Oesophageal Disease Flashcards
What is Barrett’s oesophagus? What is the main cause? Why is it a problem?
Metaplasia (abnormal reversible change) of oesophageal epithelial lining
Stratified squamous -> simple columnar
Most commonly distal
Causes:
GORD
Caucasian, Male, >50yrs, smoker, obesity, hiatus hernia, FH
Increases risk developing dysplastic (abnormal cells) & neoplastic (irreversible, uncontrolled growth) changes
Someone’s presents with a history of: GORD, retrosternal chest pain, XS belching, odynophagia, chronic cough & horseness. What do you need to ask about? What’s the next step to confirm diagnosis?
🚩 dysphagia, WL, early staiety, malaise, loss appetite, worsening dyspepsia despite PPI
Investigations: OGD -> biopsy
(Red/ velvety, some preserved pale squamous islands)
What’s the treatment for Barrett’s oesophagus?
PPI (high dose, BID)
NSAIDS stopped
Lifestyle advice
Regular endoscopy
No dysplasia - every 2-5yrs
Low grade - 6 months
High grade - 3 months (EMR/ ESD/ ablation visible lesions)
- endoscopic mucosal resection
Submucosal dissection
What are the two main types of oesophageal cancer? What are some differences between them?
- squamous CC (developing world), middle & upper 1/3s, smoking, XS alcohol, chronic achalasia, low VA, iron deficiency
- adenocarcinoma (devolved world) lower third, Barrett’s, GORD, obesity, high fat
Symptoms of oesophageal cancer
Early stage lacks well defined symptoms (often present late)
- dysphagia (progressive, solids-> liquids)
- WL (>10% in 6months)
- odynophagia, hoarseness
Urgent endoscopy/ OGD 2WW:
🚩 >55yrs + WL + upper abdo pain/ dyspepsia/ reflux
(If not fit enough CT neck thorax)
Catchexia/ dehydration/ supraclavicular lymphadenopathy/ jaundice/ hepatomegaly/ ascites
Prognosis: 5yrs survival 5-10%
Staging investigations for oesophageal cancer
- CT chest-abdo-pelvis + PeT CT (metastases)
- endoscopic USS (T stage)
- staging laparoscopy (intra peritoneal metastases)
- FNA LNs
- bronchoscope (hoarseness/ haemoptysis)
Management of oesophageal cancer
70% treated palliatively only:
Stent, RadioT, chemoT, photodynamic therapy, nutritional support, radiologically- inserted gastrostomy tube
(Median survival 4months)
Curative:
+/- neoadjuvant chemoT/ chemo-radio
SCC - upper CRT, middle/ lower CRT +/- surgery
Adenocarcinoma - oesophageal resection +/- chemo(R)T
Surgery:
- oesophagectomy, top of stomach, LNs -> stomach replaces oesophagus
- endoscopic mucosal resection (v early) -> EMR + RFA
One lung deflated 2hrs, mortality 4%, 6-9months recovery, anastomotic leak 8%, pneumonia 30%, often feeding jejunostomy
List the subcategories within the spectrum of oesophageal tears, list the main causes & site
Superficial mucosal (Mallory-Weiss)
Perforation - full thickness rupture (spontaneous= Boerhaave’s syndrome) -> physiological collapse, multi organ failure - 50-80% mortality, rare, iatrogenic/ severe forceful vomiting, left postero-lateral above diaphragm most common site
What are the triad of symptoms classically seen for oesophageal ruptures? What’s the name for this triad?
Sudden onset
- retrosternal chest pain
- resp distress
- subcutaneous emphysema (following severe vomiting or retching)
Mackler’s triad - 15% patients
Show do we investigate a suspected oesophageal rupture? What’s the prognosis?
- routine bloods including G&S urgently
- May CXR (pneumomediastinum)
- URGeNT CT chest chest-abdo-pelvis + IV & oral contrast
High clinical suspicion: urgent endoscopy theatre
Mortality 50-80%
Management of a spontaneous oesophageal perforation
Urgent aggressive resuscitation High flow O2 IV access Fluid resus Broad spectrum antibiotics
Management varies (spontaneous/ iatrogenic/ age/ comorbidity)
- control oesophageal leak- eradicate mediastinal & pleural contamination
- decompress oesophagus (trans-gastric drain or endoscopically-placed NG tube)
- nutritional support
Spontaneous ✅immediate surgery (thoaracotomy) ✅OGD
-> 10-14 days CT+contrast before starting oral intake (feeding jejunosotomy)
Management of an iatrogenic oesophageal perforation
Urgent aggressive resuscitation High flow O2 IV access Fluid resus Broad spectrum antibiotics
Management varies (spontaneous/ iatrogenic/ age/ comorbidity)
- control oesophageal leak- eradicate mediastinal & pleural contamination
- decompress oesophagus (trans-gastric drain or endoscopically-placed NG tube)
- nutritional support
Iatrogenic - more stable, may have non-operative (others: minimal contamination, Contained perforation, no symptoms/ signs mediastinitis, no solid food pleura/ mediastinum, too frail)
- suitable resus -> ICU/ HDU
- antibiotic & antifungal
- NBM 1-2weeks
- NG tube
- large-bore chest drain
- TPN / feeding jejunostomy
What are Mallory-Weiss tears?
Lacerations in oesophageal mucosa
Usually gastro-oesophageal junction
After period profuse vomiting -> haematemesis (5% cases haematemesis)
Generally self-limiting
✅ mostly conservative
How long is the oesophagus, what are different sections composed of?
25cm
Upper 1/3 skeletal muscle
Middle 1/3 transition zone both skeletal & smooth M
Lower 1/3 smooth m
Upper oesophageal sphincter - skeletal muscle prevents air entering GI tract
Lower oesophageal sphincter - smooth m, prevents stomach reflux
Explain how the oesophagus moves food
Peristaltic waves
Controlled oesophageal myenteric neurones
Primary wave - swallowing centre
Secondary wave - activated by distension
