Oesophageal Conditions Flashcards
describe the pathophysiology of GORD
frequent episodic relaxation of the LOS causes reflux of gastric contents resulting in inflammation to the oesophageal mucosa
what factors increase the frequency of reflux episodes
- hiatus hernia
- inc abdo pressure e.g. in pregnancy and obesity
- smoking
- male
- alcohol intake
what is the clinical presentation of GORD
- chest pain: burning, retrosternal sensation worse after melas, lying down, bending over, straining
- ± excessive belching, water brash sensation, nocturnal cough
what are red flag symptoms of GORD that may indicate underlying malignancy
- dysphagia
- any pt > 55 w weight loss, upper abdo pain, dyspepsia or reflux
- pt w persistent symptoms despite conservative management
- loss of appetite
how is reflux oesophagitis graded
Los Angeles classification: based on severity from the endoscopic findings of mucosal breaks in the distal oesophagus
what conditions can reproduce/mimic GORD symptoms
- upper GI malignancy
- PUD
- CAD
- biliary colic
what is the gold standard for diagnosis of GORD
24 hr pH monitoring
- amount of time acid is present in oesophagus
- correlation between presence of acid and patient’s symptoms
what investigation will patients with persistent GORD undergo
upper GI endoscopy
what investigation is performed to exclude any evidence of concurrent oesophageal dysmotility
oesophageal manometry
what is the initial conservative management of GORD
- avoid known precipitants e.g. alcohol, coffee, fatty foods
- weight loss
- smoking cessation
- PPIs
what are the 3 main indication for anti-reflux surgery in GORD
- failure to respond to medical therapy
- patient preference to avoid life-long meds
- complications e..g recurrent pneumonia
what is the main surgical intervention for GORD
fundoplication
- dissection of GOJ & hiatus
- fundus wrapped around GOJ
- hiatal opening in diaphragm then narrowed
what are the main complications of GORD
- aspiration pneumonia
- Barrett’s oesophagus
- oesophageal strictures
- oesophageal cancer
what are the 2 most common causes of oesophageal perforation
- iatrogenic (endoscopy)
- severe forceful vomiting e.g. Boerhaave’s
what is the most common site of oesophageal perforation
just above the diaphragm in left postero-lateral position 2-3cm prox to the GOJ
what is the classical presentation of oesophageal perforation
- severe sudden-onset retrosternal chest pain
- resp distress
- subcutaneous emphysema (frequently absent and Mackler’s triad only seen in ~15% patients)
what is present O/E of oesophageal perforation
- critically unwell ± features of severe sepsis
- clinical abdo sigsn may be absent due to the perforation being intra-thoracic
- dull chest percussion and reduced air entry in the presence of a pleural effusion
what are appropriate investigations for oesophageal perforation
- urgent bloods: FBC, CRP, G&S
- CXR: evidence of pneumomediastinum or intra-thoracic fluid levels
what is the investigation of choice for an oesophageal perforation
urgent CT chest-abdo-pelvis + IV and oral contrast
- may show air or fluid in mediastinum or pleural cavity; leakage of oral contrast from oesophagus into mediastinum/chest is pathognomonic (specific)
- water soluble contrast should be used to prevent worsening of inflammation due to leakage into the thoracic cavity
what is the initial management of oesophageal perforation
- these patients are often septic and haemodynamically unstable
- high flow O2
- fluid resus
- broad-spec abx and anti-fungals
what are the principles of definitive management of oesophageal perforation
- Control of the oesophageal leak, accounting for any distal obstruction
- Eradication of mediastinal and pleural contamination
- Decompress the oesophagus (typically via a trans-gastric drain or endoscopically-placed NG tube)
- Nutritional support
what is the surgical management of oesophageal perforation
- Drainage of intrathoracic contamination via insertion of large bore surgical chest drains
- spontaneous perforation needs thoracotomy ± laparotomy depending on site
- on-table endoscopy
what is a common complications post surgery for oesophageal perf
