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Alimentary System > Oesophageal Disorders > Flashcards

Oesophageal Disorders Flashcards

1
Q

What is the length of the oesophagus?

A

25cm

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2
Q

Where does the oesophagus begin and end?

A

Begins at lower level of cricoid cartilage (C6)

Terminates at T11-T12 where it enters the stomach

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3
Q

What kind of muscle is present in the oesophagus?

A

Upper 1/3 is skeletal muscle

Lower 2/3 is smooth muscle

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4
Q

What is the classification of the epithelium in the oesophagus?

A

Stratified squamous

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5
Q

What is the function of the oesophagus?

A

Transport food/liquid from the mouth to the stomach which is an active process

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6
Q

What propels swallowed materials into the stomach?

A

Oesophageal peristalsis

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7
Q

What produces oesophageal peristalsis?

A

Oesophageal circular muscles

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8
Q

What must the oesophageal circular muscles coordinate with so that food can enter the stomach?

A

Lower oesophageal sphincter (LOS)

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9
Q

What must the LOS do to allow food to enter the stomach?

A

Relax

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10
Q

What is contraction in the oesophageal body (peristalsis) and relaxation of the LOS mediated by?

A

Vagus nerve

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11
Q

What forms the LOS?

A

Striated muscle of the right crus of diaphragm

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12
Q

What is formed by the acute angle of His at gastro-oesophageal junction?

A

Mucosal rosette

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13
Q

What does GOJ stand for?

A

Gastro-oesophageal junction

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14
Q

What is the resting pressure like in distal smooth muscle of oesophagus?

A

High resting pressure due to LOS

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15
Q

What are key symptoms of oesophageal disease?

A

Heartburn

Dysphagia

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16
Q

What is heartburn?

A

Retrosternal discomfort or burning

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17
Q

What can heartburn be associated with?

A

Waterbrash (sudden flow of saliva)

Cough

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18
Q

What is a sudden flow of saliva called?

A

Waterbrash

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19
Q

What is heartburn a consequence of?

A

Reflux of acidic and/or bilious gastric contents into oesophagus

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20
Q

What do things that reduce LOS pressure result in?

A

Increased reflux/heartburn

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21
Q

What are examples of things that can reduce LOS pressure?

A

Drugs (dietary xanthines, alcohol, nicotine)

Food

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22
Q

What does persistent reflux and heartburn lead to?

A

Gastro-oesophageal disease (GORD)

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23
Q

What does GORD stand for?

A

Gastro-oesophageal disease

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24
Q

What is dysphagia?

A

Subjective sensation of difficulty in swallowing foods and/or liquids

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25
Q
A
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26
Q

What often accompanies dysphagia?

A

Odynophagia (pain when swallowing)

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27
Q

What is pain when swallowing called?

A

Odynophagia

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28
Q

What should you enquire about when a patient presents with dysphagia?

A

Type of food (solid v liquid)

Pattern (progressive, intermittent)

Associated features (weight loss, regurgitation, cough)

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29
Q

Where can the location of dysphagia be?

A

Oropharyngeal (part of throat behind the mouth)

Oesophageal

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30
Q

What is the part of the throat behind the mouth called?

A

Oropharyngeal

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31
Q

What are some possible causes of dysphagia?

A

Benign stricture

Malignant stricture (oesophageal cancer)

Motility disorders

Eosinophilic oesophagitis

Extrinsic compression (such as lung cancer0

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32
Q

What is eosinophilic oesophagitis?

A

Allergic inflammatory condition of the oesophagus

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33
Q

What are examples of motility disorders?

A

Achalasia

Presbyoesophagus

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34
Q

What are the main investigations done for oesophageal disease?

A

Endoscopy

Contrast radiology

Oesophageal pH and manometry

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35
Q

What is an endoscopy?

A

Procedure where the inside of the body is examined using an endoscope (long, thin, flexible tube) that has a light source and camcer at one end

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36
Q

What are examples of different endoscopies that can examine the oesophagus?

