DISORDERS OF THE OESOPHAGUS

Question 1

Which group of patients are most at risk of developing oesophagitis due to gastro-oesophageal reflux disease?

Answer 1

Pregnant ladies

Question 2

What are the symptoms associated with reflux oesophagitis?

Answer 2

Dyspepsia:
Upper abdominal pain
Belching
Heartburn

Retrosternal chest pain
Pain on swallowing (odynophagia)
Haematemesis
Fatigue - Anaemia
Nocturnal cough
Early morning bronchospasm

Question 3

What is odynophagia?

Answer 3

Pain on swallowing

Question 4

What is the name of the sphincter that normally prevents gastric reflux?

Answer 4

Cardiac sphincter (lower oesophageal sphincter)

Question 5

What are the risk factors for developing GORD?

Answer 5

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)

Question 6

What are the causes of oesophagitis?

Answer 6

GORD (loss of LOS tone or hiatus hernia)
Drugs with anti-cholinergic effects
NSAIDs
Infection
Chemical poisoning
Alcohol
Radiation therapy

Question 7

What are the complications of oesophagitis and GORD?

Answer 7

Oesophagitis
Mucosal erosions/ulceration
Haemorrhage +/- haematemesis/melaena
Stricture formation
Barrett's oesophagus
Cancer of the oesophagus - squamous cell carcinoma

Question 8

What investigations should be ordered for someone who presents with the signs and symptoms consistent with oesophagitis?

Answer 8

Endoscopy - cannot rule out GORD
24 hour intraluminal pH monitoring - most accurate investigaton
Barium swallow - looking for free reflux of barium

Question 9

What are the conservative treatment options for someone with oesophagitis?

Answer 9

Weight reduction
Cessation of smoking
Cessation of alcohol

Question 10

What are the medical options for someone with oesophagitis?

Answer 10

1. Antacids - such as Gaviscon
2. H2 antagonists such as Nizatidine or Ranitidine
3. PPI such as Omeprazole or Lansoprazole
4. Prokinetic drugs - Domperidone

Question 11

What surgical procedures can be used to treat someone with oesophagitis?

Answer 11

Tightening of the LOS by wrapping the fundus of the stomach around it.

Question 12

What is Barrett’s oesophagus?

Answer 12

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.

Question 13

What is the incidence of Barrett’s oesophagus in patients with prolonged GORD?

Answer 13

15%

Question 14

What are the clinical features of Barrett’s oesophagus?

Answer 14

Initially report symptoms consistent with oesophagitis but symptoms may diminish due to decreased sensation in metaplastic area.

Question 15

What are the complications of Barrett’s oesophagus?

Answer 15

40 fold increase of adenocarcinoma of the oesophagus

Question 16

How might a patient with Barrett’s oesophagus be diagnosed?

Answer 16

Endoscopy - looking for change of colour from pink to slightly orange
Biopsy for confirmation of diagnosis

Question 17

How would you manage someone with Barrett’s oesophagus?

Answer 17

PPI - Omeprazole
Endoscopic surveillance of dysplasia
High grade - indication for oesophagectomy - often found to already have adenocarcinoma

Question 18

What are oesophageal strictures?

Answer 18

A narrowing or tightening of the oesophagus that causes swallowing difficulties as a result of scarring and fibrosis.

Question 19

What are the causes of oesophageal stricture?

Answer 19

Long standing acid reflux
Ingestion of caustic (acid or alkali) substance
Radiotherapy
Sclerotherapy (for oesophageal varices)

Question 20

What are the clinical features of oesophageal strictures?

Answer 20

Dysphagia - progresses from solids to liquids as well
Weight loss
History of reflux - with symptoms having now disappeared

Question 21

What investigations would you order in someone who presented with suspected oesophageal strictures?

Answer 21

Endoscopy and biopsy (to exclude malignant disease)
Barium swallow
Endoluminal ultrasound or CT (again to exclude malignant infiltration)

Question 22

What are the complications associated with oesophageal strictures?

Answer 22

Increased incidence of malignancy

Aspiration

Question 23

What is the prognosis of someone with an oesophageal stricture?

Answer 23

Once formed it is likely to stay there for life without surgical treatment

Question 24

What are the treatment options for someone with an oesophageal stricture?

Answer 24

Dilatation undertaken endoscopically with graduated tubes of increasing size
Surgical reconstruction

Question 25

What is a pharyngeal pouch?

Answer 25

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.

Question 26

What is another name for a pharyngeal pouch?

Answer 26

Zenker's diverticulum

Question 27

What is an oesophageal diverticulum?

Answer 27

Similar to a pharyngeal pouch but sits in the mid oesophagus (traction diverticulum) or just above the lower oesophageal sphincter (epiphrenic diverticulum)

Question 28

What are the clinical features of pharyngeal pouches or oesophageal diverticulae?

Answer 28

Bad breath Regurgitation of food Dysphagia

Question 29

What investigations would you do in someone with suspected pharyngeal pouch or oesophageal diverticulum?

Answer 29

Barium swallow

Question 30

How pharyngeal pouches and oesophageal diverticulae treated?

Answer 30

Surgical resection of problematic pouches. Treatment of bad breath.

Question 31

What is achalasia?

Answer 31

Muscles of the lower part of the oesophagus fail to relax, preventing food from passing into the stomach.

Question 32

What are the clinical features of achalasia?

Answer 32

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.

Question 33

What investigations would you order for someone with the signs and symptoms of achalasia?

Answer 33

``` Chest X-ray Barium swallow Endoscopy - resistance to scope Motility studies Endoscopic ultrasound ```

Question 34

What might be seen on the barium swallow of someone with achalasia?

Answer 34

Dilatation of the oesophagus with narrowed lower portion | Called 'beak appearance'

Question 35

What might be seen on the chest x ray of someone with achalasia?

Answer 35

Pneumonia | Double cardiac shadow signifying fluid build up behind heart

Question 36

Why might you do endoscopic ultrasound in someone with achalasia?

Answer 36

Exclude submucosal malignant infiltration

Question 37

What are the complications of achalasia?

Answer 37

Increased risk of developing carcinoma | Reflux oesophagitis after treatment

Question 38

What are the treatment options for someone diagnosed with achalasia?

Answer 38

Dilatation with high pressure balloons Surgical division of muscles Calcium antagonists - only 10% benefit Botulinum toxins - injected into the LOS