上消化道（GI）疾病影响食管、胃和十二指肠——这些是消化和营养吸收的核心器官。疾病范围从广泛性疾病（GERD影响全球约40%的成年人）到复杂疾病（Barrett食管、消化性溃疡和食管狭窄）。诊断主要依靠上消化道内镜检查（胃镜/OGD），提供直接黏膜可视化、活检能力以及球囊扩张、止血和消融等治疗性介入通道。本指南涵盖与BSG、ESGE及全球消化内科指南一致的主要上消化道疾病、内镜手术和治疗策略。
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 |
上消化道治疗：质子泵抑制剂、H. pylori根除、球囊扩张与内镜手术
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.
常见问题：上消化道疾病
GERD（胃食管反流病）的症状有哪些？
GERD导致烧心（胸骨后灼烧感）、酸反流、吞咽困难（咽下困难）和餐后胸部不适。非典型症状包括慢性咳嗽、声音嘶哑和非心源性胸痛。当症状每周出现两次以上或引起食管糜烂、狭窄或Barrett食管等并发症时，诊断为GERD。
Barrett食管是什么，有危险吗？
Barrett食管是由慢性胃酸反流（GERD）引起的肠化生取代下段食管正常黏膜的状态。这是一种癌前病变。约10%的慢性GERD患者会发展为Barrett食管。定期内镜监测可早期发现异型增生，射频消融（RFA）可在约95%的病例中成功根除异型增生性Barrett食管。
消化性溃疡的病因和治疗方法是什么？
消化性溃疡是主要由幽门螺杆菌（H. pylori）感染或长期NSAID使用引起的胃或十二指肠黏膜溃疡。H. pylori是70〜90%十二指肠溃疡的原因。治疗包括质子泵抑制剂（PPI）疗法和三联或四联抗菌药物疗法进行H. pylori根除。根除效果通过治疗完成4周后的尿素呼气试验确认。
内镜球囊扩张术是什么，何时使用？
内镜球囊扩张术使用经内镜（TTS）充气球囊扩宽食管、胃或肠道的狭窄区域。用于治疗良性食管狭窄（来自GERD、术后或放疗诱发）、幽门狭窄和吻合口狭窄。对于复杂狭窄使用透视引导。良性狭窄一年的成功率约为80%。
胃镜检查（上消化道内镜检查）是什么，何时需要？
胃镜检查（食管胃十二指肠镜检查，OGD）通过口腔插入细软性摄像头，直接观察食管、胃和十二指肠。可诊断GERD、Barrett食管、消化性溃疡、H. pylori感染、食管狭窄和上消化道肿瘤。还可进行治疗性介入，包括球囊扩张、出血性溃疡止血和恶性梗阻的支架置入。