Barret's Oesophagus & Hiatus Hernia Flashcards
=What is the main complication of Barret’s oesophagus?
Oesophageal Adenocarcinoma
Define Barret’s oesophagus
Metaplastic change of the distal oesophagus from squamous epithelium -> columnar epithelium which may contribute to increasing the risk of adenocarcinoma
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
Upper 1/3: SCC (smoking)
Middle 1/3: SCC (achalasia)
Lower 1/3 Adenocarcinoma (Barret’s)
How is Barret’s oesophagus classified?
Short segment: <3cm
Long segment: >3cm
what are the top 2 RFs for Barret’s oesophagus
Obesity
GORD
How is Barret’s oesophagus Diagnosed?
OGD with biopsy
What are the surgical management options for Barret’s oesophagus?
Radio-frequency ablation
Endoscopic mucosal resection
Oesophagectomy
All + OGD in 3-6 months
How would you manage barret’s oesophagus? (Full management)
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
OGD with biopsy is used to diagnose Barret’s oesophagus.
How is it performed?
Explain the results algorithm including the management for each result
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
What is a Hiatus Hernia? Define it
Prolapse of the gastroesophageal junction (GOJ) and part or all of the stomach into the thoracic cavity via the oesophageal diaphragmatic hiatus
What are the 4 types of Hiatus Hernia? Define each
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)
A complex hernia includes other organs. What are the top 3 organs that are found?
1) Greater Omentum
2) Small bowel
3) Large Bowel
Which type of hiatus hernia is most commonly associated with GORD?
Sliding Hernia
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?
Paraesophageal hernia is associated with volvulus, incarceration and => obstruction
What is the best diagnostic test for Hiatus Hernia? What findings will it show?
Lateral CXR w/Barium swallow -> Showing air fluid level in posterior mediastinum (rather than the abdomen)
What is the best diagnostic test to confirm a suspected volvulus for a paraesophageal hiatus hernia?
CT scan best for showing suspected volvulus in paraesophageal/rolling hiatus hernia
What are the 3 most important diagnostic investigations for Hiatus Hernia? State the expected findings or rationale for each
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
Does performing an OGD rule out a hiatus hernia?
No
What is the fully surgical management of Hiatus Hernia? When is it indicated?
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
What is a gastropexy in the context of hiatus hernia repair?
Excision of hernia + gastric fixation
What is the full management plan for hiatus hernia?
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
What are the complications of hiatus hernia?
GORD complications: Oesophagitis, Ulceration, Bleeding => Fe-deficiency anaemia
Gastric volvulus -> Gastric Ischaemia (paraesophageal/rolling)
What is the presentation of a person with paraoesophageal hiatus hernia complicated by gastric volvulus?
Vomiting
Severe acute chest pain
Collapse
Air fluid level in the posterior mediastinum is seen on lateral CXR. What are your top 2 differentials?
Rolling/paraesophageal hiatus hernia
Achalasia
