Oesophageal Disorders Flashcards
1
Q
Where does the oesophagus begin and end?
A
- Begins at lower level of cricoid cartilage C6
- Terminates at T11-12 where it enters the stomach
2
Q
What type of muscle is found in the oesophagus?
A
Upper 3-4cm striated muscle, remainder is smooth muscle
3
Q
What type of epithelium is found in the oesophagus?
A
Stratified squamous epithelial lining
4
Q
What is the function of the oesophagus?
A
Transport of food/liquid from mouth to stomach which is an active process
5
Q
How is oesophageal peristalsis produced?
A
By oesophageal circular muscles and propels swallowed materials distally into the stomach
6
Q
What does oesophageal peristalsis co-ordinate with?
A
Lower oesophageal sphincter relaxation
7
Q
How is contraction in the oesophageal body and relaxation of the LOS mediated?
A
Via the vagus nerve
8
Q
What type of sphincter is the LOS?
A
Physiological
9
Q
What combination of factors contribute to the integrity of the LOS?
A
- High resting pressure in distal smooth muscle
- Striated muscle of right crus of diaphragm
- Mucosal Rosette formed by acute angle at GOJ
10
Q
When should be the only time that the LOS opens?
A
When food or liquid is passed into the stomach
11
Q
What are the symptoms of oesophageal disease/
A
- Heartburn
- Dysphagia
12
Q
What is heartburn?
A
Retrosternal discomfort or burning
13
Q
What may heartburn be associated with?
A
- Waterbrash
- Cough
14
Q
What is heartburn a consequence of?
A
Reflux of acidic &/or bilious gastric contents into the oesophagus
15
Q
How can certain foods and drugs increase reflux and heartburn?
A
Reduce the LOS pressure
16
Q
What food/drugs can increase reflux
A
- Alcohol
- Nicotine
- Dietary xanthines
17
Q
What does persistent reflux and heartburn lead to?
A
Gastro-oesophageal reflux disease (GORD) which can in turn cause long term complications
18
Q
Dysphagia
A
Subjective sensation of difficulty in swallowing foods and/or liquids
19
Q
Odynophagia
A
Pain when swallowing
20
Q
What should enquire about if some presents with dysphagia?
A
- Type of food
- Pattern
- Associated features
21
Q
What are the 2 locations of dysphagia?
A
- Oropharyngeal
- Oesophageal
22
Q
What are the causes of oesophageal dysphagia?
A
- Benign stricture
- Malignant disorders
- Eosinophilic oesophagitis (achalasia, presbyoesophagus)
- Extrinsic compression (lung cancer)
23
Q
What investigations are carried out for oesophageal disease?
A
- Endoscopy
- Oesophago-gastro-duodenoscopy (OGD)
- Upper GI endoscopy (UGIE)
- Contrast radiology
- Oeosphageal pH and manometry
24
Q
What is involved in oesophageal pH and manometry?
A
- NG catheter containing multiple pressure and pH sensors is placed in oesophagus
- Probes at both sphincters
- Assess sphincter tonicity, relaxation and motility
25
What motility disorders are there?
- Hypermotility
- Hypomotility
- Achalasia
26
What does hypermotility result in?
- Diffuse oesophageal spasms
| - Severe, episodic chest pain +/- dysphagia
27
How does hypermotility appear on barium swallow?
Corkscrew appearance
28
What is hypermotility often confused with?
Angina/MI
29
What is the cause of hypermotility?
Idiopathic
30
What does manometry of hypermotility show?
Exaggerated, uncoordinated hypertonic contractions
31
What is the treatment for hypermotility?
Smooth muscle relaxants
32
What is hypomotility associated with?
- Connective tissue disease
- Diabetes
- Neuropathy
33
What does hypomotility cause?
Failure of LOS mechanism leading to heartburn and reflux symptoms
34
Achalasia
Functional loss of myenteric plexus ganglion cells in distal oesophagus and LOS
35
What is the prevalence of achalasia?
- 1-2/100,000
| - M:F 1:1
36
When does the onset of achalasia usually occur?
3rd to 5th decade
37
What is the cardinal feature of achalasia?
Failure of the LOS to relax
38
What does achalasia result in?
Functional distal obstruction of oesophagus
39
What are the symptoms of achalasia?
- Progressive dysphagia for solids and liquids
- Weight loss
- Chest pain
- Regurgitation and chest infection
40
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
41
What is the treatment for achalasia?
- Pharmacological : nitrates, Ca channel blockers
- Endoscopic: Botulinum toxin, pneumatic balloon dilation
- Radiological: pneumatic balloon dilation
- Surgical: myotomy
42
What are the complications of untreated achalasia?
- Aspiration pneumonia and lung disease
| - Increased risk of squamous cell oesophageal carcinoma
43
What is GORD due to?
Pathological acid and bile exposure in lower oesophagus
44
What is important to note about GORD?
Many patients with frequent pathological episodes of acid/bile reflux do not experience any symptoms
45
What are the symptoms of GORD?
- Heartburn
- Cough
- Water brash
- Sleep disturbance
46
What are the risk factors for GORD?
- Pregnancy
- Obesity
- Drugs lowering LOS pressure
- Smoking
- Alcoholism
- Hypomotility
47
What is the prevalence of GORD?