A

Oesophago-gastro-duodenoscopy (OGD)

Upper GI endoscopy

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37
Q

What does OGD stand for?

A

Oesophageal-gastro-duodenalscopy

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38
Q

What does UGIE stand for?

A

Upper GI endoscopy

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39
Q

What is an exampe of a contrast radiology that can be used to examine the oesophagus?

A

Barium swallow

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40
Q

What is an oesophageal pH and manometry?

A

Naso-gastric catheter containing pressure and pH sensors placed in oesophagus

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41
Q

Where are the probs for a oesophageal pH and manometry placed?

A

At both UOS and LOS

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42
Q

Why is manometry used in investigations of dysphagia?

A

To assess sphincter tonicity, relaxation of sphincters and oesophagus

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43
Q

What does manometry messure?

A

Pressure

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44
Q

What are pH studies of the oesophagus used to investigate?

A

Refractory hearburn/reflux

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45
Q

What is manometry of the oesophagus used to investigate?

A

Dysphagia/suspected motility disorder

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46
Q

What are the 2 categories of motility disorders?

A

Hypermotility

Hypomotility

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47
Q

What is an example of hypermotility disorder?

A

Diffuse oesophageal spasm

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48
Q

What can be seen on a barium swallow for oesophageal spasm?

A

Corkscrew appearance

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49
Q

What is the common presentation of oesophageal spasms?

A

Severe, episodic chest pain with or without dysphagia

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50
Q

What is oesophageal spasm often confused with?

A

Angina/MI

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51
Q

What does a manometry for oesophageal spasms show?

A

Exaggerated, uncoordinated, hypertonic contractions

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52
Q

What are hypermotility disorders?

A

Abnormal or excessive movement of the oesophagus

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53
Q

What are hypomotility disorders?

A

Abnormal deficiency of movement of the oesophagus

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54
Q

What are hypomobility disorders associated with?

A

Connective tissue disease

Diabetes

Neuropathy

55
Q

What do hypomobility disorders lead to?

A

Failure of LOS leading to heartburn and reflux symptoms

56
Q

What is achalasia?

A

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

57
Q

What is the incidence of achalasia?

A

1-2/100000

58
Q

What is the male:female incidence of achalasia?

A

1:1

59
Q

What age does achalasia usually onset?

A

30-50

60
Q

How does achalasia affect the LOS?

A

Causes failure of the LOS to relax, resulting in obstruction of the distal oesophagus

61
Q

What are symptoms of achalasia?

A

Progressive dysphagia for solids and liquids

Weight loss

Chest pain

Regurgitation and chest infection

62
Q

What investigations are done for achalasia?

A

Manometry

63
Q

What does a manometry show for achalasia?

A

High pressure at LOS (usually 45mmHg above normal, normal being 10mmHg)

Failure of LOS to relax after swallowing

Absence of peristaltic contractions in lower oesophagus

64
Q

What is the normal pressure of the LOS?

A

10mmHg

65
Q

What is the treatment for achalasia?

A

Pharmacological - nitrates, calcium channel blockers

Endoscopic - botulinum toxin, pneumatic balloon dilation

Radiological - pneumatic balloon dilatin

Surgical - myotomy

66
Q

What is a myotomy?

A

Cut away outer layers of tissue from lower oesophagus

67
Q

What are possible complications of achalasia>

A

Aspiration pneumonia and lung disease

Increased risk of squamous cell oesophageal carcinoma

68
Q

What causes GORD?

A

Pathological acid and bile exposure in lower oesophagus

69
Q

What are symptoms of GORD?

A

Heartburn

Cough

Water brash

Sleep disturbances

70
Q

What are risk factors for GORD?

A

Pregnancy

Obesity

Drugs lowering LOS pressure

Smoking

Alcoholism

Hypomotility

71
Q

What is the male:female ratio for GORD?

A

Men are affected more than woman

72
Q

How does ethnicity change risk of GORD?

