Oesophageal Disorders Flashcards by Sophie Pitcairn

Where does oesophagus start and end?

Begins at lower level of cricoid cartridge (C6) and terminates at T11-12 where enters stomach

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Explain the structure of the oesophagus?

Upper 3-4cm is straited muscle then rest is smooth muscle
Stratified squamous epithelial lining

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What is the function of the oesophagus?

Transport of food/liquid from mouth to stomach - active

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Describe physiology of the oesophagus

Peristalsis produced by circular muscles and propels materials distally
Coordinates lower oesophageal sphincter relaxation

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What is contraction of peristalsis and relaxation of LOS caused by?

Mediated by vagus nerve

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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

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Describe heartburn

Retrosternal discomfort or burning
Can be associated with waterbrash and cough

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What is waterbrash?

Acidic taste at back of throat

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What is heartburn a consequence of?

Reflux of acidic and/or bilious gastric contents into the oesophagus

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What can reduce the LOS pressure resulting in heartburn?

Certain drugs and foods - alcohol, nicotine and dietary xanthine

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What can persistent reflux and heartburn lead to?

Gastro-oesophageal reflux disease (GORD) which can lead to long term complications

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What is dysphagia?

Subjective sensation of difficulty in swallowing foods and/or liquids
Location can be oropharyngeal or oesophageal

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What is odynophagia?

Pain when swallowing

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What are some causes of oesophageal dysphagia?

Benign stricture
Malignant stricture
Motility disorders
Eosinophilic oesophagitis
Extrinsic compression

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What are 2 types of endoscopy?

Oesophageal Gastro-duodenoscopy (OGD)
Upper GI Endoscopy (UGIE)

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What are the investigations used for oesophageal diseases?

Endoscopy
Contrast radiology - barium swallow
Oesophageal physiology - pH metry and manometry

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What is a manometry?

Measurement of pressure waves within oesophagus - catheter senses and passed down nose

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What is an example of a hypermotility disorder?

Diffuse oesophageal spasm

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How can you diagnose diffuse oesophageal spasm?

Corkscrew appearance on barium swallow
Manometry shows exaggerated and uncoordinated hypertonic contractions

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What are the symptoms of diffuse oesophageal spasm?

Severe episodic chest pain with dysphagia

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What is the cause of diffuse oesophageal spasm?

Cause is unclear

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What is the treatment for hypermotility disorders?

Smooth muscle relaxants

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What is hypomotility associated with?

Connective tissue disease, diabetes and neuropathy

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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