Oesophageal disorders Flashcards
Define dyspepsia
Upper GI symptoms typically present for 4+ weeks, including: upper abdominal pain/discomfort, heartburn, acid reflux, NaV
Define GORD
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.
What is ‘proven GORD’?
Endoscopically-determined reflux disease
How does GORD typically present?
Oesophageal symptoms: Heartburn (25%) - burning retrosternal discomfort Acid brash - acid or bile regurgitation Water brash - excessive salivation Odynophagia - pain on swallowing
Name 3 atypical clinical features of GORD
Extra-oesophageal symptoms (atypical): Chest pain, epigastric pain, bloating Nocturnal asthma Chronic cough Laryngitis (Cherry-Donner syndrome) Sinusitis
Name 5 risk factors for GORD
Lifestyle: obesity, trigger foods, smoking, alcohol, coffee, stress
Drugs: CCBs, anticholinergics, theophylline, BDZs, nitrates
Pregnancy
What complications can occur due to GORD?
Oesophagitis Ulcers Benign strictures Iron-deficiency anaemia Barrett's oesophagus ➔ Oesophageal adenocarcinoma
What is Barrett’s oesophagus?
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
Name 3 causes of GORD
Lower oesophageal sphincter problems
Delayed gastric emptying e.g. gastric outlet obstruction
Hiatus hernia
Obesity/pregnancy
What may be seen on histology of GORD?
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
What is used to grade Barrett’s oesophagus?
Prague C and M endoscopic grading system
How is Barrett’s oesophagus treated?
High-grade dysplasia: Surgical resection, endoscopic mucosal resection, or ablation
Name 3 differential diagnoses for GORD
Oesophagitis from: Corrosives NSAIDs Herpes Candida
Peptic ulcer disease
Cancer
Cardiac cause e.g. MI
Describe the pathology of strictures in GORD
Chronic fibrosis and epithelial destruction
Eventual shortening and narrowing of the lower oesophagus ➔ potential fixation and susceptibility to further reflux
What are the annual and lifetime recurrence risks of GORD? Which patient group is more likely to relapse?
Annual recurrence risk of untreated GORD: 50%
Lifetime risk of recurrence: 80%
More likely to relapse in people with severe oesophagitis
Name 4 indications for investigations for GORD
Age >45 Symptoms last >4wks Persistent vomiting GI bleeding or iron deficiency Palpable mass Dysphagia Weight loss Failed medical treatment
Why could OGD be preformed for any presentation of GORD in over 45s?
Exclude oesophageal malignancy
How is GORD investigated?
Endoscopy
24h continuous pH monitoring +- manometry
Barium swallow - may show hiatus hernia
Describe a positive pH investigation result for GORD
GORD symptoms correspond with pH peaks
What physiological features protect against GORD?
Lower oesophageal sphincter
Fundus located posteriorly and superiorly
Crus of diaphragm
Expansion of stomach
Outline the lifestyle management of GORD
Smoking cessation Weight loss Decrease alcohol consumption Small regular meals Avoid trigger foods Sleep with head of bed raised
Outline the initial medical management of GORD
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
How should refractory or recurrent GORD be medically managed?
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
What are the surgical indications for GORD?
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
Outline the surgical management of GORD
Laparoscopic ‘Nissen’ fundoplication: wrapping the fundus around the lower oesophagus
Name and differentiate between the types of hiatus hernias
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.
Outline the medical management of hiatus hernias
Weight loss
Symptomatic relief with H2RAs
PPIs
Metoclopramide - promote oesophageal and gastric emptying
What investigations are used for suspected hiatus hernia?
Barium swallow*
Upper GI endoscopy - exclude oesophageal mucosal pathology
CT thorax - acute presentation
Define hiatus hernia
Presence of part or all of the stomach within the thoracic cavity. Usually by protrusion through the oesophageal hiatus in the diaphragm.
Outline the surgical management of hiatus hernias
Prophylactic surgical hernia repair - avoid strangulation
Gastropexy: reduction and fixation of stomach to oesophagus
Nissen fundoplication: if GORD symptoms predominate
Name 3 types of oesophageal tumours
Adenocarcinoma (commonest)
Squamous carcinoma
Lipoma and GI stromal tumours
Rhabdomyo(sarco)ma
Differentiate between the pathological features of oesophageal adenocarcinoma and squamous carcinoma
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.
Describe the presentation of oesophageal tumours
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)
Name 5 risk factors for oesophageal tumours
Obesity
Smoking, alcohol, diet - squamous carcinoma
Age >45 - new dysphagia is tumour till proven otherwise
Barrett’s oesophagus
Alchalasia
Radiotherapy
How are suspected oesophageal tumours investigated?
Flexible oesophagoscopy and biopsy
Barium swallow if failed intubation or suspected post-cricoid carcinoma (often missed by endoscopy)
What staging investigations are done for oesophageal tumours?
Endoluminal USS - assess depth of local invasion
CT - local invasion, lymph involvement, liver
PET - disseminated disease
What are the commonest patters of oesophageal cancer metastases?
Lymph nodes Lung Liver Bones Adrenal glands Brain
Outline the management of oesophageal tumours
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
Define achalasia
A primary oesophageal motility disorder characterised by the absence of oesophageal peristalsis and impaired relaxation of the lower oesophageal sphincter in response to swallowing.
What is the pathology of achalasia?
Degeneration of the myenteric plexus
Describe the presentation of achalasia
Slow progressive dysphagia (fluids ➔ solids) Chest pain/Heartburn Regurgitation of undigested food (late) Weight loss Secondary recurrent aspiration pneumonia
How can achalasia be investigated?
Barium swallow
CXR
Manometry
Oesophagoscopy - exclude malignancy
What findings may be present on CXR with achalasia?
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
What findings may be present on barium swallow with achalasia?
Bird beak sign
Oesophageal dilatation
Incomplete LOS relaxation uncoordinated with peristalsis
Pooling/stasis of barium (late)
How is achalasia managed?
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
Describe the clinical presentation of oesophageal perforation
Neck, chest, or epigastric pain
Dysphagia
Dyspnoea
Describe the pathology of oesophageal perforation
Lack of a serosal later (contains collagen and elastin) in the oesophagus makes it more vulnerable.
Name 3 causes of oesophageal perforation
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
What is Boerhaave syndrome?
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.
Describe the prognosis of oesophageal perforation
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
Outline the medical management of oesophageal perforation
Referral to ICU NBM + NG suction Parenteral nutritional support Broad-spectrum ABX Analgesia
Outline the surgical options for oesophageal perforation
Primary repair
Diversion
Oesophageal resection
Oesophageal stent
Name 3 complications of oesophageal cancer
Hoarse voice
Pneumonia
Fistula
Metastases
