Oesophageal Disorders Flashcards
Where does oesophagus start and end?
Begins at lower level of cricoid cartridge (C6) and terminates at T11-12 where enters stomach
Explain the structure of the oesophagus?
Upper 3-4cm is straited muscle then rest is smooth muscle
Stratified squamous epithelial lining
What is the function of the oesophagus?
Transport of food/liquid from mouth to stomach - active
Describe physiology of the oesophagus
Peristalsis produced by circular muscles and propels materials distally
Coordinates lower oesophageal sphincter relaxation
What is contraction of peristalsis and relaxation of LOS caused by?
Mediated by vagus nerve
Describe the lower oesophageal sphincter
High resting pressure in distal smooth muscle
Straited muscle of right crus of diaphragm
Mucosal Rosette formed by acute angle at GOJ
Describe heartburn
Retrosternal discomfort or burning
Can be associated with waterbrash and cough
What is waterbrash?
Acidic taste at back of throat
What is heartburn a consequence of?
Reflux of acidic and/or bilious gastric contents into the oesophagus
What can reduce the LOS pressure resulting in heartburn?
Certain drugs and foods - alcohol, nicotine and dietary xanthine
What can persistent reflux and heartburn lead to?
Gastro-oesophageal reflux disease (GORD) which can lead to long term complications
What is dysphagia?
Subjective sensation of difficulty in swallowing foods and/or liquids
Location can be oropharyngeal or oesophageal
What is odynophagia?
Pain when swallowing
What are some causes of oesophageal dysphagia?
Benign stricture
Malignant stricture
Motility disorders
Eosinophilic oesophagitis
Extrinsic compression
What are 2 types of endoscopy?
Oesophageal Gastro-duodenoscopy (OGD)
Upper GI Endoscopy (UGIE)
What are the investigations used for oesophageal diseases?
Endoscopy
Contrast radiology - barium swallow
Oesophageal physiology - pH metry and manometry
What is a manometry?
Measurement of pressure waves within oesophagus - catheter senses and passed down nose
What is an example of a hypermotility disorder?
Diffuse oesophageal spasm
How can you diagnose diffuse oesophageal spasm?
Corkscrew appearance on barium swallow
Manometry shows exaggerated and uncoordinated hypertonic contractions
What are the symptoms of diffuse oesophageal spasm?
Severe episodic chest pain with dysphagia
What is the cause of diffuse oesophageal spasm?
Cause is unclear
What is the treatment for hypermotility disorders?
Smooth muscle relaxants
What is hypomotility associated with?
Connective tissue disease, diabetes and neuropathy
What does hypomotility cause?
Failure of LOS mechanism leading to heartburn and reflux symptoms
What is achalasia?
Functional loss of myenteric plexus ganglion cells in distal oesophagus and LOS
What is the cardinal feature of achalasia?
Failure of LOS to relax
Resulting in functional distal obstruction of oesophagus
What are the symptoms of achalasia?
Progressive dysphagia
Weight loss
Chest pain
Regurgitation and chest infection
What is the treatment for achalasia?
Pharmacological - nitrates, CCB
Botulinum toxin pneumonic balloon dilation
Myotomy
What are the complications of achalasia?
Aspiration pneumonia and lung disease
Increased risk of squamous cell oesophageal carcinoma
What is gastro-oesophageal reflux disease due to?
Pathological acid and bile exposure in lower oesophagus
What are the symptoms of gastro-oesophageal reflux disease?
Heartburn, cough, water brash and sleep distrubance
What are the risk factors for gastro-oesophageal reflux disease?
Pregnancy, obesity, drug lowering LOS pressure, smoking, alcoholism and hypomotility
How can gastro-oesophageal reflux disease be diagnosed?
Can be diagnosed on the basis f characteristic symptoms without diagnostic testing
Most patients have no visible evidence of oesophageal abnormality on endoscopy
Explain GORD without abnormal anatomy
Increased transient relaxations of the LOS
Hypotensive LOS
Delayed gastric emptying and oesophageal emptying
Decreased acid clearance
Decreased tissue resistance to acid/bile
Explain GORD due to hiatus hernia
Anatomical distortion of the OG junction
What are the 2 main types of hiatus hernia?
Sliding and para-oesophageal
Explain a hiatus hernia
Fundus of the stomach moves proximally through diaphragmatic hiatus
Obesity and ageing predispose
Para-oesophageal is more dangerous
Explain the pathophysiology of GORD
Mucosa exposed to acid-pepsin and bile
Increased cell loss and regenerative activity - inflammation
Erosive oesophagitis
What are some complications of GORD?
Ulceration
Stricture
Glandular metaplasia - Barrett’s oesophagus
Carcinoma
Explain Barrett’s Oesophagus
Intestinal metaplasia related to prolonged acid exposure in distal oesophagus
Change from squamous to mucin secreting columnar epithelial cells in lower oesophagus
Precursor to adenocarcinoma
What is the treatment for Barrett’s Oesophagus?
Endoscopic Mucosal Resection
Radio-frequency ablation
Oesophagectomy rarely
What is the treatment for GORD?
Lifestyle measures
Pharmacological
Anti-reflux surgery - fundoplication (stomach wrapped around oesophagus to strengthen)
What are the pharmacological treatments for GORD?
Alginates - Gaviscon
H2RA - ranitidine
Proton pump inhibitor - omeprazole, lansoprazole
Describe oesophageal cancer
Can be squamous cell carcinoma or adenocarcinoma
More men than women
Western Europe/USA - adenocarcinoma
What is the presentation of a patient with oesophageal cancer?
Progressive dysphagia
Anorexia and weight loss
Odynophagia, chest pain, cough, pneumonia, vocal cord paralysis and haematemesis
Describe squamous cell carcinoma
Occur in proximal and middle third of the oesophagus
Preceded by dysplasia and carcinoma in situ
Often large exophytic occluding tumours
What are risk factors for squamous cell carcinoma?
Tobacco and alcohol
Describe adenocarcinoma of oesophagus
Occurs in distal oesophagus
Associated with Barrett’s oesophagus - progression through dysplasia
What are some preceding factors for adenocarcinoma?
Obesity, male sex, middle age and Caucasian
What are some metastases of oesophageal cancer?
Hepatic, brain, pulmonary and bone
How is oesophageal cancer diagnosed?
Endoscopy and Biopsy
What is used for staging of oesophageal staging?
CT scan, endoscopic ultrasound, PET scan, bone scan
What is the treatment for oesophageal cancer?
Only potential cure is oesophagectomy and adjuvant or neoadjuvant chemo
But significant morbidity and mortality with surgery and long post op recovery
What are the options to help dysphagia in oesophageal cancer?
Endoscopic - stent , laser/APC, PEG
Chemo
Radiotherapy
Brachytherapy
What is eosinophilic oesophagitis?
Chronic immune/allergy mediated condition defined by symptoms of oesophageal dysfunction and pathologically by eosinophilic infiltration of oesophageal epithelium
When is eosinophilic oesophagitis more seen?
More common in children and young adults
More males than females
What is the presentation of eosinophilic oesophagitis?
Dysphagia and food bolus obstruction
What is seen on endoscopy when eosinophilic oesophagitis?
Multiple strictures
Mucosal stripping
What is the treatment for eosinophilic oesophagitis?
Topical/swallowed corticosteroids
Dietary elimination
Endoscopic dilatation
