19. GORD and Barretts Oesophagus Flashcards
What is dysphagia
difficulty swallowing
name some neuromuscular causes of dysphagia
o Muscular (muscular dystrophy or myasthenia gravis o Neurological (stroke Parkinson’s, MS) o Weakened muscles (impaired co-ordination in the elderly)
name some causes of narrowing of the throat/oesophagus which would cause dysphagia
o Throat cancer
o Sacs/ring in oesophagus
o GORD
name some complications of dysphagia
o Choking
o Pulmonary aspiration
o Not enough nutrition
name some treatments for dysphagia
o Muscle exercises o Change in head/neck position o Soft food/thickened drinks o Surgery o Tube feeding
in someone who presents with dysphagia what do you need too ask about current symptoms
o Any weight loss? If so how much and over what time scale? Was it deliberate?
o Has been vomiting or any bleeding
o Any changes in bowel habits (think of melaena)
o Any pain? If so where?
o Any symptoms of anaemia
in someone who presents with dysphagia what do you need to ask about their background
o Any previous investigations, in particular GI endoscopies
o Ask more about why he is on omeprazole
o Has he taken any NSAIDS or other medications, including OTC drugs
o Previous abdominal surgery
o Any relevant FH
o Lifestyle; smoking and drinking
what is Barretts oesophagus
Barrett’s metaplasia is a change from the normal squamous epithelium of the oesophagus to columnar epithelium, similar to that normally found in the stomach
Tell me more about Barretts oesophagus
o Barretts is a pre-malignant condition and increases the risk of oesophageal cancer by about 50x compared to the general population. The risk of developing cancer is still relatively low but increases significantly if dysplasia is present
in a patient who has progressive dysphagia ie they can no longer eat solid foods, only soft food what causes would you be thinking of
mechanical obstruction or stricture
- oesophageal cancer, peptic stricture or extrinsic compression off the oesophagus
why would you not suspect a patient to have a neurological cause or achalasia if they have progressive dysphagia
they are still able to swallow liquids with no bother
what is achalasia
muscles of the lower spintcher fail to relax, preventing food moving into the stomach
In someone with dysphagia what are the main investigations you would want to do
o Upper gastrointestinal endoscopy (often referred to as an OGD or simply a gastroscopy). Also ask for some blood tests
o Blood tests to look for anaemia, to check his renal function (important for the contrast enhanced CT scan and possible treatment) and liver function tests as a screen for metastases
o Barium swallow could show the site of a stricture is doesn’t allow biopsy. Expect he will also need cross sectional imaging, most likely a CT scan, for staging
in the NICE guidelines what is the criteria for 2ww referral for ? oesophageal cancer
- people with dysphagia or
- aged 55 or over with weight loss and any of the following; upper abdo pain, reflux and dyspepsia
in the NICE guidelines what is the criteria for a non-urgent direct access upper GI endoscopy to assess for oesophageal cancer
in people with haematemesis
in the NICE guidelines what is the criteria for for non-urgent direct access upper GI endoscopy in over 55s with …………
- treatment resistant dyspepsia or
- upper abdo pain with low Hb or
- raised platelet count with any of the following; nausea, vomiting, weight loss, reflux, dyspepsia, upper abdo pain or
- Nausea and committing with any of the following; weight loss, reflux, dyspepsia, upper abdo pain
Explain a 2WW referral to a patient
See notes page 3;
- important to say referral is for suspected cancer however many people who are referred do not actually have cancer
- 2ww means you will have test and see a doctor within the next 2 weeks
- refer at this stage as important if It is cancer that we catch cancer early
Explain a gastroscopy
see page 4 of notes; - test to look at the inside of the gullet (oesophagus), the stomach and the first part of the gut (small intestine) known as the duodenum - explain why doing the procedure - advise them of the risk explain about sedation - assess capacity
What is GORD
Gastro-oesophageal reflux disease (GORD) is where acid from the stomach refluxes through the lower oesophageal sphincter and irritates the lining of the oesophagus.
