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General Surgery > Oesophageal disorders > Flashcards

Oesophageal disorders Flashcards

1
Q

Define dyspepsia

A

Upper GI symptoms typically present for 4+ weeks, including: upper abdominal pain/discomfort, heartburn, acid reflux, NaV

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2
Q

Define GORD

A

Gastro-oesophageal reflux disease is a chronic condition of abnormal reflux of gastric contents into the oesophagus, which causes predominant symptoms of heartburn and acid regurgitation.

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3
Q

What is ‘proven GORD’?

A

Endoscopically-determined reflux disease

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4
Q

How does GORD typically present?

A 
Oesophageal symptoms:
Heartburn (25%) - burning retrosternal discomfort
Acid brash - acid or bile regurgitation
Water brash - excessive salivation
Odynophagia - pain on swallowing
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5
Q

Name 3 atypical clinical features of GORD

A 
Extra-oesophageal symptoms (atypical):
Chest pain, epigastric pain, bloating
Nocturnal asthma
Chronic cough
Laryngitis (Cherry-Donner syndrome)
Sinusitis
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6
Q

Name 5 risk factors for GORD

A

Lifestyle: obesity, trigger foods, smoking, alcohol, coffee, stress
Drugs: CCBs, anticholinergics, theophylline, BDZs, nitrates
Pregnancy

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7
Q

What complications can occur due to GORD?

A 
Oesophagitis
Ulcers
Benign strictures
Iron-deficiency anaemia
Barrett's oesophagus ➔ Oesophageal adenocarcinoma
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8
Q

What is Barrett’s oesophagus?

A

A precancerous stage seen in 10-15% GORD, associated with the development of oesophageal adenocarcinoma (1-10% in next 20yr).

Metaplasia of oesophageal stratified squamous epithelium ➔ simple columnar epithelium

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9
Q

Name 3 causes of GORD

A

Lower oesophageal sphincter problems
Delayed gastric emptying e.g. gastric outlet obstruction
Hiatus hernia
Obesity/pregnancy

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10
Q

What may be seen on histology of GORD?

A

Gastric metaplasia ➔ low risk of malignancy
Intestinal metaplasia ➔ 2 yearly surveillance
Low-grade dysplasia ➔ 90% develop cancer within 6yr
High-grade dysplasia ➔ 50% have adenocarcinoma

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11
Q

What is used to grade Barrett’s oesophagus?

A

Prague C and M endoscopic grading system

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12
Q

How is Barrett’s oesophagus treated?

A

High-grade dysplasia: Surgical resection, endoscopic mucosal resection, or ablation

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13
Q

Name 3 differential diagnoses for GORD

A 
Oesophagitis from:
Corrosives
NSAIDs
Herpes
Candida

Peptic ulcer disease
Cancer
Cardiac cause e.g. MI

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14
Q

Describe the pathology of strictures in GORD

A

Chronic fibrosis and epithelial destruction

Eventual shortening and narrowing of the lower oesophagus ➔ potential fixation and susceptibility to further reflux

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15
Q

What are the annual and lifetime recurrence risks of GORD? Which patient group is more likely to relapse?

A

Annual recurrence risk of untreated GORD: 50%
Lifetime risk of recurrence: 80%

More likely to relapse in people with severe oesophagitis

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16
Q

Name 4 indications for investigations for GORD

A 
Age >45
Symptoms last >4wks
Persistent vomiting
GI bleeding or iron deficiency
Palpable mass
Dysphagia
Weight loss
Failed medical treatment
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17
Q

Why could OGD be preformed for any presentation of GORD in over 45s?

A

Exclude oesophageal malignancy

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18
Q

How is GORD investigated?

A

Endoscopy
24h continuous pH monitoring +- manometry
Barium swallow - may show hiatus hernia

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19
Q

Describe a positive pH investigation result for GORD

A

GORD symptoms correspond with pH peaks

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20
Q

What physiological features protect against GORD?

