Dysphagia

Question 1

3 locations of oesophageal narrowing

Answer 1

• Level of cricoid
• Posterior to left main bronchus and aortic arch
• Lower oesophageal sphincter

Question 2

Causes of dysphagia

Answer 2

Inflammatory
• Tonsillitis, pharyngitis
• Oesophagitis: GORD
• Oral candidiasis
• Aphthous ulcers

Luminal:
• foreign body

Mural:
• Pharyngeal pouch
• Malignant stricture

Extramural:

• Rolling hiatus hernia
• Lung Ca
• Mediastinal Lymph nodes e.g. lymphoma

Question 3

Investigations of dysphagia

Answer 3

• Upper GI endoscopy
• Ba swallow
• Manometry

Question 4

Achalasia

Answer 4

Degeneration of myenteric plexus (Auerbach’s) causing a decrease in peristalsis.

LOS fails to relax

Question 5

Presentation of achalasia

Answer 5

• Dysphagia: liquids then solids
• Regurgitation (esp. at night)
• Substernal cramps
• Wt. loss
• Heart burn
• Chest pain
• vomiting

• Complications: Chronic → oesophageal SCC

Question 6

Investigations and mx of achalasia

Answer 6

Ba swallow: dilated tapering oesophagus
- Bird’s beak sign

Gold standard - Manometry

CXR: widened mediastinum

Urgent OGD: exclude malignancy

Question 7

Pharyngeal Pouch: Zenker’s Diverticulum

Answer 7

Outpouching between crico- and thyro-pharyngeal
components of the inferior pharyngeal constrictor.

Area of weakness = Killian’s dehiscence.

• Defect usually occurs posteriorly but swelling usually bulges to left side of neck

• Food debris → pouch expansion → oesophageal
compression → dysphagia

Question 8

Presentation and mix of Zenker’s diverticulum

Answer 8

Presentation:

• Regurgitation
• bad breath
• gurgling sounds

Mx:

• excision
• endoscopic stapling

Question 9

Oesophageal cancer RF

Answer 9

• EtOH
• Smoking
• Achalasia
• GORD → Barrett’s
• Plummer-Vinson
• Fatty diet
• ↓ vit A+C

Question 10

Types of oesophageal cancer

Answer 10

• 65% adenocarcinoma

• Lower 3rd
• GORD → Barrett’s → dysplasia → Ca

• 35% SCC

• Upper and middle 3rds
• Associated with OH and smoking

Question 11

Presentation of oesophageal CA

Answer 11

• Progressive dysphagia: solids harder to swallow than liquids
• FLAWS
• Retrosternal chest pain
• Lymphadenopathy

• Upper 3rd:

• Hoarseness: recurrent laryngeal nerve invasion
• Cough ± aspiration pneumonia

Question 12

Investigations for oesophageal CA

Answer 12

Bloods

• FBC: anaemia
• LFTs: hepatic mets, albumin

Diagnosis
- Upper GI endoscopy and biopsy
- Ba swallow: apple-core
stricture

Staging: TNM

• CT CAP
• PET scan
• Endoscopic USS - penetration into the oesophageal wall
• Laparoscopy / mediastinoscopy: mets
• Fine needle aspiration cytology of palpable cervical lymph nodes

Question 13

Mx of oesophageal CA

Answer 13

Discuss in an MDT

Surgical:
• SSC - chemo-radiotherapy

• Adenocarcinoma - oesophagectomy if resectable tumours
- Neo-adjuvant - to
downstage tumour

Question 14

Palliative care for oesophageal CA

LASAR

Answer 14

• Majority of pts.

• Laser coagulation
• Alcohol injection + ↓ Ascites (spironolactone)
• Stenting and Secretion reduction (e.g. hyoscine patch)
• Analgesia: e.g. fentanyl patches
• Radiotherapy: external or brachytherapy
• Referral - palliative care team

Question 15

Signs on examination for oesophageal cancer

Answer 15

Cachexia
Dehydration Supraclavicular lymphadenopathy

Signs of metastases:

• jaundice
• hepatomegaly
• ascites

Question 16

Red-flag symptoms for a suspected oesophageal malignancy requiring urgent endoscopy are:

Answer 16

Any patient with dysphagia

Any patient >55yrs with weight loss and upper abdominal pain, dyspepsia, or reflux

Question 17

Surgical approaches

Answer 17

• Ivor-Lewis (2 stage): abdominal + R thoracotomy
• McKeown (3 stage): abdominal + R thoracotomy + left neck incision
• Trans-hiatal: abdominal incision

Question 18

Complications of surgery

Answer 18

Anastomotic leak
Re-operation
Pneumonia

Question 19

Post-operative nutrition

Answer 19

Feeding jejunostomy

Question 20

Palliative options

Answer 20

difficulty in swallowing -oesophageal stent

Radiotherapy and/or chemotherapy

Thickened fluid and nutritional supplements should be offered

Radiologically-Inserted Gastrostomy (RIG) tube may need to be inserted, to bypass the obstruction - if severe dysphagia

Question 21

At what vertebral level does the oesophagus originate

Answer 21

C6

Question 22

Cause of achalasia

Answer 22

• primary - idiopathic (common)

- Secondary - Chagas’ disease

Question 23

Key features of achalasia on manometry

Answer 23

• Failure of relaxation of LOS
• Absence or reduced peristalsis
• High resting lower oesophageal sphincter tone

Question 24

Management of achalasia

Answer 24

Conservative:

• Sleeping with more pillows
• eat slowly
• fluids

Medication

• CCBs, nitrates
• Botox injection

Surgical:

• endoscopic balloon dilatation
• Lap Heller’s myotomy (typically lap)

Question 25

Heller’s myotomy

Answer 25

division of the specific fibres of the lower oesophageal sphincter which fail to relax

Question 26

2 ww referral

Answer 26

Unexplained dysphagia

OR

50+ yo + weight loss + 1 of:

• reflux
• dyspepsia
• upper Abdo pain

OGD and biopsy

Question 27

Staging oesophageal cancer

Answer 27

CT CAP and PET CT scans

Question 28

Deterioration post op after a Ivory Lewis oesophagectomy Ix

Answer 28

Bloods - clotting screen, G+S
VBG - lactate
CT chest with contrast - anastomotic leak