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MBChB - Y2 - Systems - Gastrointestinal > Oesophageal Disorders > Flashcards

Oesophageal Disorders Flashcards

1
Q

What sphincter is striated muscle of the right crus of the diaphragm?

A

Lower oesophageal sphincter

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2
Q

What are symptoms of oesophageal disease?

A

Heartburn

Often associated with waterbrash, cough

  • Certain drugs/foods, (e.g. alcohol, nicotine, dietary xanthines) can reduce the LOS pressure resulting in increased reflux / heartburn

Persistent reflux and heartburn leads to gastro-oesophageal reflux disease (GORD) which can in turn cause long-term complications

Dysphagia

Odynophagia

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3
Q

What are the causes of oesophageal dysphagia?

A

benign stricture

  • malignant stricture (oesophageal cancer)
  • motility disorders (eg achalasia, presbyoesophagus)
  • eosinophilic oesophagitis
  • extrinsic compression (eg in lung cancer)
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4
Q

What are investigations for oesophageal disease?

A
  • Oesophago-Gastro-Duodenoscopy (OGD)
  • Upper GI Endoscopy (UGIE)

Contrast radiology - barium swallow

Oesophageal pH and manometry

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5
Q

When is endoscopy used in oesophageal disease?

A

In oesophageal disease used in investigation of dysphagia or reflux symptoms with alarm features

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6
Q

What is manometry used for?

A

Used in investigation of dysphagia / suspected motility disorder

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7
Q

What does manometry measure?

A

-assesses sphincter tonicity, relaxation of sphincters and oesophageal motility.

pH studies – used in investigation of refractory heartburn/reflux

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8
Q

What are the motility disorders of the oesophagus?

A

Hypermotility

Hypomotility

Achalasia

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9
Q

What portion of motility is controlled by the vagus nerve?

A

Contraction in the oesophageal body and relaxation of the LOS is mediated by the vagus nerve

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10
Q

What is the appearace of hypermotility on a barium swallow?

A

Corckscrew appearance on the barium swallow

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11
Q

What is hypermotility often confused with and why?

A

Often confused with angina/MI becaue there is severe episodic chest pain (with or without dysphagia)

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12
Q

What is hypomotility associated with?

A

Associated with connective tissue disease,

diabetes, neuropathy

Causes failure of the LOS and therefore causes reflux symptoms

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13
Q

What causes achalasia?

A

Functional loss of myenteric plexus ganglion cells in distal oesophagus and LOS

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14
Q

What is teh cardinal feature of achalasia?

A

failure of LOS to relax and therefore distal obstruction of the oesophagus

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15
Q

What are symptoms of achalasia?

A
  • progressive dysphagia for solids and liquids
  • weight loss
  • Chest pain (30%)
  • Regurgitation and chest infection
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16
Q

What is the treatment for achalasia?

A

Pharmacological - Nitrates,

Calcium Channel blockers

Endoscopic - Botulinum Toxin

Pneumatic balloon dilation

Radiological - Pneumatic balloon

dilation

Surgical - Myotomy

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17
Q

What are the complications of achalasia?

A

Aspiration pneumonia and lung disease

nIncreased risk of squamous cell oesophageal carcinoma

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18
Q

What causes GORD?

A

Presence of acid and bile exposure in the lower oesophagus

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19
Q

What are the symptoms of GORD?

A

Many may not experience any symptoms at all

Symptoms include: heartburn, cough, water brash, sleep disturbance

Waterbrash: a sudden flow of saliva associated with indigestion.

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20
Q

What are the risk factors for GORD?

A

Pregnancy, obesity, drugs lowering LOS pressure (alcohol, nicotine, dietary xanthines), smoking, alcoholism, hypomotility

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21
Q

Why is endoscopy a poor test for GORD?

A

Most patients (>50%) with reflux symptoms have no visible evidence of oesophageal abnormality when endoscopy is performed

22
Q

When must endoscopy be performed for GORD?

A

In the presence of alarm features eg dysphagia, weight loss, vomiting

23
Q

What are the aetiologies of GORD with normal anatomy?

A

–­ Increasing Transient relaxations of the LOS

–Hypotensive LOS

–Delayed gastric emptying

–Delayed oesophageal emptying

– Decreased Oesophageal acid clearance

– Decreased Tissue resistance to acid/bile

24
Q

What are the 2 main types of hiatus hernia?

A

Sliding and para-oesophageal

25
Q

What part of the stomach moves proximally through the diaphtragmatic hiatus?

A

Fundus

26
Q

What are two risk factors for hiatus hernia?

A

Age and obesity

27
Q

What is the mucosa exposed to in GORD?

A

Acid-pepsin and bile

28
Q

What are the complications associated with GORD?

