General - oesophagus

Question 1

Barrett’s oesophagus

Answer 1

Metaplasia of the oesophageal epithelial lining, whereby normal stratified squamous epithelium is replaced by simple columnar epithelium

Question 2

Barrett’s oesophagus pathophysiology

Answer 2

Vast majority of cases are caused by chronic GORD
Epithelium of the oesophagus becomes damaged by the reflux of gastric contents, resulting in metaplastic transformation -> increases the risk of developing dysplastic and neoplastic changes
Distal oesophagus is most commonly affected

Question 3

Barrett’s oesophagus risk factors

Answer 3

Caucasian
Male
Age > 50
Smoking
Obesity

Question 4

Barrett’s oesophagus investigations

Answer 4

Histological diagnosis
Patients who undergo upper GI endoscopy should have biopsy taken and sent for histological diagnosis
- Appears red and velvety with some preserved pale squamous islands

Question 5

Barrett’s oesophagus management

Answer 5

All patients should be commenced on a PPI
Any medication that impacts the stomach protective barriers should be stopped, reduced alcohol intake and weight loss
Must undergo regular endoscopy – major risk is progression to adenocarcinoma

Question 6

GORD

Answer 6

Gastric acid from the stomach leaks up into the oesophagus
Twice as common in men compared to women

Question 7

GORD pathophysiology

Answer 7

Increased episodes of sphincter relaxation (LOS) and allow the reflex of gastric contents into the oesophagus
Refluxed acidic gastric contents result in pain and mucosal damage in the oesophagus

Question 8

GORD risk factors

Answer 8

Age
Obesity
Male gender
Alcohol
Smoking
Intake of caffeinated drink or fatty/spicy foods

Question 9

GORD clinical features

Answer 9

Chest pain – burning retrosternal sensation, worse after meals, lying down, bending over/straining
Additional symptoms – excessive belching, odynophagia, chronic cough/nocturnal cough

Question 10

GORD investigations

Answer 10

Clinical diagnosis (from a good history & resolution of symptoms after a trial of a PPI)
Patients requiring urgent endoscopy:
1) Patients with dysphagia
2) Any patient > 55 years with weight loss and upper abdominal pain/dyspepsia/reflux
24hr pH monitoring is gold standard – required for patients in whom medical treatment fails and surgery is being considered

Question 11

GORD management

Answer 11

Conservative steps – avoiding known precipitants, weight loss and smoking cessation
PPIs are first line treatment
Surgical management
1) Fundoplication – the gastro-oesophageal junction and hiatus are dissected and the fundus wrapped around the GOJ (SE: dysphagia, bloating and inability to vomit – tend to settle after 6 weeks)
2) Stretta – uses radio-frequency energy delivered endoscopically to cause thickening of the LOS
3) Linx – a string of magnetic beads is inserted around the LOS which tightens it

Question 12

GORD complications

Answer 12

Aspiration pneumonia
Barrett’s oesophagus
Oesophageal strictures
Oesophageal cancer

Question 13

Oesophageal cancer classification

Answer 13

1) Squamous cell carcinoma – typically occurring in the middle and upper thirds, more associated with smoking and excessive alcohol consumption
2) Adenocarcinoma – typically occur in the lower third of the oesophagus, consequence of Barrett’s oesophagus, risk factors for this are long-standing GORD, obesity and high fat intake

Question 14

Oesophageal cancer clinical features

Answer 14

Dysphagia, typically progressive in nature
Significant weight loss, odynophagia, hoarseness
Examination – recent weight loss or cachexia, signs of dehydration, supraclavicular lymphadenopathy or any signs of metastatic disease

Question 15

Oesophageal cancer initial investigations

Answer 15

Urgent upper GI endoscopy to be performed within 2 weeks (any malignancy seen on OGD will be biopsied and sent for histology)

Question 16

Oesophageal cancer further investigations

Answer 16

CT chest-abdomen-pelvis and PET-CT to investigate for distant metastases
Endoscopic ultrasound – measure the penetration into the oesophageal wall and assess & biopsy suspicious mediastinal lymph nodes
Staging laparoscopy – look for intra-peritoneal metastases
Any palpable cervical lymph nodes may be investigated via fine needle aspiration & any hoarseness/haemoptysis – may warrant investigation via bronchoscopy

Question 17

Oesophageal cancer curative management

Answer 17

Comprises surgery with/without neoadjuvant chemotherapy or chemoradiotherapy:
1) SCC – definitive chemo-radiotherapy
2) Adenocarcinomas – neoadjuvant chemotherapy or chemoradiotherapy followed by oesophageal resection

