Oesaphageal Disease Flashcards
What are some complications of Hiatus Hernia?
- Prone to incarceration and strangulation like any other type of hernia
- Gastric volvulus can also occur whereby the stomach twists on itself by 180 degrees leading to obstruction of the gastric passage and tissue necrosis and requires prompt surgical intervention. Classically present with Borchardt’s triad
- Severe epigastric pain
- Retching without vomiting
- Inability to pass NG tube
What are investigations for Hiatus Hernia?
Examination
- Typically, normal but in patient with sufficiently large hiatus hernia, bowel sounds may be auscultated within chest
Imaging
- Oesophagogastroduodenoscopy is gold standard investigation showing upward displacement of gastro-oesophageal junction.
- Can also be diagnosed incidentally either on CT or MRI scan. Contrast swallow may also be used although less commonly
How is Hiatus Hernia Surgically managed?
- Decompression via NG tube prior to surgical intervention
- 2 aspects of hiatus hernia surgery
- Cruroplasty – hernia reduced from thorax into abdomen and the hiatus reapproximated to appropriate size. Large defect usually requires mesh to strengthen the repair
- Fundoplication – gastric fundus wrapped around lower oesophagus
Indicated when remaining symptomatic despite maximal medical therapy, increased risk of strangulation/volvulus, nutritional failure. In suspected cases of obstruction, strangulation or stomach volvulus have their stomach
What is Achalasia?
- Primary motility disorder of the oesophagus characterised by failure of lower oesophageal spincter relaxation and oesophageal peristalsis.
- Relatively rare and mean age of diagnosis is 50 years
- Inability of oesophagus to relax cause difficulty in passing food boluses down the oesophagus and failure of relaxation of lower oesophageal sphincter means that the food bolus may get stuck and fail to pass to stomach causing vomiting, discomfort and poor nutritional status
What are differentials for Achalasia?
- Other oesophageal motility disorders
- Gastro-oesophageal reflux disease (GORD)
- Oesophageal malignancy
- Angina
What are Risk Factors for Barrett’s Oesophagus
- Caucasian
- Male
- >50yrs of age
- Smoking, Obesity
- Hiatus Hernia
- Family History
10% of patients with GORD will have Barrett’s by the time they seek medical attention
What are clinical features seen in Barrett’s Oesophagus?
History of chronic GORD
Symptoms include :
- Retrosternal chest pain
- Excessive belching
- Odynophagia
- Chronic cough and hoarseness
What are indications for surgery in management of GORD?
- Failure to respond to medical therapy
- Patient preference to avoid life-long medication
- Patients’ with complications of GORD.
Surgery is shown to be more effective than medical treatment for symptoms relief, quality of life improvement and cost.
What are criteria observed in 24hr pH monitoring?
- % total time the pH is <4
- % supine time the pH is <4
- % upright time the pH is <4
- The number of reflux episodes
- The length of the longest episode
- Symptom / reflux correlation
- A DeMeester score can be used to how a patient’s reflux pattern compares to the “average” asymptomatic person
How is Barrett’s Oesophagus monitored based on the Histology?
- No Dysplasia: Endoscopy every 2 to 5 years
- Low Grade Dysplasic: endoscopy every 6 months. Repeat endoscopy with quadratic biopsies every 1 cm. No consensus on long-term surveillance in this group
- High Grade Dysplasia: endoscopy every 3 months. If visible lesion is present, endoscopic ablation with mucosal resection (EMR) or radiofrequency ablation should be considered
What are tests done to investigate Achalasia?
- Gold standard: Oesophageal manometry to measure pressure of sphincter and surrounding muscle. Key manometry features are:
- Absence of oesophageal peristalsis
- Failure of relaxation of lower oesophageal sphincter
- High resting lower oesophageal sphincter tone
- Urgent Endoscopy: often normal in achalasia but rarely tight lower oesophageal sphincter can be observed
- Barium Swallow: rarely performed but may show proximal dilation of oesophagus with characterise bird’s beaks appearance distally
- CXR: wide mediastinum, fluid level
What are Red Flags in any Oesophageal Disease process?
These are indicative of underlying malignancy although are late symptoms:
- Dysphagia
- Weight loss
- Early satiety
- Malaise
- Loss of appetite
What causes Barrett’s Oesophagus?
- Caused by chronic gastro-oesophageal reflux disease.
- Epithelium of oesophagus becomes damaged by reflux of gastric contents resulting in a metaplastic transformation.
- Distal oesophagus most commonly affected
- Increases risk of developing dysplastic and neoplastic changes
What is a Mallory-Weiss Tear?
- Laceration in oesophageal mucosa usually at gastro-oesophageal junction
- Tend to occur due to profuse vomiting, alcoholism, food poisoning or bulimia
- Results in a short period of haematemesis (5% of cases) generally small and self-limiting in the absence of clotting abnormalities or anti-coagulation drugs.
What are some histological features of Achalasia?
Common histological feature is progressive destruction of the ganglion cell in myenteric plexus, but pathophysiology not understood fully.
What are some complications as a result of surgical management of a Hiatus Hernia?
- Recurrence of the hernia
- Abdominal bloating – due to an inability to belch secondary to the improved anti-reflux mechanism of the procedure
- Dysphagia may occur if the fundoplication is too tight and if the crural repair is too narrow. Relatively common early after surgery due to oedema. Settles to a variable degree in majority of patients but some need revisional surgery
- Fundal necrosis if the blood supply via the left gastric artery and short gastric vessels has been disrupted. Surgical emergency typically requiring major gastric resection
What are Risk factors for Oesophageal cancer?
- Smoking
- Alcohol
- GORD
- Barrett’s oesophagus
- Achalasia
- Plummer-Vinson syndrome
- Squamous cell carcinoma is also linked to diets rich in nitrosamines
- Rare: coeliac disease, scleroderma
What is Barrett’s Oesophagus?
- Metaplasia is abnormal reversible change of one cell type to another. Normal stratified squamous layer replaced by simple columnar epithelium
How is Achalasia conservatively managed?
- Sleeping with many pillows to minimise regurgitation, eating slowly and chewing food thoroughly and taking plenty of fluids with meals
- Calcium channel blockers or Nitrate partly effective for temporary relief but their action is typically short lived.
- Botox injections into lower oesophageal sphincter by endoscopy effective for few months
What are some staging investigations for Oesophageal Cancer?
- CT Chest-Abdomen-Pelvis and PET-CT scan are used together to investigate for distant metastases
- Endoscopic Ultrasound to measure the penetration into the oesophageal wall (T stage) and assess and biopsy suspicious mediastinal lymph nodes
- Staging laparoscopy (for junctional tumours with an intra-abdominal component) to look for intra-peritoneal metastases
- Palpable cervical lymph node investigated via fine needle aspiration (FNA) biopsy and any hoarseness or haemoptysis may warrant investigation via bronchoscopy
What are examination findings of Oesophageal Cancer?
Patient may have evidence of
- Recent weight loss or cachexia
- Signs of dehydration
- Supraclavicular lymphadenopathy or any sign of metastatic disease (e.g. jaundice, hepatomegaly or ascites) within 2 weeks.
What are the non-operative management steps of Oesophageal Perforation?
- Initial suitable resuscitation and transfer to Intensive Care / High Dependency Unit
- Antibiotic and anti-fungal cover
- Nil by mouth for 1 to 2 weeks
- Endoscopic insertion of an NG tube
- Large-bore chest drain insertion
- Total Parenteral Nutrition (TPN) or feeding jejunostomy insertion
