Oesophageal disorders Flashcards
Where does the oesophagus begin?
C6
Lower level of the cricoid cartilage
Where des the oesophagus terminate?
T11/12
Where it enters stomach
What is the structural difference between the upper 1/3 and lower 2/3 of oesophagus?
Upper- striated muscle
Lower- smooth muscle
What is the epithelium of the oesophagus?
Stratified squamous non keratinised epithelium
What does the vagus nerve mediate?
Peristalsis and relaxation of lower oesophageal sphincter
What is the lower oesophageal sphincter?
Striated muscle of the right crus of the diaphragm
What level of reflux is there naturally in the oesophagus?
Degree occurs physiologically
Certain drugs and food can lower LOS pressure and increase reflux without pathology
What can persistent reflux cause?
Gastro oesophageal reflux disease
What can gastrooesophageal reflux disease cause?
Dysphagia and odynophagia
What must be enquired about in dysphagia?
Type of food, pattern, associated features, location
What are the possible causes of dysphagia?
Benign stricture Malignancy stricture Motility disorders Eosiniphilic infiltrate Extrinsic compression
What investigations can be carried out for oesophageal disorders?
Endoscopy
Contract radiology- barium swallow
Oesophageal pH and manometry
What are the motility disorders of the oesophagus?
Hypermotility
Hypomotility
Achlasia
What is diagnostic of hypermotility of the oesophagus?
Corkscrew appearance on barium swallow
Exaggerated, uncoordinated hypertonic contractions with manometry
What are the symptoms of hypermotility of the oesophagus?
Severe pain, with or without dysphagia
How is hyper motility of the oesophagus treated?
Smooth muscle relaxants
What is hypo motility of the oesophagus often caused by?
Connective tissue disease
Diabetes
Neuropathy
What does hypo motility cause?
Failure of LOS mechanism, leading to heartburn and reflux symptoms
What is achalasia?
Functional loss of myenteric plexus ganglion cells in distal oesophagus and LOS
What is the cardinal feature of achalasia?
Failure of LOS to relax causing functional distal obstruction of the oesophagus
What are the symptoms of achalasia?
Progressive dysphagia Weight loss Chest pain Regurgitation Chest infection
What is the treatment of achalasia?
Nitrates and calcium channel blockers
Endoscopic pneumatic balloon dilatation
Surgical myotomy
What are the complications of achalasia?
Aspiration pneumonia and lung disease
Increased risk of squamous cell oesophageal carcinoma
What are the symptoms of gastro-oesophageal reflux disease?
Heartburn
Cough
Water brash
Sleep disturbance
What are the risk factors for gastrooesophageal reflux?
Pregnancy Obesity Drugs lowering LOS pressure Smoking Alcohol Hypomotility
How is gastrooesophageal reflux disease diagnosed?
On basis of characteristic symptoms without testing
When is an endoscopy performed with gastrooesophageal reflux?
ALARM features
Dysphagia
Weight loss
Vomiting
What can the causes of gastrooesophageal reflux disease be with normal anatomy?
Increased transient relaxations of LOS Hypotensive LOS Delayed gastric emptying Delayed oesophageal emptying Decreased oesophageal acid clearance Decreased tissue resistance to acid/bile
What can the anatomical causes of gastrooesophageal reflux disease be?
Hiatus hernia
What are the 2 main types of hiatus hernia?
Sliding
PAraoesophageal
What is the pathology of hiatus hernia?
Fundus of stomach moves proximally through hiatus in diaphragm
What is the pathology of gastrooesophageal reflux disease?
Mucosa exposed to pepsin and bile
Increased cell loss ad regenerative activity
Erosive oesophagitis
What are the complications of gastrooesophageal reflux?
Ulceration
Stricture
Glandular metaplasia
Carcinoma
What is Barrett’s oesophagus?
Intestinal metaplasia related to prolonged exposure to acid in distal oesophagus
What histological change is present in Barrett’s oesophagus?
Squamous to mucin secreting columnar epithelial cells
What is Barrett’s oesophagus a precursor to?
Dysplasia or adenocarcinoma
What is the treatment of Barrett’s oesophagus?
Endoscopic mucosal resection
Rediofrequency ablation
Oesophagectomy
What is the treatment of gastrooesophageal reflux disease?
Lifestyle measures
Pharmacologocal
For refractory disease- anti reflux surgery
What are the types of oesophageal cancer?
Squamous cell carcinoma
Adenocarcinoma
What is the usual presentation of oesophageal cancer?
Progressive dysphagia Anorexia and weight loss Odynophagis Chest pain Cough Pneumonia Vocal cord paralysis Haemetemesis
What is the pathology of squamous cell carcinoma in the oesophagus?
Large exophytic occluding tumours
Where do squamous ell carcinomas occur in the oesophagus?
Proximal and middle third
What is squamous cell carcinoma preceeded by?
Dysplasia and carcinoma in situ
What is squamous cell oesophageal carcinoma associated with?
Achalasia
Caustric strictures
Plummer-Vinson syndrome
Where are oesophageal adenocarcinomas situated?
Distal oesophagus
What is oesophageal adenocarcinoma associated with?
Barrett’s oesophagus
What are the risk factors for oesophageal adenocarcinoma?
Obesity
Male
Middle age
Caucasian
Where does oesophageal cancer commonly spread to?
Liver
Brain
Lung
Bone
What is the issue with presentation od oesophageal cancer?
Often presents late when there is already invasion of regional lymph nodes and/or liver
What is the prognosis for oesophageal cancer?
5 year survival <10%
What investigations are done for oesophageal cancer?
Diagnosis- endoscopy and biopsy Staging- CT Endocopic ultrasound PET Bone scan
What is the treatment of oesophageal cancer?
Oesophagectomy with or with our neo- and adjuvant therapy
Palliative- chemo, radio, brachytherapy, endoscopic stent, laser/APC orr PEG
What is the issue with curative oesophagectomy in oesophageal cancer?
Limited to patients with localised disease
Long recovery, high mortality