A

Ulceration (5%)

Stricture (8-15%)

Glandular metaplasia (Barrett’s oesophagus)

Carcinoma

29
Q

What is the change in epithelium in barrett’s oesophagus?

A

Change from squamous to mucin-secreting columnar (ie gastric type) epithelial cells in lower oesophagus

30
Q

What is barretts oesophagus the precursor for?

A

Precursor to dysplasia/ adenocarcinoma

Dysplasia: Abnormal cells in a tissue which may signify a stage preceding the development of cancer.

31
Q

What is treatment for Barretts oesphagus?

A

–Endoscopic Mucosal Resection (EMR)

–Radio-Frequency Ablation (RFA)

–Oesophagectomy rarely (mortality ~10%)

32
Q

Without alarm features what is the treatment of GORD?

A
  1. Lifestyle measures
  2. Pharmacological

Alginates (Gaviscon)

H2RA (Ranitidine)

Proton Pump Inhibitor (e.g. Omeprazole, Lansoprazole)

For refractory disease following investigation

Anti-reflux surgery (fundoplication)

33
Q

What is the incidence of benign tumours?

A

They are rare

34
Q

What are the two common types of oesphageal cancer?

A

Squamous Cell Carcinoma

Adenocarcinoma

35
Q

What is the prevalence of adenocarcinoma and squamous cell carcinoma in Western europe / USA?

A

Western Europe/USA Adenocarcinoma > Squamous

Rest of World Squamous >> Adenocarcinoma

36
Q

What is the presentation of oesophageal cancer?

A

Progressive dysphagia (90%)

Anorexia and Weight loss (75%)

Odynophagia

Chest pain

Cough

Pneumonia (tracheo-oesophageal fistula)

Vocal cord paralysis

Haematemesis

37
Q

Where does squamous normally occur in the oespohagus?

A

In the proximal and middle third of the oesophagus

38
Q

What are the risk factors for squamous cell carcinoma?

A

High incidence in Southern Africa, China, Iran

Tobacco and alcohol significant risk factors

Diet related (vitamin deficiency)

Associated with Achalasia, Caustic strictures, Plummer-Vinson Syndrome

39
Q

Where does adenocarcinoma often occur in the oesophagus?

A

Occurs in distal oesophagus

40
Q

What are risk factors for adenocarcinoma?

A

Associated with Barrett’s oesophagus (progresses through dysplasia to cancer)

Predisposing factors: obesity, male sex, middle age, caucasian

41
Q
A
42
Q

Where do oesophageal cancers often spread?

A

To regional lymph nodes and or liver at

No peritoneal (serosal) lining in mediastinum – local invasion (heart, trachea, aorta) often limits surgery

Metastases - Hepatic, brain, pulmonary, bone

43
Q

Why does tumour invasion into adjacent structures occur more easily in the oesophagus?

A

Oesophagus lacks a serous layer

44
Q

Why does lymph node involvement occur early in oesophageal tumours?

A

Oespohagus lymphatic vessels are mucosal (lamina propria)

Vs

Rest of the GIT lymphatic vessels are mainly submucosal

45
Q

How do we diagnose oesphageal cancer?

A
46
Q

How do we stage oesphageal cancer?

A

–CT Scan

–Endoscopic ultrasound

–PET Scan

–Bone Scan

Disease stagin by TNM classification

47
Q

TNM classification

A

TNM staging

T1- Tumor invades lamina propria or submucosa
(a-lamina propria, b-submucosa)
T2- Tumor invades muscularis propria
T3- Tumor invades adventitia
T4- Tumor invades adjacent structures
N1- Regional lymph node metastasis
M1- Distant metastasis

Stage I- T1N0M0
Stage IIa- T2T3/N0M0
Stage IIb- T1T2/N1M0
Stage III- T3N1M0, T4, any N, M0
Stage IV- M1

48
Q

What is treatment for oesophageal cancer?

A

Only potential cure is surgical oesophagectomy +/- adjuvant (after) or neoadjuvant (before) chemotherapy

Limited to patients with localised disease, without co-morbid disease, usually <70 years of age

Significant morbidity and mortality assoc with oesophagectomy (mortality ~ 10%)

Long post operative recovery

Require nutritional support

Combined chemo and radiotherapy now offer some prospect of improved long-term survival (ie > 1year) in patients with locally advanced inoperable disease - ? may ultimately offer non-surgical “cure”

49
Q

What is treatment for incurable disease? (most have incurable disease at presentation)

A

Symptom pallation (dysphagia) is often overriding priority

OPTIONS:

Endoscopic

(stent, laser/APC, PEG)

Chemotherapy

Radiotherapy

Brachytherapy

50
Q
A

MBChB - Y2 - Systems - Gastrointestinal (38 decks)

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