test respiratoire à l'urée 4 semaines après la fin du traitement.
Qu'est-ce que la dilatation endoscopique par ballonnet et dans quel cas est-elle utilisée ?
La dilatation endoscopique par ballonnet utilise un ballonnet gonflable introduit à travers l'endoscope pour élargir les zones rétrécies de l'œsophage, de l'estomac ou de l'intestin. Elle traite les sténoses œsophagiennes bénignes (d'origine peptique, postopératoire ou radique), la sténose pylorique et les rétrécissements anastomotiques. Un guidage fluoroscopique est utilisé pour les sténoses complexes. Les taux de succès pour les sténoses bénignes atteignent environ 80 % à un an.
Qu'est-ce que la gastroscopie (endoscopie digestive haute) et quand est-elle nécessaire ?
La gastroscopie (œso-gastro-duodénoscopie, OGD) utilise une fine caméra flexible introduite par la bouche pour visualiser directement l'œsophage, l'estomac et le duodénum. Elle permet de diagnostiquer le RGO, l'œsophage de Barrett, les ulcères peptiques, l'infection à H. pylori, les sténoses œsophagiennes et les cancers du tractus GI supérieur. Elle permet également des interventions thérapeutiques telles que la dilatation par ballonnet, l'hémostase des ulcères hémorragiques et la pose de prothèses pour les obstructions malignes.