Benign and malignant Oesophageal and stomach disease Flashcards
Benign obstructive oesophageal disease mechanisms
Extrinsic/ extraluminal
Transmural
Neurogenic
Luminal
Functional
Examples of extrinsic/extraluminal benign obstructive oesophageal disease
Retrosternal goitre
Bronchogenic tumor
Examples of Transmural benign obstructive oesophageal disease
GIST (GI stromal tumour)
Rare–>can resect or enucleate.
- Interstitial, cajal GI cells.
- Low malignant potential, compared to others in GIT.
Leiomyoma
- Smooth muscle tumour, more common than GIST
- Treatment= Enucleating, resection
Examples of neurogenic benign obstructive oesophageal disease
Achalasia
CREST syndrome
- Connective tissue disorder
Chaga’s disease
Achalasia
- Pathophysiology
- Classification
Failure of LES to relax/open
- Due to degeneration of myenteric (Auerbach’s) plexus
Primary
- Idiopathic (most common, in younf adulthood)
- Secondary : Chaga’s disease)
Chaga’s disease
Parasitic disease- Trypanosoma cruzi.
- Can cause enlarged oesophagus, secondary achalasia
Causes of luminar benign obstructive oesophageal disease
- Schatzki’s ring
- Benign stricture
Causes of functional benign obstructive oesophageal disease
Nutcracker oesophagus
Diffuse oesophageal spasms
Hypertensive LES.
Hiatus hernia
- Description
- Risk factors
- Types
Herniation of some/ all of the stomach through the diaphragm, into the mediastinum.
Risk factors
- M> F
- Obesity, previous surgery
Types
- Type 1, Reflux
- Type 2, Rolling.
Type 1, reflux hiatus hernia
Hernia in which there is a shifting Z line
- Most common
Herniation is due to circumferential laxity of the phrenoesophageal membrane.
- May result in GORD
Type 2, rolling hiatus hernia
Hernia in which the Z-line is non-shifiting.
Herniation is due to focal weakness of phrenoesophageal membrane.
- Risk of strangulation which can cut off blood supply/ obstruction
Symptoms
- Hiccough
- Pressure in chest
- Odynophagia
Gastric volvulus
- Pathophysiology
- Types
- Treatment
Rotation of the stomach of >180 degrees, causing a closed loop obstruction.
Types:
Mesentericoaxial
- Rotates on an axial axis.
Organoaxial
- rotates around vertical axis of organ.
Treatment
- RESUS if necessary
- NBM
- NGT decompression
- Strangulation= surgery (fundoplication, gastropexy, venting PEG)
Three investigations for obstructive oesophagopathy
OGD
- Shows mass
- Herniation
Manometry
- Rules out achalasia
- Will show LES failing to relax
Barium swallow
- Depicts achalasia (rat’s tail)
Boerhaave’s syndrome
Transmural tear of oesophagus to due sudden increase in pressure from vomiting.
Cricopharyngeus muscle of pharynx fails to contract so bolus cannot escape, causing high pressure and rupture.
GORD
- Definition
- Complications
- Risk factor
SYMPTOMATIC reflux of gastric content into the oesophagus, sometimes pharynx.
Complications
- Oesophagitis
- Stricture
- Barrett’s oesophagus–>cancer
Risk factors - Smoking - Alcohol - Hiatus hernia - Pregnancy Obesity
Pathophysiology of GORD
Lower oesophagus sphincter incompetency
- Prolonged relaxation
- Hypotensive
- Disruption of eosophago-gastric junction (hernia)
Red flag signs in dyspepsia
- Dysphagia
- Vomiting
- Weight loss
- Iron deficiency
- Blood loss
- Mass
Grades of reflux oesophagitis (1-5)
- Single or multiple erosions in single longitudinal fold
- Erosions on multiple folds
- Confluent, circular erosions. Friability
- Strictures, deep ulcers
- Barrett’s oesophagus
Differentials for GORD [7]
Infection: CMV, herpes, Candida
Peptic ulcers
Gastric cancer
Achalasia
Oesophagitis
Investigations for GORD
Bloods:
- FBC, U+E, CRP, LFT
OGD
24 Hr oesophageal pH measurement
- 8%, pH<4
- Used when: atypical symptoms, treatment not working, pre-surgery, no oesophagitis in OGD
LES manometry
- Rules out achalasia
Indications for surgical management of GORD
- Failed medical management
- Side effects
- No symptomatic relief - Consideration of quality of life and long-term medication despite medical management
- Complications of GORD
- Barrett’s
- Strictures
- large volume reflux with aspiration risk - Extra-oesophageal manifestations
Extra-oesophageal manifestations of GORD
- Asthma
- Cough
- Aspiration
- Hoarse voice
- Chest pain
Surgical procedures for GORD
Nissen’s fundoplication
- Wrap the fundus of stomach, 360, around lower oesophagus
Toupet Partial fundo
- Fundus is only partially wrapped around oesophagus. Less aggravation of dysphagia.
