Oesophageal cancer treatment - surgical candidate (2) - non-surgical candidate (2)

Surgical - Endoscopic resection of tumour +/- ablation (if early stage) - Oesophagectomy If not surgical candidate: - chemoradiotherapy or radiotherapy alone (only radiotherapy alone if can't tolerate both) - endoscopic ablation +/- stent for SYMPTOM RELIEF

Oesophageal conditions Flashcards by Heo Mun Ho

What is gastro-oesophageal reflux disease (GORD)

Reflux of acid-pepsin and bile into LOWER OESOPHAGUS

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Causes of GORD (2)

LOS malfunction - only relaxes for short time, delays oesophageal emptying so less acid clearance

Hiatus hernia (stomach moves up into chest through opening in diaphragm) - sliding or paraoesophagheal

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Pathophysiology of GORD

Mucosa exposed to EXCESS acid-pepsin –> thickening of squamous epithelium –> increased cell loss and inflammation –> ulceration if reflux is severe

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GORD risk factors (6)

Family history of GORD
Obesity
Older age
Hiatus hernia

Drugs lowering LOS pressure, e.g. CCBs
Smoking
Alcohol

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GORD symptoms (2)

Symptoms:
Dyspepsia - heartburn
Acid regurgitation/reflux –> water brash (acidic taste in back of mouth)

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GORD investigations (4)

PPI trial

UGIE (only if alarm features)
Oesophageal manometry and pH
Barium swallow

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GORD treatment

lifestyle changes (2)
medical (3)
surgery + when this is indicated

Lifestyle changes
-weight loss, avoid late night eating

Antacids
PPI - omeprazole
Hydrogen receptor blocker/antagonist - if PPI insufficient

Nissen fundoplication if not responsive to medication

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Complications of GORD (4)

Oesophageal ulcer
Oesophageal stricture (due to healing by fibrosis)
Barrett’s oesophagus
Oesophageal carcinoma

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What is Barrett’s oesophagus + cause

Pre-malignant condition caused by GORD, usually in lower oesophagus

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Pathophysiology of Barrett’s oesophagus

Glandular metaplasia:

normal squamous epithelium changes to intestinal glandular columnar epithelium because it’s more resistant to acid

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Barrett’s oesophagus risk factors (3)

Male
GORD
Older age

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Barrett’s oesophagus symptoms (2)

Dyspepsia - heartburn

Acid regurgitation

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Barrett’s oesophagus investigations (1)

Endoscopy + biopsy

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Barrett’s oesophagus treatment

for non-dysplastic (2)
dysplastic (3)

If non-dysplastic: PPI + radio frequency ablation (RFA)

If dysplastic:
PPI
RFA
Endoscopic mucosal resection

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Complications of Barrett’s oesophagus

Adenocarcinoma of oesophagus

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Causes of squamous cell carcinoma of oesophagus (less common than adenocarcinoma of oesophagus)

Carcinogens:

Polycyclic aromatic hydrocarbons & nitrosamines from smoking
Acetaldehyde from alcohol inhibits DNA repair

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Pathophysiology of squamous cell carcinoma on oesophagus + what part of oesophagus it affects

Due to preceding dysplasia and carcinoma in situ

Affects proximal 2/3 oesophagus

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Squamous cell carcinoma of oesophagus risk factors (4)

Smoking
Alcohol
Non white race
Family history of oesophageal cancer

Male - not specific to SCC, also applies for oesophageal adenocarcinoma

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Oesophageal cancer (squamous and adenocarcinoma) symptoms (3) + signs (1)

Symptoms:
Progressive dysphagia
Odynophagia
Hoarse voice (only in upper tumours compressing recurrent laryngeal n)

Signs:
Weight loss

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Oesophageal cancer investigations (5 - 1 definitive investigation + 4 staging investigations)

Endoscopy + biopsy (at least 8 biopsies)

Staging :
CT thorax/ abdomen (for M staging)
MRI thorax/abdomen (for M staging)
EUS (for T/N staging)
PET (for M staging) - done before EUS

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Oesophageal cancer treatment

surgical candidate (2)
non-surgical candidate (2)

Surgical

Endoscopic resection of tumour +/- ablation (if early stage)
Oesophagectomy

If not surgical candidate:

chemoradiotherapy or radiotherapy alone (only radiotherapy alone if can’t tolerate both)
endoscopic ablation +/- stent for SYMPTOM RELIEF

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Cause of adenocarcinoma of oesophagus

Metaplasia due to GORD –> barrett’s oesophagus

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Pathophysiology of adenocarcinoma of oesophagus + what part of oesophagus it affects

Usually in distal third of oesophagus

Metaplastic cells become dysplastic due to activation of oncogenes and inhibition of tumour suppressor genes

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Adenocarcinoma of oesophagus risk factors (5)

