Oesophageal disease Flashcards
What is the oesohpagus?
A 25cm muscular tube, connecting the pharynx to the stomach
Describe the epithelium of the oesophagus
Histologically, the upper two thirds of the oesophagus is lined by stratified squamous epitelium, which transitions distally into squamo-columnar epithelium.
Where are the two natural narrowing points of the oesophagus and what is the significance of this?
Upper oesophageal sphincter and lower oesophageal sphincter.
Dysfunction of these sphincters (particularly the lower sphincter) will result in gastro-oesophageal reflux disease (GORD)
Investigations for dysphagia
- Solids and liquids - barium swallow
- Solids only - upper GI endoscopy
Causes of dysphagia of solids and liquids
- Progressive
- Achalasia
- Neurological conditions
- Pharyngeal pouch
- Intermittent
- Oesophageal spasm
Causes of solid only dysphagia
- Acute
- foreign body
- Intermittent
- oesophageal ring or oesophagitis
- Progressive
- reflux - GORD
- >50y/weight loss - cancer
Achalasia of the oesophagus definition
A motility disorder characterised by aperistalsis of the oesophagus and inadequate relaxation of the lower oesophageal sphincter.
Pathophysiology of achalasia of the oesophagus
- The exact aetiology of achalasia is unknown
- Degeneration for the ganglionic cells in the myenteric plexus within the oesophageal wall and lower sphincter has been reported
- As a result, parasympathetic tone is reduced, which leads to inappropriate peristalsis and hypertonia of the lower oesophageal sphincter
Clinical features of achalasia of the oesophagus
- Progressive dysphagia affecting both solids and liquids
- Regurgitation is common and often relieves symptoms
- Retrosternal chest pain may also be present
Achalasia of the oesophagus - Investigations stepwise plan:
- Arrange a barium swallow examination
- bird’s beak appearance, as the proximal oesophagus is dilated and very narrow at the sphincter
- Obtain a chest X-ray
- may reveal widened mediastinum as a result of a dilated oesophagus
- Arrange for manometry to be carried out
- gold standard investigation
- high resting pressure of the lower oesophageal sphincter is diagnostic
- Consider upper GI endoscopy
- to rule out malignancy
Rare and late complication of achalasia of the oesophagus
Oesophageal cancer
Management of achalasia of the oesophagus
- Surgical myotomy (the Heller procedure) - first line if patient is fit
- Endoscopic pneumatic dilation of the lower sphincter is effective and generally used in older patients with comorbidities
Describe diffuse oesophageal spasm
This is an oesophageal motility disorder that typically presents with transient retrosternal chest pain and intermittent dysphagia
Diffuse oesophageal spasm investigations
Baruim studies often reveal a “corkscrew” oesophagus
Treatmet of diffuse oesophageal spasm
- Treatment is initiated with a trial of proton pump inhibitors
- Second line options are usually nitrates and CCBs
- Pneumatic dilation and surgical myotomy may be considered as final line options
Pharyngeal pouch definition
(Zenker diverticulum)
This is a rare condition characterised by a posteromedial outpouching of the oesophagus through the Killian dehiscene (weak area of the cricopharyngeal muscle). Food debris accumates in the pouch, eventually compressing the oesophageal body.
Pharyngeal pouch (Zenker diverticulum) presentation
Progressive dysphagia, regurgitation and halitosis
Pharyngeal pouch investigations
- Barium swallow
- Endoscopy is strongly discouraged as an initial investigation as perforation of the pouch may occur as a complication
Definition of gastro-oesophageal reflux disease
A condition in which symptoms such as heartburn are produced when reflux of gastric contents into the oesophagus or oral cavity is present.
Epidemiology of GORD
- 2-3 times more common in men
- Affects 10-20% of the western world’s population
Aetiology of GORD
- Lower oesophageal sphincter dysfunction
- resting tone is decreased, resulting in acid reflux
- Hiatus hernia
- eliminates the natural thoraco-abdominal pressure gradient that prevents reflux
- Lifestyle factors (smoking, alcohol, coffee)
- Increased intra-abdominal pressure (obesity, pregnancy)
How are hiatus hernias classified and what is the significance?
Hiatus hernais are typically classified as sliding (80%), rolling or mixed.
Patients with a rolling hiatus hernia should be considered for repair, as there is an increased risk of strangulation with rolling hiatus hernias.
