Oesophageal disease Flashcards
Where does the oseophagus begin? and end?
The end of the Cricoid cartilage (C6), ends T11-12
What nerve mediates peristalsis?
vagus
What is the most common symptom of oesophageal disease?
Heart burn
What is heartburn caused by?
Acid/alkaline environments in the bottom of the oesophagus, can be due to:
-slower emptying of the stomach/into the stomach
- issues with teh Lower Oesophageal; sphincter
Does occur commonly on swallowing
What is GORD?
Gastro-Oesophageal Reflux disease
(long term heart burn)
Whiuch foods etc can affect gord?
Anything that might affect the abikity of th eoesophageal sphincter to stay shut:
- alcohol, nicotine, dietary xanthines
Corncernng symptom of oesophagus?
Dysphagia - difficulty swallowing
What is Odynopohaia?
Pain with swallowing
Presentation of dysphagia, quesions to ask:
Food types
Pattern (regular/irregular]
Other esp alarming symptoms: weight loss, regurgitation, cough
Could do with finding out where the difficulty is; oropharyngeal or oesophageal?
What can be the common causes of dysphagia?
Strictures (benign/malig)
Motility disorders (eg achalasia)
Eosinophillic Oesophagitis
Extrinsic compression
Oesophageal investigations
Primary:
Endoscopy (upper GI (UGIE) or Oesophago-Gastro-Duodenoscopy (OGD)
Barium swallow was an investigation but isn’t used nearly as much now
Is there a small role for contrast radiology? What is it superseeded by?
Yes, mainly for dysphagia. Has been superseeded by endoscopy
What is a pH metry?
Prope down oesophagus, measures pH.
Nowadays can do with clips wirelessly and patients press when they have symptoms
What doies a manometry measure?
Pressure down the oesophagus (contractions) - useful if dysphagia/suspected motility diorder (after endoscopy)
What are he 2 catergories of motility diseases?
Hyper and hypo motile
hyper eg spasms - severe chest pain, potentially dysphasia, confused with MI. Treatment smooth muscle relaxants
Hypo - connective tissue disease/neurpothy - heartburn and reflux symptoms
Symptoms of diffuse oesophageal spasm?
Severe chest pain +/- dysphagia
Treatment of hypermotility?
Smooth muscle relaxants - questionable - apparently they don’t work.
SO: Botox, surgery (cuts), balloon stenting
Most important hypermotality disorder? Causes? Symptoms? Age rang? Gender?
Achalasia
Degenaration of inhibitory neurons in myenteric plexus in oesophagus
-progressive dysphagia
-chest pain
-weight loss (rare)
-regurgitation/Chest infection
Late 20s - 50 yo
Male:Female 1:1
Characteristic appearance on barium swallow for Achalasia? Treatment options?
Rats tail
Balloon stenting, botox, surgery (myotomy - opens up contracted area)
Pharmacological: Nitrates/CCB (relax smooth muscle
Best long term surgery / other tratment options achalisa? Long term complications ?
Surgery best long term
Complications: Aspiration pneumonia and increased risk of squamous cell oesophageal carcinoma
Most common oesophageal disease?
GORD (Gastro - Oesophageal Reflux Disease
GORD Causes? SYmptoms? Risk factors: Men or women more common? Ethnic disparity? Does it require a diagnostic test? WHen would you perform an edoscopy?
Causes:
Anything thats pathologically going to cause acid and bile exposurein the lower oesophagus… so anything that causes the lower oesophageal sphincter to not work as well.
- Hypotensive LOS, transient relaxations of LOS
-Delayed gastric emptying
-Delayed oesophageal empytying
-hiatus hernia
More common in men
More common in caucasians > black > asian
Does NOT require a diagnostic test unless alarming symptoms (dysphagia, weight loss, vomit etc), in which case you would perform one.
What are the 2 types of hiatus hernias?
Sliding (stomach slides up through the oesophageal opening)
Para-oesophageal (new hole)
What can make you more likely to get a hiatus herna?
Obesity and aging
What is the most dangerous and least common hiatus hernai?
Para-oesophageal
GORD complications?
Ulceration, stricture, glandular metaplasia (Barrett’s oesophagus), carcinoma
What is Barretts oesophagus?
Metaplasia of the cells where the damage is occuring (iturn from startified squamous cells into columar cells with mucus glands (more like stomach).
What is barrets a precursor for?
Dysplasia and cancer
What is risk of progression of baretts oesophagus?
6%
High grade dysplasia treatment
Chop out dysplasia nodules (Endoscopic Mucosal Resection (EMR) and burn (radio-frequency ablation (RFA) other parts to stop dysplasia.
Don’t really want ot do an oesophagectomy as there is a high mortality rate (10%)
Why is an oesophagectomy rare for high displasia?
High mortality
If no alarm features what is GORD tratment?
- Lifestyle measures
- meds:
Antacids (gaviscon)
Proton pump inhibitor eg Omeprazole
Stubborn disease might do surgery (fundoplication - full/partial wrap)
Oesophageal cacers - benign tumours common or rare?
rare
Men or women more common oesophageal cancer?
Men
median age?
65 but decreasing
geopgraphic distribution of adenocarcinoma or squamous cell carcinos?
Europe/USA = adenocarcinoma
Rest of world = squamous more common
presentation of Oesophageal cancer?
dysphasia (progressive)
Anorexia/weight loss
Odynophagia
cough
pheumonia (tracheo-oesophageal fistula)
Vocal chord paralysis
HAematemesis (blood vomit)
Where is the squamous cell cancinoma? What does it lead from ?
Mid/Upper oesophagus
dysplasia and carcinoma in situ
Squamous cell carcinoma risk factors/ diet?
ALCOHOL AND TOBACCO!!
Maybe related to diet
Where is Adenocarcinoma? Associated with what disease? Risk factors adenocarcinomas?
Distal Oesophagus, associated with Barrett’s oesophagus
Risk factors: Obesity, male, middle age, Caucasian
Osophageal cancer progonsis, why? Where are metastases
Very poor due to late presentation and because it is easy for cancer to spread to the local big organs such as the heart (no peritoneum and close proximity).
Metastases commonly hepatic, brain, pulmonary and bone
Oesophageal Cancer investigation and staging by what?
Diagnosis by Endoscopy.
Investigation and staging though TNM:
CT
Endoscopic ultrasound
PET scan/Bone scan
Oesophageal Cancer treatment
If fit and non metastatic (localised) cancer then surgery! (Oesophagectomy) +/- neoadjuvant/adjuvant chemotherapy. High mortality rate. Long recovery.
Can do radical treatment but still progressing.
Incurable - palliative measures
Stenting, palliative choemo/radio/brachy therapy.
Symptom control
What is eosinophilic oesophagitis?
Inflammation of the oesophagus due to some sort of allergic reaction - loadsa eosinophils.
Eoinophillic osphagitis presentation anc characteristic endoscopic findiungs. What is the treatment?
Presentation: Dysphagia and food bolus obstruction. looks like thin stripy strictures down the oesophagus.
Treatment is topical/swallowed corticosteroids, dietry elimination and potentially endoscopic dilatation
