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Alimentary System: Pathology SA > Oesophageal Disorders > Flashcards

Oesophageal Disorders Flashcards

1
Q

What is the length of the oesophagus and where does it originate and terminate

A

25cm in length

Originate
- the lower level of circoid cartilage
(C6),

Terminates
- Where it enters the stomach
(T11-12)

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2
Q

What is the muscular arrangement of the oesophagus

A

Upper third - skeletal muscle

Lower two thirds smooth muscle

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3
Q

What is the epithelium lining of the oesophagus

A

Stratified squamous

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4
Q

How does the oesophagus perform its function of transporting food/liquid from the mouth to the stomach

A

Oesophageal peristalsis (contraction) propels swallowed materials down towards the stomach

And lower oesophageal sphincter relaxes to allow swallowed material entry into the stomach

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5
Q

What muscular layer of the oesophagus allows the contraction

A

Circular muscles

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6
Q

What mediates the peristalsis and relaxation of the LOS

A

Vagus nevre

- parasympathetic intervention

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7
Q

When should the lower oesophageal sphincter only be open

A

When food and liquid pass into the stomach

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8
Q

What are the factors that contribute to the integrity of the lower oesophageal sphincter to remain contracted

A

Physiological sphincter - relaxes with physiological functions

High resting pressure in distal smooth muscle

Striated muscle of right crus of diaphragm

“Mucosal Rosette” formed by acute angle (of His) at GOJ

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9
Q

What is the symptoms of oesophageal disease

A

Heartburn - retrosternal discomfort/burning

Reflux

Dysphagia

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10
Q

What are the associated symptoms with heartburn

A

Waterbrash - sudden flow of saliva

Cough

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11
Q

What is the cause of heartburn

A

reflux of acid and/or bilious gastric contents into the oesophagus

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12
Q

When and how does reflux occur in oesophageal disease

A

after swallowing certain drugs/food

Which reduces the lower oesophageal spinchter pressure resulting increased reflux

(further causing the symptom of heart burn)

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13
Q

What is the main aetiology behind gastro-oesophgeal reflux disease

A

Persistent reflux and heart burn

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14
Q

Define dysphagia

A

subjective sensation of difficulty in swallowing foods/liquids

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15
Q

What many be accompanied with dysphagia

A

odynophagia - pain with swallowing

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16
Q

What is the associated symptoms of dysphagia

A

Weight loss
Regurgitation
Cough

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17
Q

What is the different patterns of dysphagia

A

Progressive

Intermittent - irregular intervals

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18
Q

What is the two locations of dysphagia

A

Oropharyngeal
- part of the pharynx lies between soft palate and hyoid bone

Oesophageal

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19
Q

What is the aetiology of oesophageal dysphagia

A
  • benign stricture
  • malignant stricture (oesophageal cancer)
  • motility disorders

eosinophilic oesophagitis

-extrinsic compression (eg in lung cancer)

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20
Q

What iseosinophilic oesophagitis

A

An allergic inflammatory condition of the esophagus that involves eosinophils, a type of white blood cell

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21
Q

What are the investigations for Oesophageal diseases

A

Endoscopy

Contrats radiology (barium swallow)

Oesophageal pH anf manometry (pressure)

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22
Q

What are the two endoscopic procedures for investigating oesophageal disease

A

Oesophago-Gastro-Duodenoscopy (OGD)

Upper GI Endoscopy (UGIE)

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23
Q

When is an endoscopy used in the investigation of oesophageal disease

A

In the investigation of dysphagia or reflux symptoms with alarm features

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24
Q

Although endoscopy is preferred as an overall investigation what is best for primary investigation of dysphagia

A

CT contract - Barium swallow

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25
Q

Why is Barium swallow used in a high dysphagia

A

Exclude pharyngeal pouch

or

post cricoid web prior to endoscopy

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26
Q

What occurs in an Oesophageal pH and manometry investigation

A

Naso-gastric catheter containing multiple pressure and pH sensors is placed in oesophagus
at both sphincters (UOS + LOS)

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27
Q

What does manometry specially investigate

and asses

A 
Investigates dysphagia and suspected motility disorder 
			assesses 
 - sphincter muscle tone,
 - relaxation  
 sphincters 
- oesophageal motility
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28
Q

