Oesophageal conditions Flashcards
What is gastro-oesophageal reflux disease (GORD)
Reflux of acid-pepsin and bile into LOWER OESOPHAGUS
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
Pathophysiology of GORD
Mucosa exposed to EXCESS acid-pepsin –> thickening of squamous epithelium –> increased cell loss and inflammation –> ulceration if reflux is severe
GORD risk factors (6)
Family history of GORD
Obesity
Older age
Hiatus hernia
Drugs lowering LOS pressure, e.g. CCBs
Smoking
Alcohol
GORD symptoms (2)
Symptoms:
Dyspepsia - heartburn
Acid regurgitation/reflux –> water brash (acidic taste in back of mouth)
GORD investigations (4)
PPI trial
UGIE (only if alarm features)
Oesophageal manometry and pH
Barium swallow
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
Complications of GORD (4)
Oesophageal ulcer
Oesophageal stricture (due to healing by fibrosis)
Barrett’s oesophagus
Oesophageal carcinoma
What is Barrett’s oesophagus + cause
Pre-malignant condition caused by GORD, usually in lower oesophagus
Pathophysiology of Barrett’s oesophagus
Glandular metaplasia:
normal squamous epithelium changes to intestinal glandular columnar epithelium because it’s more resistant to acid
Barrett’s oesophagus risk factors (3)
Male
GORD
Older age
Barrett’s oesophagus symptoms (2)
Dyspepsia - heartburn
Acid regurgitation
Barrett’s oesophagus investigations (1)
Endoscopy + biopsy
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
Complications of Barrett’s oesophagus
Adenocarcinoma of oesophagus
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
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
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
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
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
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
Cause of adenocarcinoma of oesophagus
Metaplasia due to GORD –> barrett’s oesophagus
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
Adenocarcinoma of oesophagus risk factors (5)
Male Barrett's oesophagus GORD Hiatus hernia Obesity
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