Belsey Mark IV
Hill repair
- Partial wrap of fundus around oesophagus
Gastropexy
- Suture the stomach to abdominal wall or diaphragm
Achalasia
- Presentation
- complications
Slowly progressive dysphagia
- Initially worse for fluids, than solids
Later disease
- Regurgitation of undigested food
Weight loss
Aspiration pneumonia
Complications
- Oesophageal SCC
Diffuse oesophageal spasm
- Description
- Diagnosis
Acute pain along the esophagus induced by ingestion (odynophagia)
- May be accompanied with dysphagia
- Due to uncoordinated contraction
Diagnosis
- Barium swallow shows ‘corkscrew’ appearance
- Manometry= diffuse hypertonicity
- Endoscopy= rules out malignancy
Achalasia
- Management
Palliative
- CCB
- Nitrates
- Lifestyle changes
Interventions
- Endoscopic guided controlled balloon dilatation: need multiple procedures, but successful in most patients.
- Botulinum toxin injections
Surgery
- Heller myotomy= cut out muscle layer of lower oesophagus, but not inner layer.
Complications: reflux, obstruction at GOJ, oesophageal perforation
- Dor patch= Partial wrapping of stomach around oesophagus. Makes low pressure valve.
Diffuse oesophageal spasm
- Management
Medications
- Oral CCB
- Relaxants= benzos
- Long acting nitrates
Pneumatic dilatations
- usually repeated
Surgical
- Open myotomy (rare)
Pharyngeal pouch
- Description
- Causes
- Presentation
Also called Zenker’s diverticulum
Acquired diverticulum arising from tissue between inferior constrictor and cricopharyngeus muscle of the oesophagus.
- Typically affects elderly
Cause
- Inappropriate relaxation of cricopharyngeus= increased pressure on tissue above during swallowing
- Lower CN dysfunction
Presentation
- Supper cervical dysphagiia
- Intermmittent lump appearing when swallowing
- Regurgiation of undigested food
- Nocturnal aspiration
Pharyngeal pouch
- Diagnosis
Observation of swallowing
- Transient neck swelling appears
Video barium swallow
- Filling of pouch
Gastroscopy avoided
Pharyngeal pouch
- Treatment
Stapled pharyngoplasty
- Endoscopic
- Staple pouch to upper oesophagus
Hiatus hernia treatment
- Lifestyle
- Medical
- Surgical (indications
Lifestyle
- Stop smoking
- Weight loss
- Reduce alcohol consumption
Medical
- PPIs
- Antacids
- Promote gastric emptying: metoclopramide
Surgical
Hiatus hernia treatment
- Surgical (indications
- Procedures
Indications
- Persistent symptoms despite maximal medical management
- Complications of rolling hernia
Procedures
- Gastropexy (with crural plication)
- Fundoplication (Nissen’s) for GORD
- Gastrectomy (rare)
Hiatus hernia
- diagnosis
CXR
- Gas bubble/ fluid in chest
Upper Gi series
- Barium examination of GIT= diagnostic
OGD (reflux symptoms)
- Oesophagitis
24 pH manometry
- Excludes achalasia, dysmotility
Upper GI cancer referral symptoms/ signs
Nausea and vomiting
Dyspepsia
Upper abdominal pain
Reflux
Haematemesis
Anaemia/ Thrombocytopenia
