Gen Surg: oesophageal conditions and cancer Flashcards
What are the two types of oesophageal cancer?
Squamous cell carcinoma and adenocarcinoma
What are the demographics and affected areas for the different types of oesophageal cancer?
Squamous call carcinoma-more common in the DEVELOPING world, middle and upper thirds of the oesophagus, associated with smoking and drinking
Adenocarcinoma- more common in the DEVELOPED world, lower 3rd of the oesophagus, associated with Barretts oesophagus
What are the RF for oesophageal squamous cell carcinoma?
Chronic achalasia, low vit A
What are the RF for oesophageal adenocarcinoma?
GORD, obesity and high fat intake
How do patients with oesophageal cancer present?
Progressive dysphagia, weight loss due to dysphagia or cancer, odynophagia, hoarseness
How would a patient with oesophageal cancer look on examination?
Evidence of recent weight loss, cachexia, signs of dehydration, supraclavicular lymphadenopathy, signs of mets (ascites, jaundice, hepatomegaly)
What are the red flag symptoms that would make you request a 2WW endoscopy?
Any patient with new onset dysphagia OR >55 years with weight loss AND one of: dyspepsia OR upper abdo pain OR reflux
How do you investigate a ?oesophageal cancer
- OGD- to visualise the malignancy
- CT CAP and PET-CT for distant mets
- Endoscopic US- to measure T-stage (penetration into oesophageal wall)
- Staging laparoscopy- look for intraperitoneal mets
- If there are any palpable cervical lymph nodes, may be investigated via FNA
- Hoarseness and haemoptysis- investigate via bronchoscopy
How do you treat a squamous cell oesophageal cancer ?
Hard to operate, definitive chemo and radiotherapy
How do you treat Adenocarcinoma off the oesophagus?
Neoadjuvant chemo or chemo-radiotherapy followed by oesophageal resection
What are the risks associated with surgical treatment of oesophageal cancer?
Anastomotic leak,
reoperation,
pneumonia and death
What does palliative treatment for oesophageal cancer consist of?
Symptom control:
Patient has difficulty swallowing–> oesophageal stent
Radiotherapy and/or chemo to help reduce tumour size to reduce sx
Nutritional support–> disease progression can lead to significant dysphagia and cachexia–> thickened fluid and nutritional supplements should be offered
RIG inserted if cannot tolerate enteral feeds
What is achalasia?
Failure of the LOS to relax
How does achalasia present?
Gradual onset of dysphagia of food and liquids
Regurg of food
Aspiration
Heartburn that often does not respond to PPI
What can achalasia lead to?
It is a risk factor for oesophageal squamous cell carcinoma
How do oesophageal varices present?
Haemetemesis, Malena, light headedness, LOC. Can also have associated signs: jaundice, ascites, raised JVP, bruising (sign of impaired coag due to liver disease), caput medusa
A pt has presented with hematemesis. You suspect oesophageal varices; what questions may you ask in the Hx?
Alcohol intake? Hep B/C?
What investigations would you do for definitive diagnosis of oesophageal varices?
OGD. or CT w/ contrast if patient is unstable for OGD or the OGD is unremarkable
During OGD, how can oesophageal varices be managed?
Endoscopic banding. Prophylactic AB and somatostatin analogues. Sengstaken- Blackmore tube/balloon tamponade. TIPS considered if band ligation does not work.
How are bleeding oesophageal varices initially managed?
A-E. Wide bore cannulas. Major haemorrhage protocol - bloods, platelets, clotting factors. May need platelet transfusion. Blood transfusion if low Hb or unstable. Coag reversal if on blood thinners.
What red flag in Hx would warrant an urgent OGD?
Adult with alcohol Hx presenting with haematemesis. Or adult who has haematemesis that is v unstable.
What causes Mallory-Weiss tear?
Severe or recurrent vomiting, followed by minor haematemesis. Tear in epithelial lining of oesophagus - so get small bleed.
How does Mallory-Weiss tear present?
Haematemesis after retching, Malena, light headedness, dizzy, abdo pain.
What investigation would you do for suspected Mallory Weiss tear?
OGD if worsening or prolonged haematemesis .
How is Mallory-weiss tear managed?
Endoscopy. Clip with or without adrenaline. Or thermal coagulation with adrenaline. Or thrombin or fibrin with adrenaline.
Define oesophagitis
Inflammation of the intraluminal epithelial layer of the oesophagus. this can be due to - GORD, infections like thrush, meds like bisphosphonates, radiotherapy, ingesting toxic substances and Chrons.
How does oesophagitis present?
Pain in the abdomen and chest (can be severe), nausea, heartburn, acidic taste in mouth, bloating/belching, symptoms worse after a meal, cough, sore throat, hoarseness of voice.
What is Zenker’s Diverticulum?
Pharyngeal pouch- it is a diverticulum of the mucosa of a the pharynx
How does Zenker’s diverticulum present?
- dysphagia,
- regurgitation of food,
- sensation of food being stuck in the throat,
- halitosis.
- Key finding is gurgling sounds found in the neck
What investigations are done for Zenker’s diverticulum?
Video fluoroscopy
What are some complications of Zenker’s diverticulum?
Aspiration pneumonia, fistulas into trachea–> obstruction or into major blood vessels–> bleeding