Question 18

Oesophageal cancer surgical treatment

Answer 18

Major undertaking as both abdominal and chest cavities need to be opened & takes 6-9 months for patients to recover to their pre-operative quality of life
Oesophagectomy – removal of the tumour, top of the stomach and surrounding lymph nodes
Main complications – anastomotic leak, re-operation, pneumonia, death
Post-operative nutrition is a major problem for these patients as they lose the reservoir function of the stomach

Question 19

Oesophageal cancer palliative management

Answer 19

Oesophageal stent to help patients who have difficulty in swallowing
Radiotherapy and/or chemotherapy can be used for palliation to reduce tumour size and bleeding
Nutritional support – thickened fluid and nutritional supplements
Severe dysphagia – radiologically-inserted gastrostomy tube may need to be inserted to bypass the obstruction

Question 20

Oesophageal motility disorders

Answer 20

Group of conditions characterised by abnormalities in oesophageal peristalsis
Less common then mechanical/inflammatory disease of the oesophagus & typically manifest with difficulty swallowing solids and liquids together

Question 21

Achalasia

Answer 21

Primary motility disorder of the oesophagus
Characterised by a failure of relaxation of the LOS and the absence of peristalsis along the oesophageal body

Question 22

Achalasia clinical features

Answer 22

Progressive dysphagia
Regurgitation of food
Other symptoms – respiratory complications, chest pain, dyspepsia and weight loss
Visible weight loss in longstanding cases

Question 23

Achalasia investigations

Answer 23

An upper GI endoscopy is essential in order to exclude a cancer
Gold standard – oesophageal manometry:
1) Absence of oesophageal peristalsis
2) Failure of relaxation of the LOS
3) High resting LOS tone

Question 24

Achalasia management

Answer 24

Advice – sleeping with multiple pillows, eating slowly and chewing food thoroughly, taking plenty of fluids with meals
Pharmacological – use of CCBs to inhibit LOS muscle contraction, botox injections into the LOS via endoscopy
Surgical – laparoscopic heller myotomy, per oral endoscopic myotomy, endoscopic balloon dilatation
Oesophagectomy for those with end-stage refractory achalasia

Question 25

Diffuse oesophageal spasm

Answer 25

Characterised by multi-focal high amplitude contractions of the oesophagus
Thought to by caused by the dysfunction of oesophageal inhibitory nerves

Question 26

Diffuse oesophageal spasm clinical features

Answer 26

Severe dysphagia to both solids and liquids
Central chest pain, usually exacerbated by food (pain can respond to nitrates)

Question 27

Diffuse oesophageal spasm investigations

Answer 27

Manometry – pattern of repetitive, simultaneous and ineffective contractions of the oesophagus
Barium swallow – corkscrew appearance

Question 28

Diffuse oesophageal spasm management

Answer 28

Calcium channel blockers – limit the strongest contractions & so provide a symptomatic improvement
Pneumatic dilatation and heller myotomy are surgical options that can be trialled for severe disease

Question 29

Oesophageal perforation

Answer 29

Full thickness rupture of the oesophageal wall
Boerhaave’s syndrome = spontaneous perforation
Surgical emergency

Question 30

Oesophageal perforation aetiology

Answer 30

Iatrogenic
After severe forceful vomiting
Most common site – just above the diaphragm in the left postero-lateral position

Question 31

Oesophageal perforation clinical features

Answer 31

Severe sudden-onset retrosternal chest pain
Respiratory distress
Subcutaneous emphysema

Question 32

Oesophageal perforation investigations

Answer 32

Routine bloods must be taken urgently
Initial imaging via a CXR may demonstrate evidence of pneumomediastinum or intra-thoracic air-fluid levels
Investigation of choice – urgent CT chest-abdomen-pelvis with IV and oral contrast
- May show air/fluid in the mediastinum or pleural cavity

Question 33

Oesophageal perforation management

Answer 33

Patient resuscitation and stabilisation
Surgical management – immediate surgery to control the leak and wash out of the chest (done via thoracotomy), on-table endoscopy, feeding jejunostomy
Non-operative management – appropriate abx and anti-fungal cover, nil by mouth 1-2 weeks with endoscopic insertion of an NG tube on drainage, large-bore chest drain insertion, TPN/feeding jejunostomy

Question 34

Mallory-weiss tears

Answer 34

Lacerations in the oesophageal mucosa, usually at the GOJ
Tends to occur after a period of profuse vomiting and in turn results in a short period of haematemesis
Small and self-limiting