3.01 General Surgery - Oesophageal Disease Flashcards
What is gastro-oesophageal reflux disease (GORD)?
A condition whereby gastric acid from the stomach leaks up into the oesophagus.
What is the pathophysiology of GORD?
Frequent relaxation of the lower oesophageal sphincter allows the reflux of gastric contents into the oesophagus, which results in pain and mucosal damage in the oesophagus.
What are the risk factors for GORD?
- age
- obesity
- male gender
- alcohol
- smoking
- caffeine intake
- fatty / spicy foods
What are the clinical features of GORD?
- retrosternal chest pain
- burning
- worse after meals
- worse when lying down
- relieved by antacids
- excessive belching
- chronic / nocturnal cough
NOTE always check for red flag symptoms (ie. dysphagia, weight loss, early satiety, malaise, loss of appetite) for underlying malignancy.
What are the differential diagnoses for GORD?
- oesophageal malignancy
- gastric malignancy
- peptic ulceration
- oesophageal motility disorders
- coronary artery disease
- biliary colic
What investigations are warranted for a patient presenting with the red-flag symptoms of an upper GI malignancy?
Red flag sx: dysphagia, weight loss, upper abdominal pain, dyspepsia, reflux.
Patients require urgent endoscopy.
Outline the main role of upper GI endoscopy.
Excludes malignancy and investigates for complications of reflux, including oesophagitis, stricturing and Barrett’s oesophagus.
What is the gold standard investigation in the diagnosis of GORD?
24hr pH monitoring, which studies the amount of time acid is present in the oesophagus.
Note a diagnosis can usually be made without upper GI endoscopy or 24hr pH monitoring, based upon clinical features and relief from PPI.
What is the medical management of GORD?
Conservative management:
- avoid alcohol, coffee and fatty / spicy foods
- weight loss
- smoking cessation
Proton pump inhibitors (PPI) are first line treatment and are very effective for the majority of patients.
What are the indications for surgical management of GORD?
- failure to respond to PPI
- patient preference to avoid life-long medication
- patients with complications of GORD
Explain the main surgical intervention that can be offered for patients with GORD.
Fundoplication
A lower oesophageal sphincter is recreated by wrapping the fundus of the stomach around the gastro-oesophageal junction.
What are the main side effects of fundoplication?
- dysphagia
- bloating
- inability to vomit
Sx often settle after 6 weeks in most patients. However, if the fundus is wrapped too tight, it can cause occlusion and needs a revision procedure.
What are the main complications of GORD?
- aspiration pneumonia
- Barrett’s oesophagus
- oesophageal strictures
- oesophageal cancer*
*7yr risk of developing adenocarcinoma is around 0.1%
Define Barrett’s oesophagus.
Metaplasia of the distal oesophageal epithelial lining, whereby normal stratified squamous epithelium is replaced by simple columnar epithelium.
What are the causes of the Barrett’s oesophagus?
Chronic GORD damages the epithelium of the oesophagus and results in metaplastic transformation from stratified squamous epithelium to simple columnar epithelium.
What are the risk factors for Barrett’s oesophagus?
- Caucasian ethnicity
- male gender
- age >50yrs
- smoking
- obesity
- hiatus hernia
How is Barrett’s oesophagus investigated?
Commonly found incidentally when performing an upper GI endoscopy for chronic / resistant GORD or to exclude malignancy.
At endoscopy, Barrett’s oesophagus appears red and velvety. A biopsy should be taken and sent for histological analysis - it is a histological diagnosis.
What is the management of Barrett’s oesophagus?
- PPI (high dose and BDS)
- medications impacting stomach barriers stopped (e.g. NSAIDS)
- regular endoscopy to ensure no adenocarcinoma
What is the main complication of Barrett’s oesophagus?
Adenocarcinoma development - regular endoscopy based upon degree of dysplasia identified by the biopsies.
How is high-grade dysplastic Barrett’s oesophagus managed?
High risk of progressing to cancer, so resected using endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD).
What are the classifications of oesophageal cancer?
- squamous cell carcinoma
- adenocarcinoma
Give some features of oesophageal squamous cell carcinoma.
- more common in developing world
- typically occurs in middle and upper third of oesophagus
- associated with smoking & excessive alcohol consumption
Give some features of oesophageal adenocarcinoma.
- more common in the developed world
- typically occurs in lower third of oesophagus
- associated with GORD, obesity and high fat intake
Describe how oesophgeal adenocarcinoma most commonly develops.
Chronic GORD results in metaplastic changes to the distal oesophagus, which sees stratified squamous epithelium change to simple columnar epithelium.
Metaplastic epithelium progresses to dysplasia, to eventually become malignant.
What are the clinical features of oesophageal cancer?
- dysphagia (progressive, affecting solids first)*
- weight loss
- odynophagia
- hoarseness
- weight loss
- supraclavicular lymphadenopathy
*Any patient with dysphagia should be assumed to have oesophageal cancer until proven otherwise.
