Oesophageal Disorders Flashcards
Where does the oesophagus begin and end?
- Begins at lower level of cricoid cartilage C6
- Terminates at T11-12 where it enters the stomach
What type of muscle is found in the oesophagus?
Upper 3-4cm striated muscle, remainder is smooth muscle
What type of epithelium is found in the oesophagus?
Stratified squamous epithelial lining
What is the function of the oesophagus?
Transport of food/liquid from mouth to stomach which is an active process
How is oesophageal peristalsis produced?
By oesophageal circular muscles and propels swallowed materials distally into the stomach
What does oesophageal peristalsis co-ordinate with?
Lower oesophageal sphincter relaxation
How is contraction in the oesophageal body and relaxation of the LOS mediated?
Via the vagus nerve
What type of sphincter is the LOS?
Physiological
What combination of factors contribute to the integrity of the LOS?
- High resting pressure in distal smooth muscle
- Striated muscle of right crus of diaphragm
- Mucosal Rosette formed by acute angle at GOJ
When should be the only time that the LOS opens?
When food or liquid is passed into the stomach
What are the symptoms of oesophageal disease/
- Heartburn
- Dysphagia
What is heartburn?
Retrosternal discomfort or burning
What may heartburn be associated with?
- Waterbrash
- Cough
What is heartburn a consequence of?
Reflux of acidic &/or bilious gastric contents into the oesophagus
How can certain foods and drugs increase reflux and heartburn?
Reduce the LOS pressure
What food/drugs can increase reflux
- Alcohol
- Nicotine
- Dietary xanthines
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 when swallowing
What should enquire about if some presents with dysphagia?
- Type of food
- Pattern
- Associated features
What are the 2 locations of dysphagia?
- Oropharyngeal
- Oesophageal
What are the causes of oesophageal dysphagia?
- Benign stricture
- Malignant disorders
- Eosinophilic oesophagitis (achalasia, presbyoesophagus)
- Extrinsic compression (lung cancer)
What investigations are carried out for oesophageal disease?
- Endoscopy
- Oesophago-gastro-duodenoscopy (OGD)
- Upper GI endoscopy (UGIE)
- Contrast radiology
- Oeosphageal pH and manometry
What is involved in oesophageal pH and manometry?
- NG catheter containing multiple pressure and pH sensors is placed in oesophagus
- Probes at both sphincters
- Assess sphincter tonicity, relaxation and motility
What motility disorders are there?
- Hypermotility
- Hypomotility
- Achalasia
What does hypermotility result in?
- Diffuse oesophageal spasms
- Severe, episodic chest pain +/- dysphagia
How does hypermotility appear on barium swallow?
Corkscrew appearance
What is hypermotility often confused with?
Angina/MI
What is the cause of hypermotility?
Idiopathic
What does manometry of hypermotility show?
Exaggerated, uncoordinated hypertonic contractions
What is the treatment for hypermotility?
Smooth muscle relaxants
What is hypomotility associated with?
- Connective tissue disease
- Diabetes
- Neuropathy
What does hypomotility cause?
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 prevalence of achalasia?
- 1-2/100,000
- M:F 1:1
When does the onset of achalasia usually occur?
3rd to 5th decade
What is the cardinal feature of achalasia?
Failure of the LOS to relax
What does achalasia result in?
Functional distal obstruction of oesophagus
What are the symptoms of achalasia?
- Progressive dysphagia for solids and liquids
- Weight loss
- Chest pain
- Regurgitation and chest infection
What 2 features are required to make a diagnosis of achalasia?
- Failure of LOS to relax after swallowing
- An absence of useful contractions in the lower oesophagus
What is the treatment for achalasia?
- Pharmacological : nitrates, Ca channel blockers
- Endoscopic: Botulinum toxin, pneumatic balloon dilation
- Radiological: pneumatic balloon dilation
- Surgical: myotomy
What are the complications of untreated achalasia?
- Aspiration pneumonia and lung disease
- Increased risk of squamous cell oesophageal carcinoma
What is GORD due to?
Pathological acid and bile exposure in lower oesophagus
What is important to note about GORD?
Many patients with frequent pathological episodes of acid/bile reflux do not experience any symptoms
What are the symptoms of GORD?
- Heartburn
- Cough
- Water brash
- Sleep disturbance
What are the risk factors for GORD?
- Pregnancy
- Obesity
- Drugs lowering LOS pressure
- Smoking
- Alcoholism
- Hypomotility
What is the prevalence of GORD?
- M>F
- Caucasian>Black>Asian
What can the typical GORD syndrome be diagnosed on the basis of?
Characteristic symptoms without diagnostic testing
Why is endoscopy a poor diagnostic test for GORD?
Most patients with reflux symptoms have no visible evidence of oesophageal abnormality when endoscopy is performed
When must endoscopy be performed in GORD?