Pathophysiology of GORD
- Reflux of gastric contents into the lower oesophagus exposes the mucosal epithelium to damage
- This triggers an inflamatory response, resulting in reflux oesophagitis
Clinical features of GORD
- Heartburn, a burning sensation origionating from the stomach that gets worse after meals and lying down
- Acid brash, a metallic taste as a result of acid regurgitation
- Dysphagia and atypical chest pain
GORD investigations
Clinical diagnosis, rarely requires investigations
- Consider proton pump inhibitor
- young patients and patients with typical symptoms can be treated empirically with a trial of high dose PPI (4-8 week course)
- Consider an UGIE
- recommended if diagnosis uncertain, patient presents over the age of 55 years or with ALARM symptoms
- Consider ambulatory intraluminal pH monitoring
- may be indicated if surgical intervention is being considered, a pH of less than 4 more than 4% of the time is diagnostic
What are the red flag symptoms associated with dyspepsia that warrant further investigation with UGIE?
ALARMS
- Anaemia
- Loss of weight
- Anorexia
- Recent onset of progressive symptoms
- Melaena, haematemesis
- Swallowing difficulty
Stepwise management of GORD
- Lifestyle modification
- Smoking cessation, dietry advice, weight reduction and self-treatment eg antacids (provides short term symptomatic relief)
- Patients should elevate the head of the bed, and avoid food likely to provoke GORD (eg spicy/fatty food, citrus fruits and chocolate), especially before bed
- Full dose PPI therapy for 4-8 weeks
- Patients with a history of oesophageal intervention (eg previous dilation) should remain on lifelong therapy
- Offer low dose PPI therapy or switch to H2 antagonist if symptoms persist or recur
- Consider laparoscopic fundoplication
- Appropriate for patients with a confirmed diagnosis of GORD (with pH monitoring) and have responded to PPI therapy but:
- are unable to be on long tern therapy
- do not wish to be on long term therapy
- have severe disease
- Appropriate for patients with a confirmed diagnosis of GORD (with pH monitoring) and have responded to PPI therapy but:
Complications of GORD
- Oesophagitis
- Barrett oesophagus
- Oesophageal carcinoma
- Benign oesophageal stricture
Definition of Barrett oesophagus
A pre-malignant condition, occuring in 10-20% of patients exposed to chronic acid reflux. Extended exposure to chemical injury causes metaplastic transformation of the normal oesophageal squamous epithelium into columnar epithelium.
Clinical features of Barrett oesophagus
Most patients are asymptomatic apart from their GORD symptoms
Diagnosis of Barrett oesophagus
Multiple endoscopic biopsies to determine extent of dysplasia
Barrett oesophagus management
- Regular endoscopic surveillance
- every 1-3 years to monitor disease progresssion and dysplasia change
- Consider continuous surveillance
- patients with low grade dysplasia may be treated conservatively
- Consider surgical oesophagectomy
- In patients with high-grade dysplasia
- Consider other treatments
- Endoscopic radiofrequency ablation, photodynamic therapy and mucosal resection
What is oesophageal cancer and what are the two histological subtypes?
Mucosal neoplasm originating from oesophageal epithelium. The two histological subtypes are squamous cell carcinoma and adenocarcinoma.
In which part of the oesophagus do adenocarcinomas and squamous cell carcinomas tend to originate?
Adenocarcinomas tend to origionate in the lower oesophagus, as this is the most common site affected by Barrett changes.
Conversely, the squamous subtype often arises in the middle third of the oesophagus.
Which subtype of oesphageal carcinoma is more common?
In the western world adenocarcinoma is more common, whereas squamous cell carcinoma is the most common subtype in Asia and Africa.
Risk factors for oesophageal carcinoma
- Smoking and alcohol (SCC)
- Pre-existing GORD and Barrett oesophagus (AC)
- Obesity (risk factor for AC by protective for SCC)
Clinical features of oesophageal carcinoma
- Often asymptomatic until later stages
- Progressive dysphagia for solids followed by liquids
- Haematemesis or malaena
- Late stages - hoarseness (mediastinal invasion), weight loss
Pathophysiology of oesophageal carcinoma
Exposure to carcinogens (ie cigarette smoke) and chronic exposure to acid reflux predisposes to dysplastic changes within the oesophageal mucosa. This local invasion may then spread to adjacent structures or metastasise further to local lymph nodes, lungs and liver.
Oesophageal cancer investigations
- Blood tests
- FBC (to look for anaemia secondary to occult GI bleed)
- U&Es (to check suitability for staging CT scan)
- LFTs (changes may indicate liver mets)
- Arrange urgent oesophagogastroduodenoscopy (OGD)
- with brushings and biopsies to confirm grade
- Staging imaging
- Chest and abdominal CT scan
- Often performed concurrently with a PET scan to screen for evidence of metastasis
- TNM staging is performed
Management of oesophageal cancer with metastatic disease
Around 70% of patients present with metastatic disease, meaning that palliative therapy is the only option.
Palliative chemotherapy and oesophageal stenting may provide symptomatic relief of dysphagia.
Management of oesophageal cancer in patients who are fit and present with local disease.
Surgical resection, alternatively this can be performed endoscopically if the patinet is unsuitable for surgery. Neoadjuvant chemotherapy may also be considered.
