GORD, Barrett's and dysmotility of oesophagus and stomach inc. oesophageal pathology Flashcards
Define GORD
Any symptomatic condition, anatomic alteration or both that results from the reflux of noxious material from the stomach into the oesophagus.
What makes up the noxious material in GORD?
Mainly gastric acid but can be pepsin and bile acids in more severe cases
What are the defence against GOR?
LOS
Surface mucosa
Bicarbonate ions
Oesophageal clearance
Symptoms of GORD?
Heartburn
Acid reflux
Chest pain
Dysphagia
Alarm features of GORD
Weight loss
anaemia
recurrent vomiting
dysphagia
Risk factors for GORD
Age FH Smoking, caffeine, alcohol (relax LOS) As BMI increases, so does chance of GORD Hiatus hernia
Complications of GORD
Oesophagitis stricture haemorrhage barretts oesophagus adenocarcinoma
What is the main investigation for GORD?
Often not required
Gastroscopy
Conservative management for GORD
stop smoking, lose weight, avoid large meals late at night, avoid alcohol, avoid fatty foods, elevate head of bed
Pharmacological management for GORD
Antacids - Gaviscon, Maalox
PPIs - Omeprazole
H2RA - Ranitidine
Surgery of no drugs work - fundoplication
Describe fundoplication
Hiatus hernia fixed, stomach partially wrapped around LOS to stop reflux
Treatment for a benign oesophageal stricture
Dilation at endoscopy - short term - risk of severe bleeding/ perforation (risk increased if malignant stricture)
High dose PPI - long term
Describe Barrett’s oesophagus
Metaplasia of oesophageal non-keratinized squamous epithelium to gastric columnar epithelium (with extensive tubular secretory glands)
What is Barrett’s?
Complication of severe long term GORD
premalignant condition whihc predisposes the pt to oesophageal adenocarcinoma
Protective response for faster regeneration
Management for Barrett’s
Surveillance for dysplasia using endoscopy
PPI - Omeprazole
Dysplasia management
More frequent surveillance
Optimise PPI dose
Surgery - Endoscopic mucosal resection
- Radiofrequency ablation
Argon gas - tube down oesophagus and argon gas pumped through to remove barrett's liningWhat happens in Achalasia?
LOS does not relax very well so there is a loss of muscle tone of peristalsis which leads to a dilated oesophagus
How is the oesophagus in achalasia described?
“birds beak” oesophagus
What do physical signs in a pt with achalasia show?
anaemia or malnutrition
What is the #1 investigation for achalasia?
oesophageal manometry
Symptoms of achalasia
regurgitation of food cough dysphagia (solids and liquids) chest pain which may increase post-prandial (may be felt in back, neck and arms) heartburn unintentional weight loss
Complications of achalasia
Aspiration pneumonia
oesophageal perforation
Treatment for achalasia
Botox injections - relax LOS muscles
Long acting nitrates or CaCB - relax LOS
Dilation at endoscopy
What is gastroparesis?
Delayed gastric emptying but no physical obstruction
Causes of gastroparesis?
Idiopathic cannabis use opiates and anti-cholinergics Diabetes mellitus Systemic sclerosis
Symptoms of gastroparesis
Feeling of fullness nausea and vomiting weight loss upper abdominal pain (very non-specific symptoms)
Investigations for gastroparesis
endoscopy first
gastric emptying studies (type of nuclear test)
Management for gastroparesis
removal of precipitating factors liquid/sloppy diet eat a little and often low fat diet promotility agents - Domperidone and Metoclopramide (to speed up gastric emptying)
What is reflux oesophagitis?
Inflammation of oesophagus due to refluxed low pH gastric content
May also be caused by defective sphincter mechanism +/- Hiatus hernia
, Abnormal oesophageal motility, Increased intra-abdominal pressure (pregnancy)
Histological changes in reflux oesophagitis
Basal zone epithelial expansion and lengthening of papillae
Intraepithelial neutrophils, lymphocytes and eosinophils
In Barrett’s oesophagus, how is the mucosa described?
Red velvety mucosa in lower oesophagus
What is allergic/ eosinophilic oesophagitis?
Corrugated (feline) or ‘spotty/wrinkled’ oesophagus
Food gets stuck in oesophagus - not dysphagia - abnormal oesophageal motility
Large numbers of intraepithelial eosinophils
pH probe is negative for reflux
What is the treatment for allergic oesophagitis?
steroids
chromoglycate
montelukast
What is the most common kind of benign oesophageal tumour?
squamous papilloma
Where does squamous cell carcinoma of the oesophagus arise from?
Squamous cell epithelium
Where does adenocarcinoma of the oesophagus arise from?
dysplasia in oesophagus
Is squamous cell carcinoma more common in females or males?
Males
Causes of squamous cell carcinoma
Vitamin A, Zinc deficiency Tannic acid/ Strong tea Smoking, Alcohol HPV Oesophagitis Genetic
What do squamous cell carcinoma cause?
Obstruction and dysphagia
Is Adenocarcinoma more common in males or females?
males
Which part of the oesophagus is adenocarcinoma most common in?
Lower 1/3rd
How do oesophageal cancers spread?
- direct invasion
- lymphatic permeation
- vascular invasion
How do oesophageal cancers present?
dysphagia - due to tumour obstruction
odynophagia
haematemesis
general symptoms of malignancy (anaemia, weight loss, loss of energy)
Paraneoplastic syndrome (hypercalcaemia and inappropriate hormone production)
How are oesophageal cancers diagnosed?
Upper Gi edoscopy and biopsy #1
barium meal
CT/MRI scan of chest and abdomen
bronchoscopy (can infiltrate to trachea)
Surgical treatment of oesophageal cancer
Removal of oesophagus and lymph nodes
only 50% of pts are suitable
Contraindications to oesophageal cancer surgery
- Direct invasion of adjacent structures
- Fixed cervical lymph nodes – too advanced
- Widespread metastases – far too advanced
- Poor medical condition
Other forms of treatment for oesophageal cancer
radiotherapy
intubations/ stents (only liquid food as no peristalsis)
canalisation
terminal care
Prognosis of oesophageal cancer
dismal prognosis
majority die within a year
5 year survival 11%
Give 3 drugs which are recognised causes of oesophageal injury
tetracycline
catopril
slow release theophylline
