Oesophageal Disorders Flashcards
what is the length of the osophagous
25cm in legnth
where does the osophagous begin
lower level of cricoid cartilage (C6)
where does the osophagous terminate
T11-12 where it enters the stomach
what is the upper part of the osophagous made from
upper 3-4cm striated muscle
what is around 20cm of the osophagous made from
smooth muscle
what type of epithelium is the lining of the osophagous made from
stratified squamous epithelium
what is the function of the osophagous
Transport of food/liquid from mouth to stomach – active process
how does the osophagous work to move food bolus downwards
Oesophageal peristalsis produced by oesophageal circular muscles and propels swallowed materials distally into the stomach
what does esophageal peristalsis coordinate with
lower oesophageal sphincter (LOS) relaxation
Contraction in the oesophageal body (peristalsis) and relaxation of the LOS is mediated by what nerve
vagus nerve
what is the Lower Oesophageal Sphincter (LOS)
what factor contribute to the integrity of the LOS
Physiological sphincter
High resting pressure in distal smooth muscle
Striated muscle of right crus of diaphragm
“Mucosal Rosette” formed by acute angle (of His) at GOJ
when should the LOS be open
when food or liquid is passed into the stomach
what is the most common symptom of oesophageal disease
heartburn
how do patients with oesophageal disease describe their symptoms
retrosternal discomfort or burning
what may retrosternal discomfort or burning be associated with
Waterbrash, Cough
what is heartburn
Heartburn is a consequence of reflux of acidic &/or
bilious gastric contents into the oesophagus
what can reduce the LOS pressure
Certain drugs/foods, (e.g. alcohol, nicotine, dietary xanthines)
what does reduced LOS pressure result in
increased reflux / heartburn
what does persistent reflux and heartburn lead to
gastro-oesophageal reflux disease (GORD) which can in turn cause long-term complications
dysphagia
Subjective sensation of difficulty in swallowing foods and/or liquids
Odynophagia
pain with swallowing (may accompany dysphagia)
what must we ask the patient
Enquire about: - Type of food (solid vs liquid)
- Pattern (progressive, intermittent)
- Associated features (weight loss, regurgitation, cough
what are causes os oesophageal dysphagia
-benign stricture
-malignant stricture (oesophageal cancer)
-motility disorders (eg achalasia, presbyoesophagus)
-eosinophilic oesophagitis
-extrinsic compression (eg in lung cancer)
what investigations are done for oesophageal disease
ENDOSCOPY
Oesophago-Gastro-Duodenoscopy (OGD)
Upper GI Endoscopy (UGIE)
ENDOSCOPY
simple, effective, safe in experienced hands – diagnostic endoscopy takes 2-3 mins
what can also be done as an investigation for oesophageal disease
Contrast radiology (barium swallow)
BA SWALLOW
primary indication is investigation of dysphagia (however endoscopy is the preferred test)
May still be used in “high” dysphagia to exclude a pharyngeal pouch or post-cricoid web prior to endoscopy
Oesophageal Physiology: pH - metry
Nasal catheter containing pH sensors at both sphincters (UOS and LOS) sphincters is placed in oesophagus
Alternative is endoscopic placement of BRAVO pH probe
pH studies – used in investigation of refractory heartburn/reflux
Oesophageal Physiology: Manometry
Nasal catheter containing multiple pressure sensors is placed in oesophagus
Manometry - used in investigation of dysphagia / suspected motility disorder (usually after endoscopy) -assesses sphincter tonicity, relaxation of sphincters and oesophageal motility.