A

Caucasians more than black more than asian

73
Q

What can GORD be diagnosed on?

A

Basis of characteristic symptoms without diagnosed testing

74
Q

What can be said about endoscopies and diagnosing GORD?

A

Poor diagnostic test due to >50% having no visible evidence of oesophageal abnormalities

But it must be performed in presence of alarming features suggesting malignancy

75
Q

What are alarming features that could suggest malignancy and so an endoscopy must be performed?

A

Dysphagia

Weight loss

Vomiting

76
Q

What is GORD aeitology?

A

Increase in transient relaxations of LOS

Hypotensive LOS

Delayed gastric emptying

Delayed oesophageal emptying

Decreased oesophageal acid clearance

Decreased tissue resistance to acid/bile

Anatomical distortion of the OGJ

77
Q

What are the 2 types of hiatus hernia?

A

Sliding

Para-oesophageal

78
Q

What happens in a hiatus hernia?

A

Stomach moves proximally through the diaphragmatic hiatus

79
Q

What does a hiatus hernia likely occur due to?

A

Obesity and aging

80
Q

Explain GORD pathophysiology?

A

Mucosa exposed to acid-pepsin and bile

Increased cell loss and regenerative ability (ie inflammation)

Erosive oesophagitis

81
Q

What are examples of GORD complications?

A

Ulceration (5%)

Stricture (8-15%)

Glandular metaplasia (Barrett’s oesophagus)

Carcinoma

82
Q
A
83
Q

Does treatment occur with or without investigation for GORD in the absence of alarming features?

A

Without investigation

84
Q

What is the treatment for GORD?

A

Lifestyle measures

Pharmacological - alginates (gaviscon), H2RA (Ranitidine), proton pump inhibitor (such as omeprazole or lansoprazole)

Surgery - anti reflux surgery (fundoplication)

85
Q

What is fundoplication?

A

Full or partial wrap of stomach around the oesophagus

86
Q

What is Barrett’s oesophagus?

A

Metaplasia related to prolonged acid exposure in distal oesophagus

87
Q

What changes in Barrett’s oesophagus?

A

Stratified squamous epithelium of oesophagus changes to glandular

88
Q

What is Barrett’s oesophagus a precurser for?

A

Dysplasia/adenocarcinoma

89
Q

What is the male:female ratio of Barrett’s oesophagus?

A

Males are affected more than females

90
Q

What is the treatment for Barrett’s oesophagus?

A

Endoscopic mucosal resection (EMR)

Radio-frequency ablation (RFA)

Oesophagectomy rarely

91
Q

What is endoscopic mucosal resection (EMR)?

A

Procedure to remove early stage cancer from lining of digestive tract

92
Q

What does EMR stand for?

A

Endoscopic mucosa resection

93
Q

What is radio-frequency ablation?

A

Tumour is ablated using the heat generated from medium frequency alternating current

94
Q

What does RFA stand for?

A

Radiofrequency ablation

95
Q

What is the procedure called where part or all of the oesophagus is removed?

A

Oesophagectomy

96
Q

How common are benign tumours for oesophageal cancer?

A

Rare, are usually malignant

97
Q

What are the two histological types of oesophageal cancer?

A

Squamous cell carcinoma

Adenocarcinoma

98
Q

Where is oesophageal cancer in the world cancer mortality rankings?

A

5th

99
Q

What is the male:female ratio of oesophageal cancer?

A

3:1

100
Q

What is more common out of adenocarcinoma and squamous cell carcinoma?

A

Adenocarcinoma in Western Europe and USA, squamous cell carcinoma everywhere else

101
Q

What is the presentation of oesophageal cancer?

A

Progressive dysphagia (90%)

Anorexia and weight loss (75%)

Odynophagia

Chest pain

Cough

Pneumonia (due to trachea-oesophageal fistula)

Vocal cord paralysis

Haematemesis

102
Q

Where in the oesophagus do squamous cell carcinomas usually occur?

A

Proximal and middle third of oesophagus

103
Q

What are squamous cell carcinomas preceded by?

