Case 11 SAP Flashcards
Prevalence dysphagia
General 20%, affects up to 50% over 60s
Types of dysphagia
Oropharyngeal and oesophageal
Neurological causes of oropharyngeal dysphagia
Stroke, head trauma, neurodegenerative disease
Muscular causes oropharyngeal dysphagia
Polymyositis/dermatomyositis, myasthenia gravies, metabolic myopathy, muscular dystrophies, Kearns-Sayre syndrome
Structural causes oropharyngeal dysphagia
Zenker diverticulum, surgical resection, tumours, cricopharyngeal achalasia, extrinsic compression
Zenker diverticulum
Outpouching of the pharynx, occurs at weak spot in muscular wall just above the cricopharyngeal muscle. May result in coughing or aspiration as bolus can be regurgitated
Oesophageal dysphagia with solids only
Likely structural
Intermittent - oesophageal ring/web or eosinophilic oesophagitis
Slow progressive - stricture oesophagitis
Rapid progressive with weight loss - cancer
Oesophageal dysphagia with liquids and solids
Dysmotility
Intermittent - with chest pain, distal oesophageal spasm
Progressive - either with chronic heartburn (scleroderma, absent contractility) or regurgitation (achalasia)
Scleroderma oesophagus
Autoimmune, connective tissue fibrosis. Oesophageal atrophy, fibrosis, strictures, smooth muscle atrophy (weak peristalsis and LOS), decreased excitatory neural input
Scleroderma oesophagus symptoms
Dysphagia, heartburn, regurgitation
Oesophageal webs and strictures description and association
Thin membranous folds that form in the oesophagus. Narrow and block either partially or fully. No clear cause but linked to chronic iron deficiency anaemia
Symptoms dysphagia
Food spillages, drooling, regurgitation, avoidance certain consistencies, nasal regurgitation, coughing/choking, food getting stuck/sensation of getting stuck, weight loss, prolonged meal duration, repeated chest infections, posture changes, changes in voice, articulations, speech, and language
Complications dysphagia
Increased risk of inhaling food leading to choking or infection (aspiration pneumonia), avoidance of eating and drinking leading to malnutrition and dehydration, and decreased quality of life
Warning signs to consider OGD endoscopy
DOC ALARM
Dysphagia, odynophagia, choking, anaemia, loss of weight, age over 55, recent onset/progressive symptoms, melaena/haematemesis
Oesophageal cancer epidemiology
3x higher in men than women
highest rates in Middle East, South Africa, Northern China, Southern Russia, and India
Upper GI neoplasms
Squamous cell carcinoma, usually upper or mid oesophagus
Lower GI carcinomas
Most adenocarcinomas, lower oesophagus downwards. Gastrointestinal stromatolites tumours (GIST) ad lymphoma are rare
Oesophageal cancer tumour types
Most are malignant (<1% benign)
Squamous cell carcinoma 90%
Adenocarcinoma
Where do oesophageal adenocarcinomas arise from?
Superficial and deep glands of the oesophagus, mainly lower third especially near the gastroesophageal junction
Risk factors for oesophageal cancer
Tobacco, alcohol, Peutz-Jeghers syndrome, Cowden syndrome, genetic mutations (PTEN tumour suppressor genes), family history, vitamin deficiencies, caustic injury, webs, achalasia, Barrett’s oesophagus, oesophageal diverticula, exposure to DNA damaging agents
Which vitamin deficiencies are linked with oesophageal cancer?
A, B, C, magnesium, niacin, zinc
Peutz-Jeghers syndrome
Autosomal dominant syndrome characterised by multiple hamartomatous polyps in the GI tract, mucocutaneous pigmentation, and increased risk of GI and non-GI cancer
Clinical symptoms oesophageal cancer
Dysphagia, odynophagia, weight loss, substernal heartburn/acid reflux, dyspnoea, cough, hoarseness, pain in retro-eternal, back, or right upper abdomen
Morphology oesophageal adenocarcinoma
Normal epithelium —> Barrett’s oesophagus —> dysplastic Barrett’s oesophagus —> oesophageal adenocarcinoma
Gastric tumour types
Poor prognosis
90% adenocarcinomas that develop in the cells of the glandular stomach lining
Less common include GIST, MALT, gastric lymphoma
GIST
Gastrointestinal stromal tumours. Arise from muscle or connective tissue in stomach wall
Gastric tumours epidemiology
2x higher in men
Eastern Asia, Eastern Europe, South America, high frequency in Japan
Incidence increased with age
Symptoms gastric cancers
No symptoms until late stages so poor prognosis
Bloating, fatigue, indigestion, heartburn, stomach pain, nausea, vomiting, unexplained weight loss. ALARM for warning signs
Risk factors gastric cancer
Smoking, alcohol, h pylori, poor diet, genetics/family history (FAP), DNA damaging agents, predisposing conditions like ulceration, adenomatous gastric polyps, chronic atrophic gastritis, dysplasia, intestinal metaplasia, Menetrier’s disease
Where do most gastric tumours arise from?
Antrum 50%
Body 30%
Fungus/cardia 20%
What are the two microscopic gastric cancer pathologies
Diffuse and intestinal
Describe diffuse gastric cancers
Discohesive cells infiltrating through all layers of the stomach wall, extensive fibrosis and inflammation, large intracytoplasmic vacuoles that push the nucleus to the periphery creating a signet ring appearance. No known precursor.
Describe intestinal (microscopic type) gastric cancer
Papillary growth, step-wise progression : chronic gastritis —> intestinal metaplasia —> dysplasia —> CIS —> invasive carcinoma
Causes of oesophagitis
GORD
Others include chemical injury, radiation therapy, physical injury, vomiting, medications (NSAIDs, antibiotics, steroids)
