Lecture 13 Oesophageal Disorders Flashcards
Where does the oesophagus begin and terminate
C6 and T11-12
What type of muscle is the upper (3-4cm) and lower muscle
Striated
Smooth
What type of cells line the lumen of the oesophagus
Stratified squamous
What is the function of the oesophagus
Transport of food/liquid from mouth to stomach – active process
How is food propelled to stomach
Oesophageal peristalsis produced by oesophageal circular muscles that coordinates with lower oesophageal sphincter relaxation
What nerve mediates the relaxation of the LOS and oesophageal peristalsis
Vagus nerve
Describe the structure of the mucosal rosette
- Striated muscle of right crus of diaphragm
* “Mucosal Rosette” formed by acute angle (of His) at GOJ
What is dysphagia
• Subjective sensation of difficulty in swallowing foods and/or liquids
What is odynophagia
pain with swallowing (may accompany dysphagia)
Name the causes of oesophageal dysphagia
- Benign stricture
- Malignant structure (oesophageal cancer)
- Motility disorders:
- Achalasia:
- Presbyoesophagus
- Eosinophilic oesophagitis
- Extrinsic compression (lung cancer)
Name Oesophageal Disease: Investigations
OGD UGIE Contrast radiology: barium swallow Nasal Catheter containing pH sensors Manometry
What causes Achalasia
Degeneration of inhibitory neurons (ganglion cells) in the myenteric plexus in the oesophagus
What is the cardinal feature of Achalasia and what does it result in
Failure of LOS to relax
Functional distal obstruction
Symptoms of Achalasia
- progressive dysphagia for solids and liquids
- weight loss
- Chest pain (30%)
- Regurgitation and chest infection
Treatment of Achalasia
- Pharmacological - Nitrates, calcium Channel blockers
- Endoscopic - Botulinum Toxin, Pneumatic balloon dilation
- Radiological - Pneumatic balloon dilation
- Surgical - Myotomy (involves cutting away some of the outer layers of tissue from the lower oesophagus to allow food and liquids to pass into the stomach more easily)
What are the complications of Achalasia
Aspiration pneumonia and lung disease
Increased risk of squamous cell oesophageal carcinoma
What are the causes of gastro-oesophageal disease
Increase in Transient relaxations of the LOS
– Hypotensive LOS
– Delayed gastric emptying
– Delayed oesophageal emptying
– Decrease in Oesophageal acid clearance
– Decrease in Tissue resistance to acid/bile
- Hiatus Hernia
Define Barrett’s Oesophagus
Intestinal metaplasia related to prolonged acid exposure in distal oesophagus. This causes a change from squamous to mucin secreting columnar cells
What is Barrett’s Oesophagus a precursor to
Adenocarcinoma
Treatment of Barrett’s Oesophagus
– Endoscopic Mucosal Resection (EMR)
– Radio-Frequency Ablation (RFA)
– Oesophagectomy rarely (mortality ~10%)
What are the 2 types of oesophageal cancer
Squamous and Adenocarcinoma
What type of cancer is more common in Western Europe/USA
Adenocarcinoma
What type of oesophageal cancer is more common in the rest of the world
Squamous
Whats the presentation of oesophageal cancer
- Progressive dysphagia (90%)
- Anorexia and Weight loss (75%)
- Odynophagia- pain when swallowing
- Chest pain
- Cough
- Pneumonia (tracheo-oesophageal fistula)
- Vocal cord paralysis
- Haematemesis- vomiting of blood
Where is the common location for squamous cell carcinoma
proximal and middle third of oesophagus
What precedes squamous cell carcinoma
Dysplasia and carcinoma in situ
What are significant risk factors for squamous cell carcinoma
Alcohol and Tobacco
What is the common location for adenocarcinoma
Distal oesophagus (due to link with Barretts)
What are predisposing factors for adenocarcinoma
Obesity, male, middle age, caucasian
What does the lack of peritoneum around the oesophagus mean
Tumour invasion of adjacent structures are more likely
What are the metastatic locations for adenocarcinoma
Liver, bone, brain, pulmonary
Investigations for Oesophageal Cancer
Endoscop & Biopsy
Staging: CT, EUS, PET, Bone
What investigation would be needed if there was suspected peritoneal spread
Laparoscopy
T1 staging
Tumour invades lamina propria
T2 staging
Tumour invades muscular propria
T3 Staging
Tumour invades adventitia
T4 staging
Tumour invades adjacent structures
N1 Staging
Regional LN metastasis
M1 staging
Distant metastasis
Stage I
T1N0M0
Stage IIa
T2T3/N0M0
Stage IIb
T1T2/N1M0
Stage III
T3N1M0, T4, any N, M0
Stage IV
M1
Treatment for oesophageal cancer
surgical oesophagectomy +/- adjuvant (after) or neoadjuvant (before) chemotherapy
• Radiotherapy
• Brachytherapy (form of radiotherapy where a sealed radiation source is placed inside or next to the area requiring treatment)
Endoscopic stent, laser, PEG
What is Eosinophiic Oesophagitis
• Chronic immune-/allergen-mediated condition defined clinically by symptoms of oesophageal dysfunction, and pathologically by an eosinophilic infiltration of the oesophageal epithelium
Who is Eosionophilic Oesophagitis commonly seen in
Males
Children and young adults
