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Stage 3 > Gastroenterology: Oesophagus > Flashcards

Gastroenterology: Oesophagus Flashcards

1
Q

What is achalasia?

A

Condition of unknown aetiology which causes failure of the lower oesophageal sphincter to relax

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2
Q

What causes achalasia?

A

Failure of the lower oesophageal sphincter to relax due to degeneration of myenteric plexus

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3
Q

What is the epidemiology of achalasia?

A

1) Equally affects men and women
2) Small % associated with underlying oesophageal cancer

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4
Q

How does achalasia present?

A

1) Gradual onset (months-years) dysphagia
2) Regurgitation of undigested food
3) Aspiration
4) Retrosternal chest pain/heartburn/substernal chest cramps - often does not respond to PPI
5) Mild weight loss

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5
Q

What investigations do you do for achalasia?

A

1) Endoscopy (also rules out other more sinister pathologies)
2) Oesophageal manometry
3) Barium swallow

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6
Q

What do you see on endoscopy in achalasia?

A

Dilated oesophagus containing residual material (also rules out other more sinister pathologies)

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7
Q

What do you see on oesophageal manometry in achalasia?

A

High pressure and incomplete lower oesophageal sphincter relaxation

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8
Q

What does a barium swallow show in achalasia?

A

Classic bird’s beak appearance in advanced disease (dilated tapering oesophagus)

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9
Q

What condition shows birds beak appearance on barium swallow?

A

Achalasia (advanced)

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10
Q

What are medical treatments for achalasia?

A

1) Botox injections
2) CCBs or nitrates - can try in patients who fail botox therapy or are not suitable surgical candidates

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11
Q

What are surgical treatments for achalasia?

A

1) Oesophageal dilatation
2) Heller’s myotomy - surgical cleavage of the muscle
Then PPIs

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12
Q

What does the oesophagus act as a passage between?

A

Pharynx + stomach

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13
Q

At what level does the oesophagus enter the abdomen through the oesophageal hiatus in the diaphragm?

A

T10

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14
Q

What causes Barrett’s oesophagus?

A

1) Prolonged exposure of normal oesophageal squamous epithelium to the reflux in GORD
2) This causes mucosal inflammation and erosion, leading to the replacement of the mucosa with metaplastic columnar epithelium

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15
Q

Which condition results in Barrett’s oesophagus?

A

GORD

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16
Q

What is the normal mucosa in the oesophagus?

A

Squamous epithelium

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17
Q

What type of mucosa replaces the squamous epithelium in Barrett’s oesophagus?

A

Metaplastic columnar epithelium

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18
Q

What is the change in the oesophageal mucosa in Barrett’s oesophagus?

A

Squamous epithelium to metaplastic columnar epithelium

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19
Q

What might you see on endoscopy of Barrett’s oesophagus?

A

The length affected may be a few cm or the whole oesophagus and can be continuous or patchy

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20
Q

What % of people with GORD develop Barrett’s oesophagus?

A

3-5%

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21
Q

What is the most significant complication of Barrett’s oesophagus?

A

Oesophageal adenocarcinoma (risk of progression is low ~ 1% in low grade dysplasia)

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22
Q

What type of oesophageal cancer can result from Barrett’s oesophagus?

A

Adenocarcinoma

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23
Q

How do you diagnose Barrett’s oesophagus?

A

Endoscopy + biopsy of endoscopically visible columnarisation allows histological corroboration

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24
Q

Which histological criteria are used to diagnose Barrett’s oesophagus after endoscopy + biopsy?