A

Dysplasia and carcinoma in situ

104
Q

What is carcinoma in situ?

A

Group of abnormal cells that are considered to be pre-cancer

105
Q

What are significant risk factors for squamous cell carcinoma?

A

Tobacco

Alcohol use

Diet is potentially related (vitamin deficiencys

106
Q

What is squamous cell carcinoma associated with?

A

Achalasia

Caustic strictures

Plummer-Vinson syndrome

107
Q

Where do adenocarcinoma usually occur?

A

Distal oeophagus

108
Q

What is adenocarcinoma associated with?

A

Barrett’s oesophagus

109
Q

What are risk factors for adenocarcinoma?

A

Obesity

Male sex

Middle age

Caucasian

110
Q

What is the physical appearance of squamous cell carcinomas normally?

A

Large exophytic (grows outwards) occluding tumour

111
Q

Where do tumours of oesophageal cancer commonly spread to?

A

Regional lymph nodes (due to lamina propria having rich lymphatic supply)

Liver

112
Q

Why does oesophageal invasion to the heart, trachea or aorta often limit surgery?

A

No peritoneal (serosal) linking in mediastinum

113
Q

What does no serosal layer make more likely in terms of cancer?

A

Tumour invasion into adjacent structures occur more easily

114
Q

Where are metastatis of oesophageal cancer common?

A

Liver

Brain

Pulmonary

Bone

115
Q

What is the prognosis of oesophageal cancer?

A

Very poor with 5 year survival less than 10%

116
Q

What investigations are done for oesophageal cancer?

A

Diagnosis by endoscopy and biopsy

Staging by CT scan, endoscopic ultrasound, PET scan, bone scan

117
Q

What is required for the diagnosis of oesophageal cancer?

A

Endoscopy and biopsy

118
Q

What classification is used for staging of oesophageal cancer?

A

TNM classification

119
Q

What are treatments for oesophageal cancer?

A

Oesophagectomy with or without adjuvant or neoadjuvant chemotherapy

Combined chemotherapy and radiotherapy

120
Q

What does adjuvant mean?

A

After

121
Q

What does neoadjuvant mean?

A

Before

122
Q

Who is oesophagectomy limited to?

A

Patients with local disease, without comorbid disease who are usually <70 years old

123
Q

What is the morbidity and mortality of oesophagectomy like?

A

Significant, moraltity is 10%

124
Q

What do people who recieve an oesophagectomy require post-operation?

A

Nutritional support

125
Q

What does treatment of oesophageal cancer usually aim to do?

A

Provide palliative care as most people present with incurable disease

126
Q

What are some symptom palliation options for oesophageal cancer?

A

Endoscopic (stent, laser, PEG)

Chemotherapy

Radiotherapy

Brachytherapy

127
Q

What is brachytherapy?

A

Kind of radiation treatment where a sealed radiation source is placed next to the area requiring treatment

128
Q

What is eosinophillic oesophagitis?

A

Chronic immune/allergen mediated condition defined clinically by symptoms of oesophageal dysfunction and pathologically by eosinophillic infiltration of the eosophageal epithelium in the absence of secondary causes of local or systemic eosinophilia

129
Q

What eosinophil count is required to pathologically be consider eosinophillic oesophagitis?

A

More than or equal to 15 eosinophils per high power microscopic fields on oesophageal biopsy

130
Q

How is the incidence and prevalence of eosinophillic oesophagitis changing?

A

Both are rising

131
Q

What is the male:female ratio of eosinophillic oesophagitis?

A

Males affected more than females

132
Q

What is the presentation of eosinophillic oesophagitis?

A

Dysphagia

Food bolus obstruction

133
Q

What is the treatment of eosinophillic oesophagitis?

A

Topical/swallowed corticosteroids

Dietary elimination

Endoscopic dilation

134
Q

What is endoscopic dilation?

A

Procedure that inflates a region of the oesophagus

Alimentary System (41 decks)

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