DISORDERS OF THE OESOPHAGUS Flashcards
Which group of patients are most at risk of developing oesophagitis due to gastro-oesophageal reflux disease?
Pregnant ladies
What are the symptoms associated with reflux oesophagitis?
Dyspepsia:
Upper abdominal pain
Belching
Heartburn
Retrosternal chest pain Pain on swallowing (odynophagia) Haematemesis Fatigue - Anaemia Nocturnal cough Early morning bronchospasm
What is odynophagia?
Pain on swallowing
What is the name of the sphincter that normally prevents gastric reflux?
Cardiac sphincter (lower oesophageal sphincter)
What are the risk factors for developing GORD?
Loss of tone of cardiac sphincter caused by:
Hiatus hernia
Chronic cough
Obesity
Eating too much fat (cholecystokinin secretion reduces sphincter tone)
Smoking
Pregnancy
Scleroderma and systemic sclerosis (can feature esophageal dysmotility)
Increased acid production:
Medication (such as steroids)
Infection with H.pylori
Zollinger-Ellison syndrome (overproduction of gastrin)
Hypercalcaemia (overproduction of gastrin)
What are the causes of oesophagitis?
GORD (loss of LOS tone or hiatus hernia) Drugs with anti-cholinergic effects NSAIDs Infection Chemical poisoning Alcohol Radiation therapy
What are the complications of oesophagitis and GORD?
Oesophagitis Mucosal erosions/ulceration Haemorrhage +/- haematemesis/melaena Stricture formation Barrett's oesophagus Cancer of the oesophagus - squamous cell carcinoma
What investigations should be ordered for someone who presents with the signs and symptoms consistent with oesophagitis?
Endoscopy - cannot rule out GORD
24 hour intraluminal pH monitoring - most accurate investigaton
Barium swallow - looking for free reflux of barium
What are the conservative treatment options for someone with oesophagitis?
Weight reduction
Cessation of smoking
Cessation of alcohol
What are the medical options for someone with oesophagitis?
- Antacids - such as Gaviscon
- H2 antagonists such as Nizatidine or Ranitidine
- PPI such as Omeprazole or Lansoprazole
- Prokinetic drugs - Domperidone
What surgical procedures can be used to treat someone with oesophagitis?
Tightening of the LOS by wrapping the fundus of the stomach around it.
What is Barrett’s oesophagus?
Metaplasia of the distal oesophageal mucosa due to prolonged irritation. Epithelium goes from squamous epithelial cells into columnar epithelial cells. It is a protective mechanism, however, it predisposes the patient to cancer.
What is the incidence of Barrett’s oesophagus in patients with prolonged GORD?
15%
What are the clinical features of Barrett’s oesophagus?
Initially report symptoms consistent with oesophagitis but symptoms may diminish due to decreased sensation in metaplastic area.
What are the complications of Barrett’s oesophagus?
40 fold increase of adenocarcinoma of the oesophagus
How might a patient with Barrett’s oesophagus be diagnosed?
Endoscopy - looking for change of colour from pink to slightly orange
Biopsy for confirmation of diagnosis
How would you manage someone with Barrett’s oesophagus?
PPI - Omeprazole
Endoscopic surveillance of dysplasia
High grade - indication for oesophagectomy - often found to already have adenocarcinoma
What are oesophageal strictures?
A narrowing or tightening of the oesophagus that causes swallowing difficulties as a result of scarring and fibrosis.
What are the causes of oesophageal stricture?
Long standing acid reflux
Ingestion of caustic (acid or alkali) substance
Radiotherapy
Sclerotherapy (for oesophageal varices)
What are the clinical features of oesophageal strictures?
Dysphagia - progresses from solids to liquids as well
Weight loss
History of reflux - with symptoms having now disappeared
What investigations would you order in someone who presented with suspected oesophageal strictures?
Endoscopy and biopsy (to exclude malignant disease)
Barium swallow
Endoluminal ultrasound or CT (again to exclude malignant infiltration)
What are the complications associated with oesophageal strictures?
Increased incidence of malignancy
Aspiration
What is the prognosis of someone with an oesophageal stricture?
Once formed it is likely to stay there for life without surgical treatment
What are the treatment options for someone with an oesophageal stricture?
Dilatation undertaken endoscopically with graduated tubes of increasing size
Surgical reconstruction
What is a pharyngeal pouch?
Diverticulum of the mucosa of the pharynx, just above the cricopharyngeal muscle (i.e. above the upper sphincter of the esophagus). It is a false diverticulum as it does not involve all layers of the oesophageal wall.
What is another name for a pharyngeal pouch?
Zenker’s diverticulum
What is an oesophageal diverticulum?
Similar to a pharyngeal pouch but sits in the mid oesophagus (traction diverticulum) or just above the lower oesophageal sphincter (epiphrenic diverticulum)
What are the clinical features of pharyngeal pouches or oesophageal diverticulae?
Bad breath
Regurgitation of food
Dysphagia
What investigations would you do in someone with suspected pharyngeal pouch or oesophageal diverticulum?
Barium swallow
How pharyngeal pouches and oesophageal diverticulae treated?
Surgical resection of problematic pouches. Treatment of bad breath.
What is achalasia?
Muscles of the lower part of the oesophagus fail to relax, preventing food from passing into the stomach.
What are the clinical features of achalasia?
Intermittent sudden dysphagia - where both solids and liquids are unable to pass
Regurgitation - may result in aspiration
Chest pain - due to non-peristaltic contraction of the oesophageal muscles.
What investigations would you order for someone with the signs and symptoms of achalasia?
Chest X-ray Barium swallow Endoscopy - resistance to scope Motility studies Endoscopic ultrasound
What might be seen on the barium swallow of someone with achalasia?
Dilatation of the oesophagus with narrowed lower portion
Called ‘beak appearance’
What might be seen on the chest x ray of someone with achalasia?
Pneumonia
Double cardiac shadow signifying fluid build up behind heart
Why might you do endoscopic ultrasound in someone with achalasia?
Exclude submucosal malignant infiltration
What are the complications of achalasia?
Increased risk of developing carcinoma
Reflux oesophagitis after treatment
What are the treatment options for someone diagnosed with achalasia?
Dilatation with high pressure balloons
Surgical division of muscles
Calcium antagonists - only 10% benefit
Botulinum toxins - injected into the LOS