hyper motility example
diffuse oesophageal spasm
hyper motility appearance on barium swallow
“Corkscrew appearance”
symptoms of hypermotility
-Severe, episodic chest pain +/- dysphagia
-Often confused with angina/MI
cause of hyper motility
Cause unclear (idiopathic)
manometry results for hyper motility
Manometry shows exaggerated,
uncoordinated, hypertonic contractions
-Rx smooth muscle relaxants
what is hypomotiity associated with
connective tissue disease,
diabetes, neuropathy
what does hypo motility cause
Causes failure of LOS mechanism leading to
heartburn and reflux symptoms
ACHALASIA
Functional loss of myenteric plexus ganglion
cells in distal oesophagus and LOS
what is the incidence of achalasia
1-2/100,000
Male:Female incidence = 1:1
what is the onset for achalasia
usually 3rd - 5th decade
cardinal feature of achalasia
failure of LOS to relax
Result: functional distal obstruction of oesophagus
symptoms of achalasia
progressive dysphagia for solids and liquids
weight loss
Chest pain (30%)
Regurgitation and chest infection
treatment of achalasia
Pharmacological - Nitrates,
Calcium Channel blockers
Endoscopic - Botulinum Toxin
Pneumatic balloon dilation
Radiological - Pneumatic balloon
dilation
Surgical - Myotomy
COMPLICATIONS of achalsia
Aspiration pneumonia and lung disease
Increased risk of squamous cell oesophageal carcinoma
what percentage of adults experience daily GORD symptoms
7% adults
Many patients with frequent, pathological episodes of acid/bile reflux do not experience
any symptoms!!
symptoms of GORD
heartburn, cough, water brash, sleep disturbance
risk factors for GORD
Pregnancy, obesity, drugs lowering LOS pressure, smoking, alcoholism, hypomotility
are men or women more effected by GORD
Men > Women
what ethnicities are most affected by GORD
Caucasian > Black > Asian
how is typical reflux syndrome diagnosed
on the basis of the characteristic symptoms, without diagnostic testing.
is endoscopy a good way to diagnose GORD
Endoscopy is a poor diagnostic test. Most patients (>50%) with reflux symptoms have no visible evidence of oesophageal abnormality when endoscopy is performed.
when must endoscopy be performed
in the presence of ‘alarm’ features suggestive of malignancy (eg dysphagia, weight loss, vomiting)
GORD without abnormal anatomy
↑ Transient relaxations of the LOS
Hypotensive LOS
Delayed gastric emptying
Delayed oesophageal emptying
↓Oesophageal acid clearance
↓ Tissue resistance to acid/bile
GORD due to Hiatus Hernia
Anatomical distortion of the OG junction
(many patients have both)
what are the two main types of hiatus hernia
Sliding and Para-oesophageal
sliding hiatus hernia
the stomach intermittently slides up into the chest through a small opening in the diaphragm.
Para-oesophageal hiatus hernia
occurs when the lower part of the esophagus, the stomach, or other organs move up into the chest.
GORD pathophysiology
Mucosa exposed to
acid-pepsin and bile
Increased cell loss
and regenerative activity
(ie inflammation)
Erosive oesophagitis
GORD complications
Ulceration (5%)
Stricture (8-15%)
Glandular metaplasia (Barrett’s oesophagus)
Carcinoma
Barrett’s Oesophagus
Intestinal metaplasia related to prolonged acid exposure in distal oesophagus
Change from squamous to mucin-secreting columnar (ie gastric type) epithelial cells in lower oesophagus
what is Barretts oesophagus abprecusor to
dysplasia/ adenocarcinoma
does Barretts oesophagus affect men or women more
Men»_space; women
what is the cancer rate of Barretts oesophagus
Cancer rate ~0.3% per yr
Barrett’s Oesophagus
HIGH GRADE DYSPLASIA
Risk of developing oesophageal cancer 6%/year
treatment for Barretts oesophagus high grade dysplasia
Endoscopic Mucosal Resection (EMR)
Radio-Frequency Ablation (RFA)
Oesophagectomy rarely (mortality ~10%)
treatment of GORD
Mainly empirical (i.e. without investigation) in absence of alarm features