In the presence of alarm feature suggestive of malignancy
What is the aetiology of GORD without abnormal anatomy?
- Increased transient relaxations of the LOS
- Hypotensive LOS
- Delayed gastric emptying
- Delayed oesophageal emptying
- Decreased oesophageal acid clearance
- Decreased tissue resistance to bile/acid
What is the aetiology of GORD due to hiatus hernia?
Anatomical distortion of the OG junction
What are the 2 main types of hiatus hernia?
- Sliding
- Para-oesophageal
What happens in hiatus hernias?
Fundus of stomach moves proximally through the diaphragmatic hiatus
What are the predispositions to hiatus hernias?
- Obesity
- Ageing
What is the pathophysiology of GORD?
- Mucosa exposed to acid-pepsin and bile
- Increased cell loss and regenerative activity
- Erosive oesophagitis
What are the complications of GORD?
- Ulceration
- Stricture
- Glandular metaplasia (Barretts oesophagus)
- Carcinoma
Barretts oeosphagus
Intestinal metaplasia related to prolonged acid exposure in distal oesophagus
What happens in Barretts oesophagus?
Change from squamous to mucin secreting columnar epithelial cells in lower oesophagus
What is Barrett’s oesophagus a precursor to?
- Dysplasia
- Adenocarcinoma
What is the prevelance of Barrett’s oesophagus?
M»F
What is the risk of developing cancer in high grade dysplasia Barrett’s oesophagus?
6% per year
What is the treatment for high grade dysplasia Barrett’s oesophagus?
- Endosocpic mucosal resection (EMR)
- Radio-frequency Ablation (RFA)
- Oesophagectomy rarely
What is the treatment for GORD?
- Lifestyle measures
- Pharacological
What pharmacological interventions are there for GORD?
- Alginates (Gaviscon)
- H2RA (Ranitidine)
- Proton pump inhibitor
What treatement is there for GORD following investigation (refractory disease/symptoms)?
-Anti-reflux surgery (Fundoplication: full/partial wrap)
What are the 2 main types of oesophageal cancer?
- Squamous cell carcinoma
- Adenocarcinoma
What is the prevalence of oesophageal cancer?
M>W
What is the median age of diagnosis for oesophageal cancer?
65 and decreasing
How does the type of cancer vary internationally?
- Western Europe/USA adenocarcinoma>squamous
- Rest of world squamous>adenocarcinoma
How does oesophageal cancer present?
- Progressive dysphagia
- Anorexia and weight loss
- Odynophagia
- Chest pain
- Cough
- Pneumonia
- Vocal cord paralysis
- Haematemesis
What type of tumours often occur with squamous cell carcinomas?
Large exophytic occluding tumours
Where do squamous cell carcinomas usually occur?
Proximal and middle third of oesophagus
What is squamous cell carcinoma 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 in squamous cell carcinomas?
Tobacco and alcohol
What is squamous cell carcinoma associated with?
- Achalasia
- Caustic strictures
- Plummer-Vinson syndrome
Where do adenocarcinomas occur?
Distal oesophagus
What are adenocarcinomas associated with?
Barretts oesophagus
What are the predisposing factors for adenocarcinomas?
- Obesity
- male
- Middle age
- Caucasian
When does oesophageal cancer usually present?
Late
Why can tumour invasion into adjacent structures occur more easily in the oesophagus?
-There is no serosal layer unlike the rest of the GIT
Why does lymph node involvement often occur early in oesophageal tumours?
The lamina propria has a rich lymphatic supply
Where have tumours commonly spread when oesophageal cancer presents?
Regional nodes +/- liver
Where are the common sites of metastases for oesophageal cancer?
- Liver
- Brain
- Lungs
- Bone
What is the prognosis for oesophageal cancer?
5 yr survival <10%
How is oesophageal cancer diagnosed?
- Endoscopy
- Biopsy
How is oesophageal cancer staged?
- CT scan
- Endoscopic ultrasound
- PET scan
- Bone scan
What classification is used in the staging of oesophageal cancer?
TNM staging
What is the only potential cure for oesophageal cancer?
Surgical oesophagectomy +/- adjuvant or neoadjuvant chemotherapy
Who is surgery for oesophageal cancer limited to?
Patients with localised disease without co-morbid disease usually <70 years of age
What are the disadvantaged of surgery for oesophageal cancer?
- Significant morbidity and mortality associated with oeosphagectomy
- Long post operative recovery
- Requires nutritional support
What can be offered to patients with locally advanced inoperable disease to increase life expectancy?
Combined chemo and radiotherapy
What is often the overriding priority in oesophageal cancer treatment?
Symptom palliation
What options are there for symptom palliation of oesoopheal cancer?
- Endoscopic (stent, laser/APC, PEG)
- Chemotherapy
- Radiotherapy
- Brachytherapy