A

Prague criteria

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25
How do you manage Barrett's oesophagus that is pre-malignant/high grade dysplasia?
1) Oesophageal resection OR eradicative mucosectomy - if young and fit 2) Endoscopic targeted mucosectomy or mucosal ablation by epithelial laser, radiofrequency (HALO) or photodynamic ablation (PD) - in others
26
How do you manage Barrett's oesophagus with low-grade dysplasia?
Annual endoscopic surveillance
27
How do you manage Barrett's oesophagus with no pre-malignant changes?
1) Surveillance endoscopy + biopsy every 1-3 years 2) High dose long term PPI
28
Which patients should have a one-off screening endoscopy for Barrett's oesophagus?
Longstanding GORD e.g. > 5 years esp. > 50 years old
29
What is dysphagia?
Difficulty in swallowing and is an alarming symptom that requires urgent investigation with endoscopy
30
What are neurological causes of dysphagia?
1) Cerebrovascular disease 2) Parkinson's disease 3) Motor neurone disease 4) Bulbar palsy
31
What motility disorders can cause dysphagia?
1) Achalasia 2) Diffuse oesophageal spasm 3) Systemic sclerosis
32
What are mechanical/obstructive causes of dysphagia?
1) Benign strictures 2) Malignancy 3) Pharyngeal pouch 4) Extrinsic pressure from lung cancer 5) Mediastinal lymph nodes 6) Retrosternal goitre
33
What are other causes of dysphagia?
1) Oesophagitis 2) Globus (psychological)
34
What type of cause does swallowing of liquids and solids being equally affected from the start suggest?
Motility disorders e.g. achalasia
35
What does progressive dysphagia of solids and then liquids suggest?
Benign or malignant stricture
36
What does difficulty in making the swallowing suggest?
Neurological cause
37
What does painful dysphagia (odynophagia) suggest?
1) Candida infection 2) Malignancy 3) Ulcer or spasm
38
What does a bulging neck on swallowing, gurgling or halitosis suggest?
Pharyngeal pouch
39
What diagnosis does dysphagia + iron deficiency anaemia suggest?
Plummer-Vinson syndrome (also known as Paterson–Brown–Kelly syndrome)
40
What is Plummer-Vinson syndrome (also known as Paterson–Brown–Kelly syndrome)?
Rare disease - upper oesophageal web, post cricoid dysphagia + iron deficiency anaemia (signs of which include glossitis, angular stomatitis and pallor) - associated with squamous cell carcinoma of the oesophagus
41
What type of oesophageal cancer is Plummer-Vinson syndrome associated with?
Squamous cell carcinoma
42
What are the two types of oesophageal cancer?
1) Adenocarcinoma 2) Squamous cell carcinoma
43
Which type of oesophageal cancer is the leading cause in the Western world?
Adenocarcinoma - due to increasing rates of metabolic syndrome
44
Which type of oesophageal cancer is the most common worldwide?
Squamous cell carcinoma
45
In which part of the oesophagus does squamous cell carcinoma usually present?
Top ⅔ of oesophagus
46
In which part of the oesophagus does adenocarcinoma usually present?
Lower 1/3
47
What is oesophageal adenocarcinoma associated with?
Obesity + GORD
48
How does GORD lead to oesophageal adenocarcinoma?
1) Recurrent reflux leads to metaplastic formations of mucin-producing glandular tissue known as Barrett's oesophagus 2) Ongoing reflux will lead to the development of neoplasia 3) Barrett's oesophagus has an annual rate of conversion to oesophageal adenocarcinoma at a rate of around 0.5% per year
49
What is a direct cause of ongoing reflux and therefore obesity?
Metaplastic change from squamous cell to glandular cells
50
What is the most important risk factor for oesophageal cancer (both types)?
Smoking
51
What are other risk factors for oesophageal cancer as well as smoking?
1) High alcohol intake 2) Achalasia 3) Zenker diverticulum (pharyngeal pouch) 4) Oesophageal web 5) High intake of hot beverages 6) Dietary intake of increase dietary nitrosamines, areca or betel nuts
52
How does oesophageal cancer present?
1) Progressive dysphagia from solids to liquids ± pain on swallowing (odynophagia) 2) Weight loss 3) Hoarseness
53
What is different in the presentation of oesophageal cancer vs motility disorders e.g. oesophageal spasm and achalasia?
Cancer - progressive dysphagia from solids to liquids Motility - dysphagia to solids and liquids from the start
54
How do you manage any patient presenting with dysphagia?
Immediately refer for an upper GI endoscopy to rule out oesophageal cancer
55
When do patients with oesophageal often present and why?
Late - bc dysphagia only really occurs when there is obstruction of > ⅔ of the lumen
56
What causes hoarseness in oesophageal cancer?
Local invasion of the recurrent laryngeal nerve
57
What is always the initial investigation for oesophageal cancer?
Upper GI endoscopy (unless contraindicated) - allows visualisation of the tumour and grading via biopsy
