Gen Surg: oesophageal conditions and cancer

Question 2

What are the two types of oesophageal cancer?

Answer 2

Squamous cell carcinoma and adenocarcinoma

Question 3

What are the demographics and affected areas for the different types of oesophageal cancer?

Answer 3

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

Question 4

What are the RF for oesophageal squamous cell carcinoma?

Answer 4

Chronic achalasia, low vit A

Question 5

What are the RF for oesophageal adenocarcinoma?

Answer 5

GORD, obesity and high fat intake

Question 6

How do patients with oesophageal cancer present?

Answer 6

Progressive dysphagia, weight loss due to dysphagia or cancer, odynophagia, hoarseness

Question 7

How would a patient with oesophageal cancer look on examination?

Answer 7

Evidence of recent weight loss, cachexia, signs of dehydration, supraclavicular lymphadenopathy, signs of mets (ascites, jaundice, hepatomegaly)

Question 8

What are the red flag symptoms that would make you request a 2WW endoscopy?

Answer 8

Any patient with new onset dysphagia OR >55 years with weight loss AND one of: dyspepsia OR upper abdo pain OR reflux

Question 9

How do you investigate a ?oesophageal cancer

Answer 9

• 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

Question 10

How do you treat a squamous cell oesophageal cancer ?

Answer 10

Hard to operate, definitive chemo and radiotherapy

Question 11

How do you treat Adenocarcinoma off the oesophagus?

Answer 11

Neoadjuvant chemo or chemo-radiotherapy followed by oesophageal resection

Question 12

What are the risks associated with surgical treatment of oesophageal cancer?

Answer 12

Anastomotic leak,
reoperation,
pneumonia and death

Question 13

What does palliative treatment for oesophageal cancer consist of?

Answer 13

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

Question 14

What is achalasia?

Answer 14

Failure of the LOS to relax

Question 15

How does achalasia present?

Answer 15

Gradual onset of dysphagia of food and liquids
Regurg of food
Aspiration
Heartburn that often does not respond to PPI

Question 16

What can achalasia lead to?

Answer 16

It is a risk factor for oesophageal squamous cell carcinoma

Question 17

How do oesophageal varices present?

Answer 17

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

Question 18

A pt has presented with hematemesis. You suspect oesophageal varices; what questions may you ask in the Hx?

Answer 18

Alcohol intake? Hep B/C?

Question 19

What investigations would you do for definitive diagnosis of oesophageal varices?

Answer 19

OGD. or CT w/ contrast if patient is unstable for OGD or the OGD is unremarkable

Question 20

During OGD, how can oesophageal varices be managed?

Answer 20

Endoscopic banding. Prophylactic AB and somatostatin analogues. Sengstaken- Blackmore tube/balloon tamponade. TIPS considered if band ligation does not work.

Question 21

How are bleeding oesophageal varices initially managed?

Answer 21

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.

Question 22

What red flag in Hx would warrant an urgent OGD?

Answer 22

Adult with alcohol Hx presenting with haematemesis. Or adult who has haematemesis that is v unstable.

Question 23

What causes Mallory-Weiss tear?

Answer 23

Severe or recurrent vomiting, followed by minor haematemesis. Tear in epithelial lining of oesophagus - so get small bleed.

Question 24

How does Mallory-Weiss tear present?

Answer 24

Haematemesis after retching, Malena, light headedness, dizzy, abdo pain.

Question 25

What investigation would you do for suspected Mallory Weiss tear?

Answer 25

OGD if worsening or prolonged haematemesis .

Question 26

How is Mallory-weiss tear managed?

Answer 26

Endoscopy. Clip with or without adrenaline. Or thermal coagulation with adrenaline. Or thrombin or fibrin with adrenaline.

Question 27

Define oesophagitis

Answer 27

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.

Question 28

How does oesophagitis present?

Answer 28

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.

Question 29

What is Zenker’s Diverticulum?

Answer 29

Pharyngeal pouch- it is a diverticulum of the mucosa of a the pharynx

Question 30

How does Zenker’s diverticulum present?

Answer 30

• dysphagia,
• regurgitation of food,
• sensation of food being stuck in the throat,
• halitosis.
• Key finding is gurgling sounds found in the neck

Question 31

What investigations are done for Zenker’s diverticulum?

Answer 31

Video fluoroscopy

Question 32

What are some complications of Zenker’s diverticulum?

Answer 32

Aspiration pneumonia, fistulas into trachea–> obstruction or into major blood vessels–> bleeding