Barret's Oesophagus & Hiatus Hernia

Question 1

=What is the main complication of Barret’s oesophagus?

Answer 1

Oesophageal Adenocarcinoma

Question 2

Define Barret’s oesophagus

Answer 2

Metaplastic change of the distal oesophagus from squamous epithelium -> columnar epithelium which may contribute to increasing the risk of adenocarcinoma

Question 3

What type of tumour is most common in the:
Upper 1/3:
Middle 1/3:
Lower 1/3 of the oesophagus:

For each state the most characteristic RF

Answer 3

Upper 1/3: SCC (smoking)
Middle 1/3: SCC (achalasia)
Lower 1/3 Adenocarcinoma (Barret’s)

Question 4

How is Barret’s oesophagus classified?

Answer 4

Short segment: <3cm
Long segment: >3cm

Question 5

what are the top 2 RFs for Barret’s oesophagus

Answer 5

Obesity
GORD

Question 6

How is Barret’s oesophagus Diagnosed?

Answer 6

OGD with biopsy

Question 7

What are the surgical management options for Barret’s oesophagus?

Answer 7

Radio-frequency ablation
Endoscopic mucosal resection
Oesophagectomy
All + OGD in 3-6 months

Question 8

How would you manage barret’s oesophagus?

Answer 8

1) Preventative/lifestyle:
Dietician for:
1) Smaller meals at regular intervals
2) Avoid late night food intake
3) Avoid gastric irritants (caffeine, chocolate, spicy food)
4) Weight loss (RF)

Quit.ie = Smoking cessation

AAA, education, limit to 14U => Alcohol control

Speech and language therapy (for severe cases)

2) Medical:
PPI - Pentroprazole, omeprazole
H2 blockers - Ranitidine

Mucosal protection: Sucralfate
Ant-acid: Gaviscon

Pro-kinetic: Metoclopramide
+/- eradication of H-Pylori (PAC 500, PMC 250)

3) Surgical:
Radio-frequency ablation
Endoscopic mucosal resection
Oesophagectomy
All + OGD in 3-6 months

Question 9

OGD with biopsy is used to diagnose Barret’s oesophagus.

How is it performed?
Explain the results algorithm including the management for each result

Answer 9

Taken every 1 cm and from all 4 quadrants

If no dysplasia -> Repeat OGD in 6-12 months then every 3-5yrs

If Low-grade dysplasia -> Repeat OGD in 3-6 months or Radiofrequency ablation w/ OGD in 3-6 months post-op

If High grade Dysplasia -> Confirm with 2 pathologists and perform Endoscopic Mucosal resection or Oesophagectomy and either way repeat OGD in 3-6 months post-op

Question 10

What is a Hiatus Hernia? Define it

Answer 10

Prolapse of the gastroesophageal junction (GOJ) and part or all of the stomach into the thoracic cavity via the oesophageal diaphragmatic hiatus

Question 11

What are the 4 types of Hiatus Hernia? Define each

Answer 11

1) Sliding (GOJ slides into chest)
2) Paraesophageal/rolling (Gastric fundus in chest but GOJ remains in situ)
3) Combined (both GOJ and fundus in chest)
4) Complex (Both + other organs)

Question 12

Which type of hiatus hernia is most commonly associated with GORD?

Answer 12

Sliding Hernia

Question 13

The majority of hiatus hernia is asymptomatic or with GORD. Between Sliding and paraesophageal hiatus hernia, which is associated with more complications and what are these complications?

Answer 13

Paraesophageal hernia is associated with volvulus, incarceration and => obstruction

Question 14

What is the best diagnostic test for Hiatus Hernia? What findings will it show?

Answer 14

Lateral CXR w/Barium swallow -> Showing air fluid level in posterior mediastinum (rather than the abdomen)

Question 15

What is the best diagnostic test to confirm a suspected volvulus for a paraesophageal hiatus hernia?

Answer 15

CT scan best for showing suspected volvulus in paraesophageal/rolling hiatus hernia

Question 16

What are the 3 most important diagnostic investigations for Hiatus Hernia? State the expected findings or rationale for each

Answer 16

Lateral CXR w/Barium swallow -> Showing air fluid level in posterior mediastinum (rather than the abdomen)

CT scan best for showing suspected volvulus in paraesophageal/rolling hiatus hernia

OGD to visualize mucosa

Question 17

Does performing an OGD rule out a hiatus hernia?

Answer 17

No

Question 18

What is the fully surgical management of Hiatus Hernia? When is it indicated?

Answer 18

Indicated if symptoms persist despite maximal medical management

Hernia repair surgery involves 3 parts Laparoscopic/robotic reduction of hernia + Gastropexy + Nissen Fundoplication

+ Followup CXR to assess position of stomach and assess for recurrence/reherniation

Question 19

What is a gastropexy in the context of hiatus hernia repair?

Answer 19

Excision of hernia + gastric fixation

Question 20

What is the full management plan for hiatus hernia?

Answer 20

1) Preventative/lifestyle:
Dietician for:
1) Smaller meals at regular intervals
2) Avoid late night food intake
3) Avoid gastric irritants (caffeine, chocolate, spicy food)
4) Weight loss (RF)

Quit.ie = Smoking cessation

AAA, education, limit to 14U => Alcohol control

Speech and language therapy (for severe cases)

2) Medical:
PPI - Pentroprazole, omeprazole
H2 blockers - Ranitidine

Mucosal protection: Sucralfate
Ant-acid: Gaviscon

Pro-kinetic: Metoclopramide
+/- eradication of H-Pylori (PAC 500, PMC 250)

3) Surgical:
Hernia repair surgery involves 3 parts Laparoscopic/robotic reduction of hernia + Gastropexy + Nissen Fundoplication

+ Followup CXR to assess position of stomach and assess for recurrence/reherniation

Question 21

What are the complications of hiatus hernia?

Answer 21

GORD complications: Oesophagitis, Ulceration, Bleeding => Fe-deficiency anaemia
Gastric volvulus -> Gastric Ischaemia (paraesophageal/rolling)

Question 22

What is the presentation of a person with paraoesophageal hiatus hernia complicated by gastric volvulus?

Answer 22

Vomiting
Severe acute chest pain
Collapse

Question 23

Air fluid level in the posterior mediastinum is seen on lateral CXR. What are your top 2 differentials?

Answer 23

Rolling/paraesophageal hiatus hernia
Achalasia