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Year 3 - Surgery > 3.01 General Surgery - Oesophageal Disease > Flashcards

3.01 General Surgery - Oesophageal Disease Flashcards

1
Q

What is gastro-oesophageal reflux disease (GORD)?

A

A condition whereby gastric acid from the stomach leaks up into the oesophagus.

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2
Q

What is the pathophysiology of GORD?

A

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.

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3
Q

What are the risk factors for GORD?

A
  • age
  • obesity
  • male gender
  • alcohol
  • smoking
  • caffeine intake
  • fatty / spicy foods
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4
Q

What are the clinical features of GORD?

A
  • 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.

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5
Q

What are the differential diagnoses for GORD?

A
  • oesophageal malignancy
  • gastric malignancy
  • peptic ulceration
  • oesophageal motility disorders
  • coronary artery disease
  • biliary colic
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6
Q

What investigations are warranted for a patient presenting with the red-flag symptoms of an upper GI malignancy?

A

Red flag sx: dysphagia, weight loss, upper abdominal pain, dyspepsia, reflux.

Patients require urgent endoscopy.

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7
Q

Outline the main role of upper GI endoscopy.

A

Excludes malignancy and investigates for complications of reflux, including oesophagitis, stricturing and Barrett’s oesophagus.

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8
Q

What is the gold standard investigation in the diagnosis of GORD?

A

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.

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9
Q

What is the medical management of GORD?

A

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.

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10
Q

What are the indications for surgical management of GORD?

A
  1. failure to respond to PPI
  2. patient preference to avoid life-long medication
  3. patients with complications of GORD
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11
Q

Explain the main surgical intervention that can be offered for patients with GORD.

A

Fundoplication

A lower oesophageal sphincter is recreated by wrapping the fundus of the stomach around the gastro-oesophageal junction.

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12
Q

What are the main side effects of fundoplication?

A
  • 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.

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13
Q

What are the main complications of GORD?

A
  • aspiration pneumonia
  • Barrett’s oesophagus
  • oesophageal strictures
  • oesophageal cancer*

*7yr risk of developing adenocarcinoma is around 0.1%

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14
Q

Define Barrett’s oesophagus.

A

Metaplasia of the distal oesophageal epithelial lining, whereby normal stratified squamous epithelium is replaced by simple columnar epithelium.

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15
Q

What are the causes of the Barrett’s oesophagus?

A

Chronic GORD damages the epithelium of the oesophagus and results in metaplastic transformation from stratified squamous epithelium to simple columnar epithelium.

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16
Q

What are the risk factors for Barrett’s oesophagus?

A
  • Caucasian ethnicity
  • male gender
  • age >50yrs
  • smoking
  • obesity
  • hiatus hernia
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17
Q

How is Barrett’s oesophagus investigated?

A

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.

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18
Q

What is the management of Barrett’s oesophagus?

A
  • PPI (high dose and BDS)
  • medications impacting stomach barriers stopped (e.g. NSAIDS)
  • regular endoscopy to ensure no adenocarcinoma
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19
Q

What is the main complication of Barrett’s oesophagus?

A

Adenocarcinoma development - regular endoscopy based upon degree of dysplasia identified by the biopsies.

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20
Q

How is high-grade dysplastic Barrett’s oesophagus managed?

A

High risk of progressing to cancer, so resected using endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD).

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21
Q

What are the classifications of oesophageal cancer?

A
  • squamous cell carcinoma
  • adenocarcinoma
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22
Q

Give some features of oesophageal squamous cell carcinoma.

A
  • more common in developing world
  • typically occurs in middle and upper third of oesophagus
  • associated with smoking & excessive alcohol consumption
23
Q

Give some features of oesophageal adenocarcinoma.

A
  • more common in the developed world
  • typically occurs in lower third of oesophagus
  • associated with GORD, obesity and high fat intake
24
Q

Describe how oesophgeal adenocarcinoma most commonly develops.

A

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.

25
Q

What are the clinical features of oesophageal cancer?

A
  • 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.

26
Q

What are the investigations for a patient presenting with dysphagia?

