Oesophageal Disorders Flashcards
What is heartburn a consequence of?
Acid and/or bilous gastric content reflux into the oesophagus
What causes gastro-oesophageal reflux disease?
Reduction in lower oesophageal sphincter pressure resulting in persistent reflux and heartburn
What percentage of adults experience daily GORD symptoms?
7%
What is the typical presentation of GORD?
Heartburn
Cough
Water brash
Sleep disturbance
What are the risk factors for GORD?
Pregnancy Smoking Obesity Drugs lowering LOS pressure Alcoholism Hypomotility
Typical reflux syndrome can be diagnosed on the basis of
characteristic symptoms, without diagnostic testing
Why is endoscopy a poor diagnostic test for GORD?
Most patients with reflux (>50%) will have no visible evidence of oesophageal abnormality on endoscopy
Under what circumstances should an endoscopy be performed in reflux disease?
In the presence of alarm features suggestive of malignancy
What is the aetiology of GORD?
Increased transient relaxations of LOS, LOS hypotension, delayed gastric and oesophageal emptying, decreased oesophageal acid clearance and tissue resistance to acid/bile
What is the aetiology of GORD due to hiatus hernia?
Anatomical distortion of the OG junction
What is the pathophysiology of GORD?
Mucosa exposed to acid, pepsin and bile, increased cell loss and inflammation, erosive oesophagitis
What are the possible complications of GORD?
Ulceration
Stricture
Glandular metaplasia
Carcinoma
What are the treatment options for GORD?
Lifestyle changes
Pharmacological - alginates and proton pump inhibitors
Anti-reflux surgery for refractory disease
What are the two types of hiatus hernia?
Sliding
Para-oesophageal
What are the risk factors for a hiatus hernia?
Obesity
Increasing age
What happens in Barrett’s Oesophagus?
Intestinal metaplasia due to prolonged acid exposure in the distal oesophagus - change from squamous to mucin-secreting columnar epithelial cells
What two conditions can develop from Barrett’s oesophagus?
Dysplasia
Adenocarcinoma
What are the treatment options for Barrett’s oesophagus?
Endoscopic mucosal resection
Radio-frequency ablation
Oesophagectomy (rarely)
What is dysphagia?
Difficulty swallowing foods and/or liquids
What is odynophagia?
Pain when swallowing
What are the two types of dysphagia?
Oropharyngeal
Oesophageal
What are the symptoms associated with dysphagia?
Weight loss
Regurgitation
Cough
What are the causes of oesophageal dysphagia?
Benign stricture Malignant stricture Motility disorders Eosinophilic oesophagus Extrinsic compression
Give an example of a motility disorder which might cause oesophageal dysphagia
Achalasia
Presbyoesophagus
What investigations would you do in oesophageal disease?
Oesophago-gastro-duodenoscopy
Upper GI endoscopy
Contrast radiology
Oesophageal pH and manometry
What are the symptoms of hypermotility?
Severe episodic chest pain
Dysphagia
What would be seen in manometry of hypermotility?
Uncoordinated, exaggerated hypertonic contractions
What is hypermotility?
Diffuse oesophageal spasm
What conditions is hypomotility associated with?
Connective tissue disease
Diabetes
Neuropathy
What is caused by hypomotility?
Failure of the lower oesophageal sphincter mechanism leading to heartburn and reflux
What is achalasia?
Functional loss of the inhibitory neutrons in the myenteric plexus ganglion cells in the distal oesophagus and lower oesophageal sphincter
At what age is the usual onset of achalasia?
30-50 years
What is the cardinal feature of achalasia?
Failure of the lower oesophageal sphincter to relax
What does achalasia result in?
Functional distal obstruction of the oesophagus
What are the symptoms of achalasia?
Progressive dysphagia Weight loss Chest pain Regurgitation Chest infection
What are the possible treatments for achalasia?
Pharmacological - nitrates and CCBs
Endoscopic - Botulinum Toxin
Radiological - pneumatic balloon dilation
Surgical - myotomy
What are the possible complications of achalasia?
Aspiration pneumonia and lung disease
Squamous cell oesophageal carcinoma
What are the most common histological types of oesophageal carcinoma?
Squamous cell carcinoma
Adenocarcinoma
What is the 5 year survival of oesophageal carcinoma?
< 10%
What are the possible presentations of oesophageal cancer?
Progressive dysphagia Anorexia and weight loss Odynophagia Chest pain Cough Pneumonia Vocal cord paralysis Haematemesis
What are the typical characteristics and location of squamous cell oesophageal cancer?
Usually large, exophytic, occluding tumours
Occur in proximal and middle thirds of oesophagus
What are the major risk factors for squamous cell oesophageal carcinoma?
Smoking
Alcohol abuse
What is squamous cell oesophageal cancer associated with?
Achalasia
Caustic strictures
Plummer-Vinson syndrome
In what part of the oesophagus does adenocarcinoma typically occur?
Distal third
What is oesophageal adenocarcinoma associated with?
Barrett’s oesophagus
What are the risk factors for oesophageal adenocarcinoma?
Obesity
Male sex
Middle age
Caucasian
What investigations would be done for oesophageal carcinoma?
Endoscopy and biopsy
Staging: CT, EUS, PET scan, bone scan
What are the treatment options for oesophageal carcinoma?
Oesophagectomy +/- adjuvant/neoadjuvant chemotherapy - only potentially curative option
Combined chemo and radiotherapy
Palliative care
What options are there for palliative care of oesophageal carcinoma?
Endoscopic stent APC PEG chemo/radiotherapy brachytherapy