58
What needs to be done after oesophageal cancer is diagnosed with endoscopy?
Tumour must be staged to asses whether it is resectable
59
When is an oesophageal tumour not resectable?
If there is extensive local spread or any distant metastases
60
What investigations can be done in oesophageal cancer to stage the tumours?
1) CT chest, abdo + pelvis 2) MRI 3) Endoscopic ultrasound 4) FDG-PET scan 5) Laparoscopy
61
What is the first line investigation in oesophageal cancer after endoscopy?
CT chest, abdo, pelvis
62
What is another name for a pharyngeal pouch?
Zenker's diverticulum
63
What is a pharyngeal pouch?
A herniation of the pharyngeal mucosa through a point of weakness between the thyropharyngeus and cricopharynxgeus muscle in the inferior constrictor of the pharynx
64
How does pharyngeal pouch present?
1) Dysphagia 2) Chronic cough 3) Halitosis 4) Regurgitation of undigested food 5) Weight loss 6) Aspiration 7) Bulging neck on swallowing 8) Gurgling
65
What investigation do you avoid in suspected pharyngeal pouch?
Endoscopy - due to risk of perforating the lesion
66
What is the first line investigation in pharyngeal pouch?
Barium swallow
67
What would you see on barium swallow in pharyngeal pouch?
Residual pool of contrast within the pouch
68
How do you manage pharyngeal pouch/Zenker's diverticulum?
1) Small and asymptomatic - no treatment necessary 2) Surgical approaches - resection of the diverticulum/pouch or incision of cricopharynxgeus muscle
69
What kind of pain does oesophageal spasm cause?
Constricting chest pain
70
What are triggers for oesophageal spasm?
1) Food 2) Hot drinks 3) Alcohol 4) Lying flat
71
How can you differentiate between angina and oesophageal spasm with GTN?
GTN relieves angina pain within minutes, GTN relieves oesophageal spasm more slowly
72
What is the dysphagia like in oesophageal spasm?
Intermittent
73
How does diffuse oesophageal spasm present?
1) Intermittent dysphagia 2) ± constricting chest pain
74
How do you diagnose oesophageal spasm?
Barium swallow
75
What would you see on barium swallow in oesophageal spasm?
Abnormal contractions e.g. corkscrew oesophagus
76
What are causes of a benign oesophageal stricture?
1) GORD 2) Corrosives 3) Surgery 4) radiotherapy
77
How do you treat benign oesophageal structure?
Endoscopic balloon dilatation
78
What causes a malignant stricture?
Oesophageal, gastric or pharyngeal cancer
79
What does an apple core effect on barium swallow suggest?
Malignant oesophageal structure - cancer
80
What does a malignant oesophageal stricture look like on barium swallow?
1) Shouldered edges lead to an apple core effect with an irregular mucosal pattern 2) On video fluoroscopy there would be no peristalsis visible in this segment 3) Normal gastro-oesophageal junction
81
How do benign oesophageal strictures look like on barium swallow?
More funnelled appearance with a normal mucosal pattern
82
What are two examples of benign oesophageal strictures?
1) Oesophageal web or ring (Plummer-Vinson syndrome) 2) Peptic stricture
83
How does the dysphagia present in an oesophageal stricture (benign or malignant)?
Progressive dysphagia - solids then liquids
84
What are causes of oesophageal ulceration?
1) Steroid use 2) HSV, CMV, Candida (in HIV infection)
85
How do you treat oesophagitis?
PPI e.g. lansoprazole
86
What is a complication of oesophagitis?
Upper GI bleed
87
What are the two types of hiatus hernia?
1) Sliding (80%) - when the gastro-oesophageal junction slides up into the chest 2) Rolling (20%) - when GOJ reminds in abdomen but a bulge of stomach herniates up into the chest alongside the oesophagus
88
In which type of hiatus hernia is acid reflux most common?
Sliding - bc the lower oesophageal sphincter becomes less competent (less common in rolling bc GOJ remains intact)
89
What is the epidemiology of hiatus hernia?
1) Common - 30% of patients > 50 years 2) Especially obese women 3) 50% have symptomatic GOR
90
How do you diagnose hiatus hernia?
Barium swallow (upper GI endoscopy visualises mucosa ?oesophagitis but cannot reliably exclude hiatus hernia)
91
How is oesophagitis diagnosed?
Upper GI endoscopy
92
How do you treat hiatus hernia?
1) Lose weight 2) Treat reflux symptoms 3) Surgery
93
What are indications for surgery in hiatus hernia?
1) Intractable symptoms despite aggressive medical therapy 2) Complications of GORD 3) Repair rolling hiatus hernia prophylactically (even if asymptomatic) as it may strangulate, which needs prompt surgical repair (and has high mortality and morbidity rate)
94
How do you treat rolling hiatus hernia?
Surgically repair prophylactically even if asymptomatic - bc it may strangulate, which needs prompt surgical repair and has high mortality and morbidity rate

Stage 3 (61 decks)

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