A

Urgent upper GI endoscopy - red flag sx of oesophageal cancer.

Any malignancy seen will be biopsied and sent for histology.

27
Q

Before undergoing curative treatment, what investigations can be used to stage oesophageal cancer?

A
  • CT CAP / PET-CT to investigate distant metastases (M and N staging)
  • endoscopic ultrasound to measure penetration into oesophageal wall (T staging)
28
Q

How is oesophageal cancer managed?

A
  • chemoradiotherapy
  • oesophageal resection
  • palliate
29
Q

What is the palliative management of oesophageal cancer?

A
  • oesophageal stent to help relieve dysphagia
  • chemoradiotherapy
  • nutritional support
30
Q

At what vertebral level does the oesophagus originate?

A

C6

31
Q

What are oesophageal motility disorders?

A

A group of conditions characterised by abnormalities in oesophageal peristalsis.

They typically manifest with difficulty swallowing solids and liquids together.

32
Q

What is the function of

a) upper oesophageal (UOS)

b) lower oesophageal sphincter (LOS)

A

a) prevents air entering the GI tract

b) prevents reflux from the stomach

33
Q

What is diffuse oesophageal spasm?

A

A disease characterised by multi-focal high amplitude contractions of the oesophagus, caused by dysfunction of oesophageal inhibitory nerves.

34
Q

What are the clinical features of diffuse oesophageal spasm?

A
  • severe dysphagia to both solids and liquids
  • central chest pain
  • exacerbated by food
  • responds to nitrates, therefore difficult to distinguish from angina
35
Q

How is diffuse oesophageal spasm investigated?

A

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.

36
Q

How is diffuse oesophageal spasm managed?

A
  • CCB first line (limit the strongest contractions and provide symptomatic improvement)

Surgical options available however carry a high risk of disease recurrence.

37
Q

What is achalasia?

A

The failure of relaxation of the LOS and the absence of peristalsis along the oesophageal body.

38
Q

What are the histological findings of achalasia?

A

Progressive destruction of the ganglion cells in the myenteric plexus.

39
Q

What are the clinical features of achalasia?

A
  • progressive dysphagia with solids and liquids
  • regurgitation of food
  • respiratory complications (e.g. nocturnal cough, aspiration)
  • chest pain
  • dyspepsia
  • weight loss
40
Q

How is achalasia investigated?

A

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.

41
Q

What are the three key features of manometry for achalasia?

A
  • absence of oesophageal peristalsis
  • failure of relaxation of LOS
  • high resting LOS tone
42
Q

How is achalasia managed?

A

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

43
Q

Aside from achalasia and diffuse oesophageal spasms, give some other causes of oesophageal dysmotility.

A
  • systemic sclerosis
  • dermatomyositis
  • polymositis
44
Q

What is the muscle type found in the

a) upper third

b) middle third

c) lower third

of the oesophagus?

A

a) skeletal muscle

b) skeletal muscle and smooth muscle

c) smooth muscle

45
Q

What is oesophageal perforation?

A

Full thickness rupture of the oesophageal wall, often called Boerhaave’s syndrome.

46
Q

Outline the pathology of physiological consequences of oesophageal perforation.

A

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.

47
Q

What is the most common site of oesophageal perforation?

A

Just above the diaphragm in the left postero-lateral position.

48
Q

What are the clinical features of oesophageal tears?

A

Sudden onset:

  • retrosternal chest pain
  • respiratory distress
  • subcutaneous emphysema
49
Q

How is suspected oesophageal perforation investigated?

A
  • routine bloods, including group and save
  • CXR
  • GOLD STANDARD is CT CAP with IV/PO contract
50
Q

What is the general management of oesophageal rupture?

A
  • 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.

51
Q

What is the surgical management of an oesophageal ruptures?

A
  • immediate surgery
  • control leak
  • wash out of chest
52
Q

What is the prognosis of an oesophageal perforation?

A

Morbidity and mortality is high

53
Q

What is a Mallory-Weiss tear?

A

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.

Year 3 - Surgery (30 decks)

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