Oesophageal disorders

Question 1

List the main investigations used to diagnose oesophageal disease

Answer 1

Endoscopy
Contrast radiology (barium swallow)
Oesophageal pH
Oesophageal manomentry (measures pressure)

Question 2

What disease is characterised by persistent acid reflux into the oesophagus?

Answer 2

Gastro-oesophageal reflux disease (GORD)

Question 3

Describe the presentation of GORD

Answer 3

Heartburn - related to meals, worse when lying down or straining, relieved by antacids
Acid brash/ water brash
Cough
Sleep disturbance
Odynophagia (sometimes) - due to severe oesophagitis or stricture

Rarely may present with chest/epigastric pain, bloating

Question 4

What type of hernia can cause GORD?

Answer 4

Hiatus hernia (stomach protrudes through oesophageal hiatus of diaphragm)

Question 5

Is endoscopy used to diagnose GORD?

Answer 5

Sometimes but there is often no visible damage to the oesophageal lining; GORD is usually diagnosed on the basis of history and examination only

Question 6

When MUST an endoscopy be performed?

Answer 6

If “alarm” features are present as these suggest malignancy:

• dysphagia
• weight loss
• vomiting

Question 7

What are the potential complications of GORD?

Answer 7

Oesophagitis, leading to ulceration
Anaemia
Oesophageal stricture
Barrett's oesophagus
Oesophageal carcinoma

Question 8

Describe the pharmacological options for GORD management

Answer 8

Alginates, e.g. gaviscon
H2-receptor antagonists e.g. ranitidine
Proton pump inhibitors e.g. ameprazole, lansoprazole

Question 9

What surgical procedure can be used to treat GORD?

Answer 9

Laparoscopic fundoplication:
- laparoscopic insertion of a magnetic bead band which keeps the distal oesophagus closed when the patient is not swallowing
(MRI is contraindicated after this procedure)

Question 10

What is achalasia?

Answer 10

Lower oesophageal sphincter failure: functional distal obstruction of the oesophagus due to loss of myenteric plexus ganglion cells in the distal oesophagus and lower oesophageal sphincter

• this causes loss of motility of the sphincter
• failure of the sphincter to relax causes functional stenosis/stricture
• also impairs peristalsis

Question 11

Describe the clinical presentation of achalasia

Answer 11

Progressive dysphagia; first with solids, then liquids
Weight loss (also suggests malignancy)
Chest pain in 30% - retrosternal, occurs after eating
Regurgitation - can cause chest infections

Question 12

How might achalasia present on X-ray?

Answer 12

May show signs of inhalation

May show dilated oesophagus behind the heart

Question 13

Which diagnostic test detects up to 90% of achalasia cases? What would it show?

Answer 13

Manometry

• high resting pressure in cardiac sphincter
• incomplete relaxation on swallowing
• absent peristalsis

Question 14

Which classes of drugs might be used to treat achalasia?

Answer 14

Nitrates

Calcium channel blockers

Question 15

List two procedures that are used to treat achalasia

Answer 15

Pneumatic balloon dilatation

Myotomy (laparoscopic)

Question 16

Describe the potential complications associated with achalasia

Answer 16

Aspiration pneumonia due to inhalation of material lodged in oesophagus
Increased risk of squamous cell carcinoma
Complications of treatment; perforation of oesophagus, GORD

Question 17

Which conditions can (indirectly) cause dysphagia?

Answer 17

Diabetes mellitus
Old age
Depression
MS
Systemic sclerosis