What symptoms does the pH studies specifically investigate

A

Refractory heartburn and reflux

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29
Q

What is examples of motility disorder resulting in oesophageal disease

A

Hyper-motility

Hypo-motility

Presbyoesophagus

Achalasia

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30
Q

Define Presbyoesophagus

A

Degenerative motor function in ageing oesophagus

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31
Q

What happens in hyper- motility

A

Idiopathic Oesophageal spasm

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32
Q

What is the presentation of hyper motility

A

Severe episodic chest pain with or without dysphagia

confused with angina/MI

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33
Q

What is seen in the imaging Ba swallows of Hyper-motility

A

Ba swallow - corkscrew appearances

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34
Q

What does the investigation of monastery shows in hyper-motility

A

Exaggerated uncoordinated, hypertonic contractions

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35
Q

What is the treatment of hyper-motility

A

Smooth muscle relaxants

36
Q

What is the aetiology of hypo-motility

A

Connective tissue disease
Diabetes
Neuropathy

37
Q

What is the result of hypo-motility

A

Failure of Lower oesophageal spinchter

38
Q

What is the symptoms of hypo-motility

A

Heart burn

reflux symptoms

39
Q

What is the aeitology of achalasia

A

Degeneration and functional loss of inhibitory neurons (ganglion cells) in the myenteric plexus in the distal oesophagus and LOS

40
Q

Why is achalasia suspected to have an inflammatory aetiology

A

Often surrounded by lymphocytes

41
Q

What is the result of Achalasia

A

Failure of LOS to relax

Causing functional distal obstruction of oesophagus
preventing food from entering the stomach

42
Q

What is the symptoms of achalasia

A

Progressive dysphagia for solids and liquids

Weight loss

Chest pain (30%)

Regurgitation

Chest infection

43
Q

What investigation is used to diagnose achalasia

A

Manometry

44
Q

What are the diagnostic findings in a manometry of achalasia

A

High pressure in the LOS at rest
( usually above 45mm Hg normal being 10mm)

MOST IMPORTANT 2:

Failure of the LOS to relax after swallowing

An absence of useful (peristaltic) contractions in the lower oesophagus

45
Q

What is the treatment options of achalasia

A

Pharmacological

  • Nitrates,
  • Calcium Channel blockers

Endoscopic
- Botulinum Toxin

Surgical
- Myotomy (muscle cut)

Pneumatic balloon dilation (either radiological or endoscopically)

46
Q

What is the complications of achalasia

A

Aspiration pneumonia and lung disease

Increased risk of squamous cell oesophageal carcinoma

47
Q

What is the pathology of gastro-oesophageal reflux disease GORD

A

Pathological acid and bile exposure in the lower oesophageal

48
Q

What is the symptoms of GORD

A

Heart burn
Cough
Water Brash
Sleep disturbance

{Many patients with frequent, pathological episodes of acid/bile reflux do not experience any symptoms!}

49
Q

What is the risk factors of GORD

A 
Pregnancy 
Obesity 
Drugs lowering the LOS pressure 
Smoking 
alcohol 
Hypo-mobility
50
Q

Why is endoscopy a poor diagnostic test for GORD

A

Most patients (>50%) with reflux symptoms have no visible evidence of oesophageal abnormality when endoscopy is performed

51
Q

Diagnosis of GORD is due to characteristic symptoms but

When must endoscopy be performed

A

When there is presence of alarm features:
Dysphagia, weight loss,
Vomiting

that may suggest malignancy

52
Q

What is the two main aetiologies of GORD

A

abnormal oesophageal anatomy

Hiatus hernia

(many patients have both)

53
Q

What abnormal oesophgeal anatomy can result in GORD occurring

A

Increased transient relaxations of the LOS

Hypotensive LOS

Delayed gastric/oesophageal emptying

Decreased Oesophageal acid clearance

Decreased Tissue resistance to acid/bile

54
Q

Define Hiatus hernia and the two types

A

Sliding - Fundus of stomach moves through the oesophageal hiatus

Para-oespphgaeal - funds of stomach moves proximal through diaphragmatic hiatus

55
Q

What is the pathophysiology of GORD

A

The mucosa is exposed to acid pepsin and bile

This increases cell loss and regenerative activity = inflammation

eventually causing erosive oesophagi’s

56
Q

What is the complications of GORD

A

Ulceration

Stricture

Barrets
oesophagus (glandular metaplasia)

Carcinoma

57
Q

What is the aetiology of Barretts oesophagus

A

Intestinal metaplasia related to prolonged acid exposure in distal oesophagus

58
Q

What is the pathology of Barretts oesophagus

A

Change from squamous to mucin-secreting columnar epithelial cells in lower oesophagus