A

Lower oesophageal sphincter
Fundus located posteriorly and superiorly
Crus of diaphragm
Expansion of stomach

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21
Q

Outline the lifestyle management of GORD

A 
Smoking cessation
Weight loss
Decrease alcohol consumption
Small regular meals
Avoid trigger foods
Sleep with head of bed raised
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22
Q

Outline the initial medical management of GORD

A

Review and stop any drugs that exacerbate symptoms

  • Relax LOS: nitrates, anticholinergics, CCBs
  • Damage mucosa: NSAIDs, K+ salts, bisphosphonates

Full-dose Omeprazole or Lansoprazole for 4 weeks
If severe oesophagitis ➔ 8 weeks

23
Q

How should refractory or recurrent GORD be medically managed?

A

Consider alternative diagnosis
Check patient adherence to initial management
Reinforce lifestyle advice
Further 4wks of PPI at full-dose or double-dose, or
Add H2R antagonist at bedtime
If severe ➔ 8wk PPI

Offer full-dose PPI long-term as maintenance treatment
Switch to H2RA if endoscopy-negative reflux

24
Q

What are the surgical indications for GORD?

A

Refractory to treatment, persistent, or unexplained
Controlled on PPI/H2RA, but does not want long-term or cannot tolerate treatment
Associated with risk factors for Barrett’s oesophagus

Large volume reflux with risk of aspiration pneumonia
Complications: stricture and severe ulceration

25
Q

Outline the surgical management of GORD

A

Laparoscopic ‘Nissen’ fundoplication: wrapping the fundus around the lower oesophagus

26
Q

Name and differentiate between the types of hiatus hernias

A

Sliding hiatus hernia (80%): Gastro-oesophageal junction slides up into the chest. Gross acid reflux is commoner.

Rolling hiatus hernia (20%): Gastro-oesophageal junction remains in chest, but a bulge of the stomach herniates into the chest, alongside the oesophagus. Symptoms include hiccough, ‘pressure’ in chest, odynophagia.

27
Q

Outline the medical management of hiatus hernias

A

Weight loss
Symptomatic relief with H2RAs
PPIs
Metoclopramide - promote oesophageal and gastric emptying

28
Q

What investigations are used for suspected hiatus hernia?

A

Barium swallow*
Upper GI endoscopy - exclude oesophageal mucosal pathology
CT thorax - acute presentation

29
Q

Define hiatus hernia

A

Presence of part or all of the stomach within the thoracic cavity. Usually by protrusion through the oesophageal hiatus in the diaphragm.

30
Q

Outline the surgical management of hiatus hernias

A

Prophylactic surgical hernia repair - avoid strangulation
Gastropexy: reduction and fixation of stomach to oesophagus
Nissen fundoplication: if GORD symptoms predominate

31
Q

Name 3 types of oesophageal tumours

A

Adenocarcinoma (commonest)
Squamous carcinoma
Lipoma and GI stromal tumours
Rhabdomyo(sarco)ma

32
Q

Differentiate between the pathological features of oesophageal adenocarcinoma and squamous carcinoma

A

Adenocarcinoma:
Associated with dietary nitrosamines, GORD, and Barrett’s oesophagus.
Most commonly occurs in the lower 1/3 of oesophagus.

Squamous carcinoma:
Associated with smoking, alcohol, poor fruit/veg intake, chronic achalasia, and chronic caustic strictures.
May occur anywhere in the oesophagus.

33
Q

Describe the presentation of oesophageal tumours

A 
Painless progressive dysphagia (any new dysphagia, esp in over 45s, is assumed to be tumour until proven otherwise)
Haematemsis - rare
Heartburn/GORD - if LOS involvement
Weight loss/malnourishment
Incidental finding

Disseminated disease: Cervical lymphadenopathy, hepatomegaly (mets), epigastric mass (para-aortic lymph)

Local invasion: Dysphonia (RLN palsy), cough and haemoptysis (tracheal), neck swelling (SVC obstruction), Horner’s syndrome (Miosis, partial ptosis, anhidrosis)

34
Q

Name 5 risk factors for oesophageal tumours

A

Obesity
Smoking, alcohol, diet - squamous carcinoma
Age >45 - new dysphagia is tumour till proven otherwise
Barrett’s oesophagus
Alchalasia
Radiotherapy

35
Q

How are suspected oesophageal tumours investigated?