leakage
- repeat CT scan + oral contrast at 10-14 days before starting oral intake
- may warrant feeding jejunostomy at time of initial surgery
what is non-operative treatment for oesophageal perforation
- urgent resus
- abx + anti-fungal
- NBM 1-2 weeks
- large-bore chest drain insertion
- TPN or feeding jejunostomy
describe the anatomy of the oesophagus
- upper 1/3: skeletal muscle
- middle 1/3: transitional zone of both skeletal and smooth muscle
- lower 1/3: smooth muscle
what is the function of the upper and lower oesophageal sphincter
- UOS: skeletal muscle and prevents air from entering the alimentary canal
- LOS: composed of smooth muscle and prevents reflux from the stomach
how does food pass down the oesophagus
- peristaltic waves controlled by the oesophageal myenteric neurones
- primary wave is under the control of the swallowing centre
- secondary wave activated in response to distension
- as food descends, the LOS relaxes to allow food to pass
what is achalasia
primary motility disorder of the oesophagus, characterised by a failure of relaxation of the lower oesophageal sphincter and the absence of peristalsis along the oesophageal body
what is a common histological feature of achalasia
progressive destruction of the ganglion cells in the myenteric plexus
what do patients with long standing achalasia have an increased risk of
oesophageal cancer
what are the clinical features of achalasia
- progressive dysphagia with both solids and liquids
- regurgitation of food
- resp symptoms e.g. nocturnal cough or aspiration, chest pain, dyspepsia, weight loss
- O/E: maybe visible weight loss but rarely obvious sign
what feature of achalasia is visible on barium swallow
may show proximal dilation of the oesophagus with a characteristic ‘bird’s beak’ appearance distally (due to the failed dilation of the lower oesophageal sphincter)
what is the investigation of choice for achalasia
OGD to exclude any mechanical cause (including cancer) as the cause of symptoms
what might endoscopy show in severe cases of achalasia
dilated oesophagus with retained food and increased resistance at the GOJ
what is the gold standard in diagnosis of motility disorders
high-resolution oesophageal manometry
what does oesophageal manometry involve
pressure sensitive probe inserted into the oesophagus approx 5cm prox to LOS which measures the pressure of the sphincter and surrounding muscle
what are the 3 key features of achalasia on manometry
- Absence of oesophageal peristalsis
- Failure of relaxation of the lower oesophageal sphincter
- High resting lower oesophageal sphincter tone
how is achalasia classified
Chicago: based on pattern of contractility in oesophageal body
* Type I = classical achalasia, 100% failed peristalsis and LOS fails to relax completely
* Type II = Pan-oesophageal pressurisation to > 30mmHg, with at least 20% of swallows, and no normal peristalsis
* Type III = No normal peristalsis, with preserved fragments of distal peristalsis or premature contractions in >20% swallows
what is the conservative management of achalasia
- sleep w mulitple pillows to minimise regurg
- eat slow and chew food properly
- take plenty of fluids
- CCBs e.g. sublingual Nifedipine to inhibit LOS contraction
- botox injections into LOS via endosocpy?
what are the 3 main surgical intervention for achalasia
- Laparoscopic Heller Myotomy (cardiomyotomy) – the division of the specific fibres of the lower oesophageal sphincter which fail to relax - with care taken to only divide the muscle fibres and avoid mucosal breach (long term improvement seen but reflux often an issue so concurrent fundoplication performed)
- Per Oral Endoscopic Myotomy (POEM) – a cardiomyotomy at the LOS is performed from the inside of the oesophageal lumen, through a submucosal tunnel (high rates of post op GORD)
- Endoscopic Balloon Dilatation – insertion of a balloon into the lower oesophageal sphincter, which is dilated to stretch the muscle fibres
what intervention will those with end-stage refractory achalasia require
oesophagectomy
- cardioplasty where this is not appropriate
