Esophageal disease

Question 1

Investigation for Achalasia

Answer 1

> Oesophageal manometry

• lack of progressive peristalsis
• abnormally high pressure at the LES

> CXR

• widened mediastinum with air-fluid level
• absence of gastric air bubbles

> Barium swallow
- “Bird’s peak”

> OGD
- rule out mechanical stricture and malignancy

> EUS
- characterizing tumour

Question 2

How to determine whether tumors from oesophagal or gastric origin?

Answer 2

AJCC 8th: epicentre <2cm into gastric cardia staged as oesophagal Ca

Question 3

Management for Achalasia

Answer 3

> Medical

• Nitroglycerine [unwilling or unable to tolerate invasive therapy and for failed botulinum toxin injections]
• Endoscopic injection of botulinum toxin [If not fit for more definitive treatment]

> Endoscopic

• Per-oral endoscopic myotomy (POEM) [Choice for Type III]
• Pneumatic balloon dilatation [Type I or II]

> Surgical
- Laparoscopic Heller esophagomyotomy (myotomy of the lower oesophagus) with anterior 180-degree partial fundoplication (reduce post-op reflux) [Type I or II]

Question 4

TMN staging for esophageal Ca

Answer 4

> T
T1: invade submucosal
T2: invade muscularis propria
T3: invade adventitia 
T4: invade adjacent structures

> N
N1: 1-2 regional LN
N2: 3-6 regional LN
N3: 7 or more regional LN

> M
M1: distance metastasis

Question 5

Surgery approach option for esophageal Ca

Answer 5

• Ivor-Lewis transthoracic
• Thoracoabdominal
• Transhiatal
• Tri-incisional

Question 6

SCC vs Adenocarcinoma of esophagus

Answer 6

> SCC

• Incidence greater than adenocarcinoma
• RF: Alcohol and Smoking

> Adenocarcinoma

• Incidence increase due to increase prevalence of GERD and obesity
• EF: Chronic GERD

Question 7

Diagnostic investigation esophageal cancer

Answer 7

• Barium swallow: may show proximal dilatation, mucosal irregularity, and annular constriction
• OGDS: allow biopsy

Question 8

Staging investigation for esophageal cancer

Answer 8

• Endoscopic ultrasound
• CXR: lung metastasis
• CT TAP
• PET scan

Question 9

How to differentiate hepatitis and pancreatitis

Answer 9

• Right upper quadrant pain
• Scleral icterus
• Tender hepatosplenomegaly
• Marked elevation of serum AST, bilirubin, and ALP
• Serum amylase/ lipase normal

Question 10

Blood test for esophageal cancer

Answer 10

• FBC (anemia, aspiration pneumonia)
• BUSE (vomiting)
• LFT (low albumin from nutritional deprivation)

Question 11

Complication of esophageal cancer

Answer 11

• Anemia
• Aspiration pneumonia
• Electrolyte imbalance
• Malnutrition

Question 12

Post-op management for esophageal cancer

Answer 12

• Enteral feeding on POD 2 -> barium swallow performed on POD 7 (NG tube remain in place until barium swallow demonstrates no anastomotic leak)
• Subcutaneous heparin until POD7/ start ambulatory

Question 13

Causes of dysphagia

Answer 13

> Neuromuscular

• Achalasia
• Multiple sclerosis

> Obstructive

• Intra-luminal (foreign body)
• Intra-mural (tumor, stricture)
• Extra-luminal (anterior mediastinal mass - 4T: thyroid, thymus, teratoma, terrible lymphoma)

Question 14

Complication of esophagectomy

Answer 14

• Aspiration pneumonia
• Anastomotic leakage
• Chylothorax
• Injury to recurrent laryngeal nerve

Question 15

Palliative management of esophageal cancer

Answer 15

• Stenting

- Endoscopic laser