59
Q

What do the epithelial cells become a precursor of in Barrett’s oesophagus

What risk does this increase

A

Dysplasia/adenocarcinoma

Therefore have an increased risk of developing oesophageal cancer in high grade dyslplasia

60
Q

What is the treatment of Barretts Oesophagus with high grade dysplasia

A

Endoscopic Mucosal Resection (EMR)

Radio-Frequency Ablation (RFA)

Oesophagectomy (rarely due to high mortality)

61
Q

What is the treatment options for GORD

A

Lifestyle measures

Pharmacological

  • Aliginates (gaviscon)
  • H2RA (ranitidine)
  • PPI (omeprazole, lansoprazole)

Anti-reflux surgery

-Fundoplication

62
Q

What is fundoplication

A

Full or partial wrapping of the fundus of the stomach around the oesophagus in order to strengthen spinchter

63
Q

What is the two cell types of oesophageal cancer

A

Squamous cell carcinoma

adenocarcinoma

64
Q

How common are benign tumours in oesophageal cancer

A

rare

65
Q

What is the symptoms of oesophageal cancer

A

Anorexia and Weight loss

Odynophagia -pain when swallowing

Chest pain

Cough

Pneumonia (tracheo-oesophageal fistula)

Vocal cord paralysis

Haematemesis

66
Q

Where is squamous cell carcinoma likely to occur in oesophageal cancer

A

Proximal and middle third of the oesophagus

67
Q

What is the morphology and pathology of squamous cell carcinoma in oesophageal cancer

A

Large exophlitic occluding tumours

Preceded by dysplasia and carcinoma in situ

68
Q

What is the risk factors of squamous cell carcinoma

A

Smoking
alcohol
vitamin deficiency/diet

69
Q

What is squamous cell carcinoma Oesophageal cancer associated with

A

Achalaisa

Caustic strictures

Plummer vinson syndrome

70
Q

Where is adenocarcinoma oesophageal cancer occur in the oesophagus

A

In the distal oesophagus

71
Q

What is adenocarcinoma oesophageal cancer associated with

A

Barrets oesophagus

Obesity

72
Q

What is the predisposing factors of adenocarcinoma oesophageal cancer

A

obesity, male sex, middle age, caucasian

73
Q

What is the presentation of oesophageal cancer

A

Usually presents late and tumours have commonly spread to
Regional lymph nodes
or/and Liver

74
Q

Why is tumour invasion easy in oesophageal cancer

A

Oesophagus lacks a serosal layer, so tumours can easily invade into adjacent structures

75
Q

Where does local invasion occur in oesophageal cancer

A

Heart
Trachea
Aorta

76
Q

What does local invasion of oesophgeal cancer limit

A

Limits surgery intervention - more difficult to treat in late stage presentation

77
Q

What does lymph node envelopment occur early in oesophageal tumours

A

The Lamina propria

has a rich lymphatic supply compared to the rest of the GI tract

78
Q

Where does metastases of oesophageal cancer occur

A

Hepatic,
Brain,
Pulmonary,
Bone

79
Q

How is oesophageal cancer diagnoses

A

Endoscopy and >8 biopsy

80
Q

What investigations are used for Staging of oesophageal cancer and what do they investigation

A

CT scan
- distant metastases

Endoscopic ultrasound
- T,N staging

PET Scan

Bone scan

Laparoscopy
-peritoneal spread (ascites on EUS/CT)

81
Q

What is oesophageal cancer staged by

A

TNM staging

T1- Tumor invades lamina propria or submucosa
(a-lamina propria, b-submucosa)
T2- Tumor invades muscularis propria
T3- Tumor invades adventitia
T4- Tumor invades adjacent structures
N1- Regional lymph node metastasis
M1- Distant metastasis
82
Q

What is the Curative treatment for Oesophageal cancer

A

oesophagectomy +/- adjuvant/ neoadjuvant chemotherapy

Potential long term survival
- combined chemo and radio

83
Q

Who is oesophagectomy limited to in the treatment of oesophageal cancer

A

patients with localised disease, without co-morbid disease, usually <70 years of age

84
Q

What is the disadvantages to oesophagectomy

A

Significant morbidity and mortality - 10%

Long post-operative recovery

require nutritional support

85
Q

Most oesophageal cancer is incurable at presentation so what is the palliative options of treatment

A

Endoscopic
(stent, laser/APC, PEG)

Chemotherapy

Radiotherapy

Brachytherapy (radioactive plants in tissue)

Alimentary System: Pathology SA (27 decks)

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