Lifestyle measures
Pharmacological
Alginates (Gaviscon)
H2RA (Ranitidine)
Proton Pump Inhibitor (e.g. Omeprazole, Lansoprazole)
what are the pharmacological treatment measures of GORD
Alginates (Gaviscon)
H2RA (Ranitidine)
Proton Pump Inhibitor (e.g. Omeprazole, Lansoprazole)
GORD treatment for refractory disease/symptoms
following investigation
Anti-reflux surgery
(Fundoplication – full / partial wrap)
are benign tumours rare in oesophageal cancer
they are rare
what are the two types of carinoma for oesophageal cancer
Squamous Cell Carcinoma
Adenocarcinoma
five oesophageal cancer facts
5th in World Cancer Mortality Rank
Men>Women 3:1
Median Age 65 years – age decreasing
Western Europe/USA Adenocarcinoma > Squamous
Rest of World Squamous»_space; Adenocarcinoma
presentation of oesophageal cancer
Progressive dysphagia (90%)
Anorexia and Weight loss (75%)
Odynophagia
Chest pain
Cough
Pneumonia (tracheo-oesophageal fistula)
Vocal cord paralysis
Haematemesis
squamous cell carcinoma features
Often large exophytic occluding tumours
Occur in proximal and middle third of oesophagus
what precedes squamous cell carcinomas
Preceded by dysplasia and carcinoma in situ
where is there a high incidence of squamous cell carcinoma
Southern Africa, China, Iran
what are significant risk factors for squamous cell carcinoma
tobacco and alcohol significant risk factors
?diet related (vitamin deficiency)
what is squamous cell carcinoma associated with
Achalasia, Caustic strictures, Plummer-Vinson Syndrome
where does adenocarcinoma occur
distal oesophagus
what is adenocarcinoma associated with
Barrett’s oesophagus (progresses through dysplasia to cancer)
what are predisposing factors of adenocarcinoma
obesity, male sex, middle age, caucasian,
oesophageal cancer when does it usually present
Usually presents late and tumours have commonly spread to regional nodes and/or liver at presentation
what does the oesophagus lack unlike the rest of the GIT
No peritoneal (serosal) lining in mediastinum – local invasion (heart, trachea, aorta) often limits surgery
THIS MEANS THAT TUMOUR INVASION INTO ADJACENT STRUCTURES CAN OCCUR MORE EASILY
The Lamina propria (which is in the mucosal layer) has a rich lymphatic supply – in the remainder of the GIT lymphatic vessels are mainly submucosal
THIS MEANS THAT LYMPH NODE INVOLVEMENT OFTEN OCCURS EARLY IN OESOPHAGEAL TUMOURS
oesophageal cancer Metastases
Hepatic, brain, pulmonary, bone
survival rate for oesophageal cancer
Prognosis poor: 5 yr survival < 10%
diagnostic investigations for osophageal cancer
Diagnosis by Endoscopy & Biopsy
how is staging done for oesophageal cancer
CT Scan- CT scan of chest, abdomen and pelvis for distant metastasis
Endoscopic ultrasound
PET Scan
Bone Scan
Disease staging by
TNM classification
Laparoscopy may be needed where there is suspicion of peritoneal spread on CT or EUS such as in the presence of small volume ascites.
osophageal cancer treatment
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”
Most have incurable disease at presentation
Symptom palliation (mainly dysphagia) is often overriding priority
OPTIONS:
Endoscopic
(stent, laser/APC, PEG)
Chemotherapy
Radiotherapy
Brachytherapy
Eosinophilic Oesophagitis
Chronic immune-/allergen-mediated condition defined clinically by symptoms of oesophageal dysfunction, and pathologically by an eosinophilic infiltration of the oesophageal epithelium (≥15 eosinophils per high-power microscopy field on oesophageal biopsy) in the absence of secondary causes of local or systemic eosinophilia.
Incidence and prevalence are increasing
More commonly seen in children and young adults
Males > females
Eosinophilic Oesophagitis
Presentation: Dysphagia & Food bolus obstruction
Endoscopic findings:
Treatment:
- topical/swallowed corticosteroids
- dietary elimination
- endoscopic dilatation
