Oesophageal Disorders Flashcards
What spinal level does the oesophagus run along?
C6 to T11-12
Which type of muscle is present in the oesophagus?
Striated in upper 3-4cm
Smooth
Which tye of epithelium lines the oesophagus?
Stratified squamous epithelium
Function of the lower Oesophageal sphincter
Physiological sphincter
High resting pressure in distal smooth muscle
Striated muscle of right crus of diaphragm
Mucosal rosette formaed by acute angle at Gastro Oesophageal Junction
Symptoms of oesophageal disease
Heartburn
Dysphagia
What symptoms may accompany heartburn?
Waterbrash
Cough
Causes of heartburn
Reflux of acidic/bilious gastric contents
Drugs and foods can lower the LOS pressure causing increased reflux
Which drugs and food can increase reflux?
Alcohol
Nicotine
Dietary xanthines (coffee, tea, chocolate)
Persistent reflux can lead to which disease?
GastroOesophageal Reflux Disease
GORD
Term for pain with swallowing
Odynophagia
What should be asked about in a history of dysphagia?
Type of food (solid or liquid)
Pattern (progressive, intermittent)
Associated features - weight loss, regurgitation, cough
Location - oesophageal or oropharyngeal
Causes of dysphagia
Benign stricture Malignant stricture Motility disorder - alchalasia, presbyoesophagus Eosinophilic oesophagitis Extrinsic compression
Invesitgations of oesophageal symptoms
Oesophago Gastro Duodenoscopy (OGD)
Upper GI Endoscopy
Endoscopy
Contrast radiology
Opesophageal pH and manometry
Describe the investigations of oesophageal pH and manometry
Nasogastric tube or catheter containing multiple pressure and pH sensors is inserted into oesophagus
Probes at UOS and LOS
Manometry is used to investigate..?
Dysphagia
Motility
Sphincter tonicity
pH studies are used to investigate…
Refractory heartburn
Reflux
2 types of oesophageal motility disorders
Hypermotility
Hypomotility
Hypermotility in the oesophagus gives rise to what kind of symptoms
Diffuse oesophageal spasm
Severe episodic chest pain
Dysphagia
What sign is present on Barium swallow in hypermotility of the oesophagus?
Corkscrew appearance
Which condition can oesophageal hypermotility mimic?
Angina
MI
What are the findings on manometry in hypermotility of the oesophagus?
Exaggerated, uncoordinated, hypertonic contractions
Treatment of oesophageal hypermotility
Relaxants - Nitrates
Hypomotility of the oesophagus is associated with what other conditions?
Connective tissue diseases
SLE
Diabetes
Neuropathy
Why does the LOS fail to relax in achalasia?
Inhibitory neurons of the myenteric plexus have degenerated
Leads to a function distal obstruction of the oesophagus
How does the oesophagus appear in achalasia?
Dilated - Rats tail
Symptoms of achalasia?
Progressive dysphagia Weight loss Chest pain Regurgitation Chest infetion
Treatment of achalsia
Calcium channel blockers and nitrates
Botulinum and Pneumatic balloon dilation
Radio - pneumatic balloon
Surgical - Myotomy
What conditions are associated with achalasia?
Aspiration
Lung disease
Squamous carcinoma
Symptoms of GORD
ASYMPTOMATIC Heartburn Cough Water brash Sleep disturbance
ERisk factors for GORD
Pregnancy Obesity Drugs lowering LOS pressure Smoking Alcohol Hypomotility
When is endosocopy indicated?
Only if ALARM features of malignancy
Complications of GORD
Ulceration
Stricture
Glandular metaplasia
Carcinoma
Describe changes in Barrett’’s oesophagus
Prolonged acid exposure leads to intestinal metaplasia
Precursor to dyplasia –> adenocarcinoma
Treatment of Barrett’s oesophagus
Endoscopic mucosal resection
Radiofrequency ablation
Oesophagectomy
Treatment of GORD
Lifestyle factors addressed Alginates - Gaviscon H2RA- Ranitidine PPI- Omeprazole, Lanzoprazole Anti reflux suregery - FUNDOPLICATION
Types of tumour in oesophageal cancer
Squamous cell carcinoma
Adenocarcinoma
Presentation of oesophageal cancer
Progressive dysphagia Weight loss Anorexia Odynophagia Chest pain Cough Pneumonia Tracheo oesophageal fistula Vocal cord paralysis Haematemesis
Squamous cell carcinomas occur in which part of the oesophagus
Proximal and middle 1/3
Where has the highest incidence of SCC in oesophagus?
Southern Africa
China
Iran
What increases the risk of SCC of the oesophagus?
Smoking
Alcohol
Possibly vitamin deficiency
Consequences of SCC in oesophagus
Achalasia
Caustic strictures
Plummer-Vinson syndrome
Where in the oesophagus does adenocarcinoma occur?
Distal oesophagus
What condition is associated with adenocarcinoma of the oesophagus?
Barrett’s
Predisposing risk factors for adenocarcinoma of the oesophagus
Obesity
Male
Middle age
Caucasian
Why is surgery limited in adenocarcinoma of the oesophagus>
No serosal layer leads to local invasion of the trachea, heart and aorta
Where does adenocarcinoma of the oesophagus tend to metastasise?
Liver, brain, bones, lungs
Prognosis of oesophageal cancer
5 year survival less than 10%
Investigation of oesophageal cancer
Endoscopy and biopsy CT EUS PET scan Bone scan TNM
Management of oesophageal cancer
Surgical oesophagectomy - adjuvant or neoadjuvant chemo
Only in localised disease, no comorbidities and less than 70 years of age
Long recovery and nutritional support needed
Palliative treatment of oesophageal cancer
Endoscopic stent/;aser/APC/PEG
Chemo and Radiotherapy
Brachytherapy
What is eosinophilic oesophagitis?
Chronic immune/allergen mediated condition
Eosinophilic infiltration
Rings, furrows, white patches in mucosa
Fragile - scope can strip lining
Treatment of eosinophilic oesophagitis
Topical/oral corticosteroids
Dietary elimination
Endoscopic dilatation if multiple strictures - be wary of iatrogenic damage
Side effects of laparoscopic hiatus hernia repair and fundoplication
Dysphagia Difficulty to belch and vomit Gas bloating Excess flatulence Diarrhoea
Type of hiatus hernia leading to GORD
Sliding
Paraoesophageal
Types of approach to oesophagectomy
Ivor Lewis
Transhiatal
Left thoraco abdominal
Conduits used in oesophagectomy
Stomach
Colon
Morbidity and mortality of oesphagectomy
20-30%
5% mortality
Investigations for antireflux surgery
Endoscopy
Oesophageal pH and Manometry
Side effects of laparoscopic hiatus hernia repair and fundoplication
Dysphagia Difficulty to belch and vomit Gas bloating Excess flatulence Diarrhoea
