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GI Tract > GI - Oesophagus and Reflux > Flashcards

GI - Oesophagus and Reflux Flashcards

1
Q

Length of Oesophagus

A

25cm

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2
Q

Portions of the oesophagus

A

Cervical - Cricoid (C5/6) to T1
Thoracic: T1 - Oesophagus Hiatus (T10)
Abdominal: T10 - GOJ

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3
Q

What makes up the Upper Oesophageal Sphincter

A

Cricoid and thyroid cartilage, hyoid bone and 3 pharyngeal muscles

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4
Q

What makes up the lower oesophageal sphincter

A

Intrinsic: Physiological, smooth muscle. Tone is 10-15mmHg (over intragastric pressure)

Extrinsic: Crural diaphragm

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5
Q

Histology of Oesophagus

A

Epithelium: Stratified Squamous Epithelium

2 muscularis externa/ muscularis propria - circular and longitudinal

Striated muscle for upper 1/3, Smooth Muscle for lower 2/3

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6
Q

Innervation of oesophagus

A

Sympathetic: Cervical and Thoracic sympathetic Trunk. Relaxes wall and constricts BVs

Parasympathetic: Vagus nerve. Glandular Contractions, Muscles of oesophagus (peristalsis)

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7
Q

What Innervates the myenteric plexus?

A

The vagus nerve

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8
Q

What are the nuclei for the upper and lower oesophagus

A

UES and Upper Oesophagus: Nucleus ambiguus

LES and Lower Oesophagus: Dorsal motor nuclei

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9
Q

Blood Supply

A

Artery: Thyroid A, branches of gastric, inferior phrenic + splenic

Vein: Sup - IVC, azygous, hemiazygous. Inf - L gastric and short gastric anastamose to the splenic vein

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10
Q

Why do oesophageal varacies occur in portal hypertension

A

Because the left gastric and short gastric vein drain the bottom of the esophagus to the portal system

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11
Q

Physiology of swallowing

A
  • Food from soft palate down pharynx
  • UES relaxes, epiglottis closes over, respiration pauses
  • primary peristalis pushes bolus down
  • LES opens @ swallow initiation
  • 2ndry peristalsis: in case of distention

Controlled by swallowing center of medulla oblongata

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12
Q

Oesophageal Investigations

A
  • Endoscopy
  • high resolution manometry
  • pH monitor
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13
Q

What can can endoscopy be used for?

A

Can see down 2nd part duodenum

Diagnose mucosal/ structural abnormality - barrett’s oesophagus. Varices, stricture, adenocarcinoma.

Intervention
Mucosal Biopsy

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14
Q

high resolution manometry - how it works, what it diagnoses

A
  • Catheter and local anesthetic
  • Records pressure while you swallow
  • diagnoses motility disorders - Achalasia, oesophageal spasm
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15
Q

pH monitor - how it works and what it does

A

Catheter in nose, keep pH monitor 5cm above LES and record for 24 hours

Diagnoses acid reflux - confirm pre-surgery or inf non-responsive to PPI

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16
Q

Red Flags for oesophageal disorders

A
  • Unexplained weight loss
  • Dysphagia
  • Persistant vomiting
  • GI blood loss ( haemoptysis, occult stool)
  • Upper Abdominal Mass
17
Q

What is GORD?

A

Retrograde passage of acidic gastric contents up oesophagus

18
Q

Signs and Symptoms of GORD?

A
  • Dyspepsia (Abdominal discomfort - pain, nausea)
  • vomiting
  • Regurgitation
  • Heartburn
  • Epigastric Pain
  • Food Sticking
  • Extraoesophageal ( wheeze, cardiac pain, pharangeal sympt)
19
Q

Relieving and Exacerbating factors

A

Worse - lying down, after meal

Better - milk

20
Q

Causes of GORD

A

Lowered ‘defenses’

  • Hiatus Hernia
  • Transient LOS relaxations
  • less Sphincter Pressure (<2/3mmHg below stomach pressure)
  • TIssue resistance
  • decreased luminal clearance mechanisms
Increased Offenses 
- Duodenogastral reflux
- Decreased Gastric Emptying 
- Increased HCL/ Pepin production 
Increased Abdominal Pressure
21
Q

Types of Hiatus Hernia

A

Sliding - 20% - GOJ

Rolling - 80% - GOJ and Fundus of stomach

22
Q

Complications of GORD

A

Oesophagitis

  • Strictures
  • Inflammation of squamous mucosa due to acid damage

Barett’s Oesophagus
- Metaplasia of squamous mucosa to columnar

Adenocarcinoma
- dysphagia of mucosa

23
Q

Treatment of GORD

A

Lifestyle
(Smoking/ alcohol/ diet)

Pharmaceutical

  • Antacids (Mg/ Al/ Na/ Ca)
  • Alginates (NA alginate)
  • mucosal agents
  • H2 receptor antagonist (Cimitidine/ Ranitidine)
  • PPI (Omeprazole)
  • Sucralfate
  • Prokinetic

Surgical

  • Nillson Fundoscopy - tie stomach around oes to help sphincter pressure
  • Linx procedure - metal ring to act as sphincter
  • Halo - Burning of oesophageal mucosa to remove barett’s
  • EMR: mechanical removal of mucosa
24
Q

Mechanism of Action of Antacids and Alginates

A

Antacids
- Mild Reflux
- Increase pH and Reduce Pepsin and binds bile acids
-Al - constipation, Mg - diarrhoea
- Na: avoid in CHD and renal disease
Interacts with tetracyclins, digoxin, prednisolone

Alginates

  • NA Alginate
  • Add to antacid
  • Foaming agent forms protective barrier around mucosa
25
Q

Mechanism of Action of H2RA

A
  • Cimitidine/ Rantidine
  • Binds Histamine Receptor on Parietal cells and prevents histamine-mediated acid release
  • Can cause constipation, diarrhoea, deranged LFT, headache and dizziness
    Binds Cyctochrome C - warfarin/ phenytoin
  • Tachyphylaxis occurs - rapid loss of response to drug with time
26
Q

Mechanism of Action of PPI

A
  • Omeprazole
  • selectivley accumulates in canniculi of parietal cells as becomes active in H+, cationic sulfamide binds irreversibly with groups on proton pump = long lasting inhibition

Usually well tolerated, but can cause diarrhoea, rash , headache, C. diff infection
Interacts with CytP450
LT, May cause atrophic gastritis (parietal cell atrophy leads to hypochlorhydria

27
Q

Mechanism of Action of Prokinetics and Sucralfate

A

Prokinestics

  • metoclopramide.
  • Increases ACh release
  • Increases gastric emptying and sphincter pressure
  • Compli: drowsiness, diarrhoea

Sucralfate
- Complex sucrose polymer that acts as cytoprotective agent. Promotes bicarb production and acts as acid buffer

28
Q

Protective Mechanisms against GORD

A

Intrinsic Sphincter - tone of 10-15mmHg
Extrinsic Sphincter - reflex contraction when intra-abdominal pressure increases
Intra-abdominal Oesophagus - intra-abdominal pressure helps sphinter respond to increased IAP
Angle of His/ Flap Valve - pressure increase in stomach closes cardiac sphincter
Secondary peristalsis: in response to distention
Bicarbonate in mucus

GI Tract (4 decks)

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