Male
Barrett's oesophagus
GORD
Hiatus hernia
Obesity

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3 ways that oesophageal cancer spreads + what 4 places can it spread to

Direct Lymphatic Blood Liver, lung, brain, bone

How does the fact that the oesophagus lacks a serosal layer affect prognosis

It means that local tumour invasion into adjacent structures (heart, trachea, aorta) is easier so limits surgery

The lamina propria (mucosa) of the oesophagus is rich in lymphatics compared to the rest of the GIT where lymphatics are mainly submucosal, what does this mean in terms of metastases

lymph node metastases therefore occur earlier in oesophageal tumours

What are the 3 oesophageal motility disorder categories

Hypermotility Hypomotility Achalasia

What is an example of an oesophageal hypermotility disorder

Diffuse oesophageal spasm

Pathophysiology of oesophageal hypermotility disorders

Idiopathic Muscles are over-reactive --> spasm Confused with angina/MI

Diffuse oesophageal spasm symptoms (2)

Episodic chest pain | Dysphagia

Oesophageal motility disorders (hypermotility/ hypomotility/ achalasia) investigations

UGIE Oesophageal manometry - KEY FOR ACHALASIA Barium swallow

Pathophysiology of oesophageal hypomotility disorders

Failure of LOS mechanism --> reflux and heartburn symptoms

Oesophageal hypomotility disorders symptoms (2)

Heartburn | Acid regurgitation --> waterbrash

What is achalasia

Functional distal oesophageal obstruction affecting motility due to failure of LOS to relax to allow food to get into stomach

Pathophysiology of achalasia

Functional loss of myenteric plexus ganglion cells in distal oesophagus and LOS --> failure of LOS muscle to relax after swallowing so it's continuously closed and unable to open when necessary --> so obstructing distal oesophagus

Achalasia risk factors (2)

Allgrove syndrome | Herpes and measles viruses

Achalasia symptoms (3) and signs (2)

Symptoms: Dysphagia Retrosternal pain Regurgitation Signs: Weight loss Recurrent chest infection

Achalasia treatment - pharmacological (2) - endoscopic therapy (2) - surgical

Pharmacological: - Nitrates - CCBs Endoscopic therapy: - Botulinum toxin injection - Pneumatic balloon dilation Surgical: -Myotomy (cutting muscles of LOS to allow it to relax )

Complications of achalasia (3)

Aspiration pneumonia GORD Increased squamous cell carcinoma risk

What is a sliding hiatus hernia

Fundus of stomach moves up diaphragmatic hiatus and up through oesophagus

What is a para-oesophageal hiatus hernia

Fundus of stomach moves up diaphragmatic hiatus then alongside oesophagus

Biggest risk factor of hiatus hernia

Obesity

Hiatus hernia treatment

Fundoplication

Oesophageal cancer prognosis

5 yr survival less than 15%

What is eosinophilic oesophagitis

Chronic immune/allergen mediated inflammation of oesophagus from inappropriate response to unharmful allergens

Pathophysiology of eosinophilic oesophagitis

Eosinophilic infiltration of oesophageal epithelium as a response to an allergen --> oesophageal dysfunction

Eosinophilic oesophagitis risk factors (3)

Male Atopic disease Family history of it

Eosinophilic oesophagitis symptoms (2) + signs (1)

Symptoms: DYSPHAGIA Heartburn/chest discomfort Signs: Avoiding eating/changing the way they eat (e.g. chewing more throroughly/more slowly, drinking lots while eating; to prevent food from getting stuck)

Eosinophilic oesophagitis treatment (3) - medical - lifestyle change - surgical

Corticosteroid Dietary elimination therapy - a specific diet Endoscopic dilation

Eosinophilic oesophagitis investigations (2)

``` UGIE + biopsy (at least 2 biopsies from 2 different locations) PPI trial (to see if it's GORD) ```

2 types of oesophageal carcinomas

Adenocarcinoma | Squamous carcinoma

Local effects of oesophageal cancer (3)

Oesophageal obstruction --> dysphagia Ulcer Perforation

Causes of dysphagia (5)

``` Benign stricture (narrowing) Malignant stricture (from oesophageal tumour) Motility disorders - achalasia Eosinophilic oesophagitis Extrinsic compression ```

Investigations of general oesophageal disease

Endoscopy - only indicated for ALARM features Barium swallow Oesophageal pH and manometry

2 types of hiatus hernia

Sliding | Para-oesophageal

Main type of drug used to treat GORD

PPI

When is an oesophagectomy indicated

If fit and no metastases

Name a type of oesophagectomy

Ivor Lewis approach - first stomach is mobilised and oesophagus is resected then stomach is anastomosed

Most appropriate investigation of hiatus hernia

Barium meal

Achalasia increases the risk of adenocarcinoma or squamous cell carcinoma of the oesophagus

SCC