the oesophagus is lined with what kind of cells
the stomach is lined with what kind of cells
squamous epithelial for oesophagus
columnar epithelial lining for stomach
How does someone with GORD usually present
Dyspepsia is a non-specific term used to describe indigestion. It covers the symptoms of GORD: • Heartburn • Acid regurgitation • Retrosternal or epigastric pain • Bloating • Nocturnal cough • Hoarse voice
what can endoscopy be used to assess
for peptic ulcers, oesophageal or gastric malignancy
Patients with evidence of a GI bleed need admission and urgent endoscopy. Name the evidence you would see
meleana or coffee ground vomit
what are the key red flags to ask about in someone with GORD
- Dysphagia (difficulty swallowing) at any age gets a two week wait referral
- Aged over 55 (this is generally the cut off for urgent versus routine referrals)
- Weight loss
- Upper abdominal pain / reflux
- Treatment resistant dyspepsia
- Nausea and vomiting
- Low haemoglobin
- Raised platelet count
what lifestyle advise can you give to someone with GORD
- Reduce tea, coffee and alcohol
- Weight loss
- Avoid smoking
- Smaller, lighter meals
- Avoid heavy meals before bed time
- Stay upright after meals rather than lying flat
what acid neutralising medications can you tell the patient to take when required
- Gaviscon
* Rennie
Name some examples of PPIs which reduce acid secretion in the stomach
Omeprazole
lansoprazole
What is the alternative to PPI
ranitidine which is a H2 receptor antagonist (anti-histamine) which also reduces stomach acid
what is the surgery called for people with reflux
laparoscopic fundoplication
What kind of bacteria is H.pylori
gram negative aerobic bacteria
How does H.pylori cause damage
- It causes damage the epithelial lining of the stomach resulting in gastritis, ulcers and increasing the risk of stomach cancer.
- It avoids the acidic environment by forcing its way into the gastric mucosa. The breaks it creates in the mucosa exposes the epithelial cells underneath to acid.
- It also produces ammonia to neutralise the stomach acid.
- The ammonia directly damages the epithelial cells. Other chemicals produced by the bacteria also damage the epithelial lining.
how do you test for H.Pylori
They need 2 weeks without using a PPI before testing for H. pylori for an accurate result.
Tests
• Urea breath test using radiolabelled carbon 13
• Stool antigen test
• Rapid urease test can be performed during endoscopy.
what is the treatment for H. Pylori
The eradication regime involves triple therapy with a proton pump inhibitor (e.g. omeprazole) plus 2 antibiotics (e.g. amoxicillin and clarithromycin) for 7 days.
what is Barretts oesophagus
- Constant reflux of acid results in the lower oesophageal epithelium changing in a process known as metaplasia from a squamous to a columnar epithelium.
- when this change happens patients usually get an improvement in reflux symptoms
Barretts oesophagus is considered a ‘premalignant’ condition and is a risk factor for the development of what
adenocarcinoma of the oesophagus
in some patients there is a progression from Barretts oesophagus (columnar epithelia) with no dysplasia to what
low grade dysplasia to high grade dysplasia and then to adenocarcinoma.
What is dysplasia
Presence of cells of an abnormal type within a tissue
what is the treatment of Barretts oesophagus
PPI
some evidence that regular aspirin can reduce the rate of adenocarcinoma however this is not yet in guidelines
what therapy is used to destroy the epithelium so that it is replaced with normal cells in Barretts oesophagus with dysplasia
Ablation treatment during endoscopy using photodynamic therapy, laser therapy or cryotherapy
The majority of cancers of the lower third of oesophagus are what main types
squamous cell cancer or adenocarcinoma
Name some investigations from the lecture for people with ? oesophageal cancer
- OGD, bloods, ECG/PFT (pulmonary function tests)/CXR
- CT TAP
- EUS
- PET
- Laparoscopy- camera into lining looking for metastasis
- CPx- fitness level, some sort of cardiovascular test which determines your chance of getting surgery/therapy
name some treatments from the lecture for people with oesophageal cancer
- Surgery- open vs laparoscopic
- Chemotherapy- neoadjuvant/definitive/palliative
- Radiotherapy- SCC
- Endoscopic- EMR/ESD
- Combination
- Palliative- stenting/PEG/PEJ/ jejunal feeding/surgical bypass/ paracentesis/drugs etc
Tell me about the structure of the oesophagus
• Skeletal top 1/3, skeletal and smooth in the middle 1/3, smooth muscle in the lower 1/3rd of the oesophagus
what is odynophagia and what conditions can typically cause this
pain when swallowing
oesophageal ulcers or tumours
what is peristalsis
wave like propulsion of food
In what kind of patients are fungal infections of the oesophagus more likely in
patients who are immunocompromised for example patients taking inhaled or oral steroids, patients on anti-rejection drugs following organ transplantation or patients infected with HIV
treatment is with oral anti-fungals
what type of fungus is most frequent in patients who are immunocompromised
candidiasis