- M>F
| - Caucasian>Black>Asian
48
What can the typical GORD syndrome be diagnosed on the basis of?
Characteristic symptoms without diagnostic testing
49
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
50
When must endoscopy be performed in GORD?
In the presence of alarm feature suggestive of malignancy
51
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
52
What is the aetiology of GORD due to hiatus hernia?
Anatomical distortion of the OG junction
53
What are the 2 main types of hiatus hernia?
- Sliding
| - Para-oesophageal
54
What happens in hiatus hernias?
Fundus of stomach moves proximally through the diaphragmatic hiatus
55
What are the predispositions to hiatus hernias?
- Obesity
| - Ageing
56
What is the pathophysiology of GORD?
- Mucosa exposed to acid-pepsin and bile
- Increased cell loss and regenerative activity
- Erosive oesophagitis
57
What are the complications of GORD?
- Ulceration
- Stricture
- Glandular metaplasia (Barretts oesophagus)
- Carcinoma
58
Barretts oeosphagus
Intestinal metaplasia related to prolonged acid exposure in distal oesophagus
59
What happens in Barretts oesophagus?
Change from squamous to mucin secreting columnar epithelial cells in lower oesophagus
60
What is Barrett's oesophagus a precursor to?
- Dysplasia
| - Adenocarcinoma
61
What is the prevelance of Barrett's oesophagus?
M>>F
62
What is the risk of developing cancer in high grade dysplasia Barrett's oesophagus?
6% per year
63
What is the treatment for high grade dysplasia Barrett's oesophagus?
- Endosocpic mucosal resection (EMR)
- Radio-frequency Ablation (RFA)
- Oesophagectomy rarely
64
What is the treatment for GORD?
- Lifestyle measures
| - Pharacological
65
What pharmacological interventions are there for GORD?
- Alginates (Gaviscon)
- H2RA (Ranitidine)
- Proton pump inhibitor
66
What treatement is there for GORD following investigation (refractory disease/symptoms)?
-Anti-reflux surgery (Fundoplication: full/partial wrap)
67
What are the 2 main types of oesophageal cancer?
- Squamous cell carcinoma
| - Adenocarcinoma
68
What is the prevalence of oesophageal cancer?
M>W
69
What is the median age of diagnosis for oesophageal cancer?
65 and decreasing
70
How does the type of cancer vary internationally?
- Western Europe/USA adenocarcinoma>squamous
| - Rest of world squamous>adenocarcinoma
71
How does oesophageal cancer present?
- Progressive dysphagia
- Anorexia and weight loss
- Odynophagia
- Chest pain
- Cough
- Pneumonia
- Vocal cord paralysis
- Haematemesis
72
What type of tumours often occur with squamous cell carcinomas?
Large exophytic occluding tumours
73
Where do squamous cell carcinomas usually occur?
Proximal and middle third of oesophagus
74
What is squamous cell carcinoma preceded by?
Dysplasia and carcinoma in situ
75
Where is there a high incidence of squamous cell carcinoma?
- Southern Africa
- China
- Iran
76
What are significant risk factors in squamous cell carcinomas?
Tobacco and alcohol
77
What is squamous cell carcinoma associated with?
- Achalasia
- Caustic strictures
- Plummer-Vinson syndrome
78
Where do adenocarcinomas occur?
Distal oesophagus
79
What are adenocarcinomas associated with?
Barretts oesophagus
80
What are the predisposing factors for adenocarcinomas?
- Obesity
- male
- Middle age
- Caucasian
81
When does oesophageal cancer usually present?
Late
82
Why can tumour invasion into adjacent structures occur more easily in the oesophagus?
-There is no serosal layer unlike the rest of the GIT
83
Why does lymph node involvement often occur early in oesophageal tumours?
The lamina propria has a rich lymphatic supply
84
Where have tumours commonly spread when oesophageal cancer presents?
Regional nodes +/- liver
85
Where are the common sites of metastases for oesophageal cancer?
- Liver
- Brain
- Lungs
- Bone
86
What is the prognosis for oesophageal cancer?
5 yr survival <10%
87
How is oesophageal cancer diagnosed?
- Endoscopy
| - Biopsy
88
How is oesophageal cancer staged?
- CT scan
- Endoscopic ultrasound
- PET scan
- Bone scan
89
What classification is used in the staging of oesophageal cancer?
TNM staging
90
What is the only potential cure for oesophageal cancer?
Surgical oesophagectomy +/- adjuvant or neoadjuvant chemotherapy
91
Who is surgery for oesophageal cancer limited to?
Patients with localised disease without co-morbid disease usually <70 years of age
92
What are the disadvantaged of surgery for oesophageal cancer?
- Significant morbidity and mortality associated with oeosphagectomy
- Long post operative recovery
- Requires nutritional support
93
What can be offered to patients with locally advanced inoperable disease to increase life expectancy?
Combined chemo and radiotherapy
94
What is often the overriding priority in oesophageal cancer treatment?
Symptom palliation
95
What options are there for symptom palliation of oesoopheal cancer?
- Endoscopic (stent, laser/APC, PEG)
- Chemotherapy
- Radiotherapy
- Brachytherapy