A

Flexible oesophagoscopy and biopsy

Barium swallow if failed intubation or suspected post-cricoid carcinoma (often missed by endoscopy)

36
Q

What staging investigations are done for oesophageal tumours?

A

Endoluminal USS - assess depth of local invasion
CT - local invasion, lymph involvement, liver
PET - disseminated disease

37
Q

What are the commonest patters of oesophageal cancer metastases?

A 
Lymph nodes
Lung
Liver
Bones
Adrenal glands
Brain
38
Q

Outline the management of oesophageal tumours

A

Palliative (many present with incurable disease)

  • Endoluminal metal stent for dysphagia
  • External beam radiotherapy
  • Systemic chemotherapy

Potentially curative

  • Squamous: Radical chemoradiotherapy or neoadjuvant chemo + resection
  • Adeno (small) or high-grade dysplasia in Barrett’s oesophagus: Surgical resection, endoscopic mucosal resection, or ablation
  • Adeno (large): Neoadjuvant chemo + resection
39
Q

Define achalasia

A

A primary oesophageal motility disorder characterised by the absence of oesophageal peristalsis and impaired relaxation of the lower oesophageal sphincter in response to swallowing.

40
Q

What is the pathology of achalasia?

A

Degeneration of the myenteric plexus

41
Q

Describe the presentation of achalasia

A 
Slow progressive dysphagia (fluids ➔ solids)
Chest pain/Heartburn
Regurgitation of undigested food (late)
Weight loss
Secondary recurrent aspiration pneumonia
42
Q

How can achalasia be investigated?

A

Barium swallow
CXR
Manometry
Oesophagoscopy - exclude malignancy

43
Q

What findings may be present on CXR with achalasia?

A

Fluid filled dilated oesophagus
Right convex opacity behind right cardiac border
Small/absent gastric air bubble
Anterior displacement and bowing of trachea
Patchy alveolar opacities - aspiration pneumonia

44
Q

What findings may be present on barium swallow with achalasia?

A

Bird beak sign
Oesophageal dilatation
Incomplete LOS relaxation uncoordinated with peristalsis
Pooling/stasis of barium (late)

45
Q

How is achalasia managed?

A

Endoscopic balloon dilatation (80% success rate)
Heller’s cardiomyotomy - division of LO circular muscle
(Complications: reflux, gastro-oesophageal obstruction, oesophageal perforation)
Botulinum injections

*PPI after intervention to minimise risk of GORD

46
Q

Describe the clinical presentation of oesophageal perforation

A

Neck, chest, or epigastric pain
Dysphagia
Dyspnoea

47
Q

Describe the pathology of oesophageal perforation

A

Lack of a serosal later (contains collagen and elastin) in the oesophagus makes it more vulnerable.

48
Q

Name 3 causes of oesophageal perforation

A

Iatrogenic (80%) - esp. endoscopy and stricture dilatation
Trauma (blunt and penetrating)
Foreign body or corrosive material ingestion
Oesophageal cancer
Boerhaave syndrome (15%) - spontaneous transmural perforation of oesophagus secondary to straining or vomiting

49
Q

What is Boerhaave syndrome?

A

Spontaneous transmural perforation of oesophagus secondary to straining or vomiting.

Most commonly occurs in males aged 40-60 typically after vomiting, drinking and eating binges.

50
Q

Describe the prognosis of oesophageal perforation

A

Rare but serious medical emergency with a very high mortality rate, esp. if diagnosis is delayed (5-75%)

Infection and inflammatory reaction can quickly spread to nearby tissues and organs. Complications include pneumonia, mediastinitis, sepsis, empyema, and ARDS

51
Q

Outline the medical management of oesophageal perforation

A 
Referral to ICU
NBM + NG suction
Parenteral nutritional support
Broad-spectrum ABX
Analgesia
52
Q

Outline the surgical options for oesophageal perforation

A

Primary repair
Diversion
Oesophageal resection
Oesophageal stent

53
Q

Name 3 complications of oesophageal cancer

A

Hoarse voice
Pneumonia
Fistula
Metastases

General Surgery (23 decks)

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