What are the investigations for a patient presenting with dysphagia?
Urgent upper GI endoscopy - red flag sx of oesophageal cancer.
Any malignancy seen will be biopsied and sent for histology.
Before undergoing curative treatment, what investigations can be used to stage oesophageal cancer?
- CT CAP / PET-CT to investigate distant metastases (M and N staging)
- endoscopic ultrasound to measure penetration into oesophageal wall (T staging)
How is oesophageal cancer managed?
- chemoradiotherapy
- oesophageal resection
- palliate
What is the palliative management of oesophageal cancer?
- oesophageal stent to help relieve dysphagia
- chemoradiotherapy
- nutritional support
At what vertebral level does the oesophagus originate?
C6
What are oesophageal motility disorders?
A group of conditions characterised by abnormalities in oesophageal peristalsis.
They typically manifest with difficulty swallowing solids and liquids together.
What is the function of
a) upper oesophageal (UOS)
b) lower oesophageal sphincter (LOS)
a) prevents air entering the GI tract
b) prevents reflux from the stomach
What is diffuse oesophageal spasm?
A disease characterised by multi-focal high amplitude contractions of the oesophagus, caused by dysfunction of oesophageal inhibitory nerves.
What are the clinical features of diffuse oesophageal spasm?
- severe dysphagia to both solids and liquids
- central chest pain
- exacerbated by food
- responds to nitrates, therefore difficult to distinguish from angina
How is diffuse oesophageal spasm investigated?
Manometry - a pressure sensitive probe inserted into the oesophagus, which measures the pressure of the LOS and surrounding muscle.
Findings will reveal a pattern of repetitive, simultaneous and ineffective contractions of the oesophagus.
How is diffuse oesophageal spasm managed?
- CCB first line (limit the strongest contractions and provide symptomatic improvement)
Surgical options available however carry a high risk of disease recurrence.
What is achalasia?
The failure of relaxation of the LOS and the absence of peristalsis along the oesophageal body.
What are the histological findings of achalasia?
Progressive destruction of the ganglion cells in the myenteric plexus.
What are the clinical features of achalasia?
- progressive dysphagia with solids and liquids
- regurgitation of food
- respiratory complications (e.g. nocturnal cough, aspiration)
- chest pain
- dyspepsia
- weight loss
How is achalasia investigated?
In any patient presenting with dysphagia, upper GI endoscopy performed - in severe cases of achelasia, the oesophagus may be dilated and increased resistance at GOJ.
Gold standard investigation in oesophageal manometry.
What are the three key features of manometry for achalasia?
- absence of oesophageal peristalsis
- failure of relaxation of LOS
- high resting LOS tone
How is achalasia managed?
Conservative management:
- sleep with multiple pillows
- eat slowly
- drink fluids with meals
Medical management:
- CCB (inhibit LOS muscle contraction)
- botox injections into LOS via endoscopy
Surgical management:
- endoscopic balloon dilatation
Aside from achalasia and diffuse oesophageal spasms, give some other causes of oesophageal dysmotility.
- systemic sclerosis
- dermatomyositis
- polymositis
What is the muscle type found in the
a) upper third
b) middle third
c) lower third
of the oesophagus?
a) skeletal muscle
b) skeletal muscle and smooth muscle
c) smooth muscle
What is oesophageal perforation?
Full thickness rupture of the oesophageal wall, often called Boerhaave’s syndrome.
Outline the pathology of physiological consequences of oesophageal perforation.
Often due to vomiting.
Perforation results in leakage of stomach contents into the mediastinum and pleural cavity, triggering a severe and overwhelming inflammatory response.
This results in physiological collapse, multi-organ failure, and death.
What is the most common site of oesophageal perforation?
Just above the diaphragm in the left postero-lateral position.
What are the clinical features of oesophageal tears?
Sudden onset:
- retrosternal chest pain
- respiratory distress
- subcutaneous emphysema
How is suspected oesophageal perforation investigated?
- routine bloods, including group and save
- CXR
- GOLD STANDARD is CT CAP with IV/PO contract
What is the general management of oesophageal rupture?
- control oesophageal leak
- eradication of mediastinal and pleural contamination
- decompress the oesophagus (NG tube)
- nutritional support
Patients are often septic and haemodynamically unstable so will require aggressive resuscitation.
What is the surgical management of an oesophageal ruptures?
- immediate surgery
- control leak
- wash out of chest
What is the prognosis of an oesophageal perforation?
Morbidity and mortality is high
What is a Mallory-Weiss tear?
Lacerations in the oesophageal mucosa, usually at the GOJ.
Occur after a period of profuse vomiting, resulting in a short period of haematemesis.
They are generally small and self-limiting, in the absence of clotting abnormalities or anti-coagulation drugs.
