Oesophageal disorders Flashcards
What is dysphagia?
Subjective sensation of difficulty in swallowing foods and/or liquid
What should you enquire about if someone presents with dysphagia?
- Type of food
- Pattern (progressive, intermittent)
- Associated features: weight loss, regurgitation, cough
- Location: Orophayngeal, Oesophageal
What are the causes of dysphagia?
- Benign stricture
- Malignant stricture (oesophageal cancer)
- Motility disorders (e.g. achalasia, presbyoesophagus)
- Eosinophilic oesophagitis (inflammatory allergic disorders): In children treat with dietary avoidances and in adults treat with steroids
- Extrinsic compression (e.g. in lung cancer)
Explain hypermotility
- e.g. diffuse oesophageal spasm
- Corkscrew appearance on Ba swallow
- Severe epigastric pain +/- dysphagia
- Often confused with angina/ MI
- Cause unclear
- Treatment: Rx smooth muscle relaxants
Explain hypo-motility
- Associated with connective tissue disease, diabetes, neuropathy
- Causes failure of LOS mechanisms leading to heartburn and reflux symptoms
Explain achalasia
- Functional loss of myenteric plexus ganglion cells in distal oesophagus and LOS
- Equal male to female ratio
- Usually presents from 3rd to 5th decade
- Cardinal feature: failure of LOS to relax
- Result: functional distal obstruction of the oesophagus
What are the symptoms of achalasia?
progressive dysphagia for solids and liquids, weight loss, chest pain, regurgitation and chest infection
What is the treatment of achalasia? (along with complications of these)
- Pharmacological treatment: Nitrates, Calcium channel blockers (don’t work well)
- Endoscopic treatment: Botulinum toxin (works but only lasts a few months) , pneumatic balloon dilatation (lasts longer than Botox)
- Radiological treatment: Pneumatic balloon dilatation
- Surgical: myotomy (only thing that will fix it)
- Complications: aspiration pneumonia and lung disease; Increased risk of squamous cell oesophageal carcinoma
What is GORD?
Due to pathological exposure to acid (and bile) in the lower oesophagus
What are the symptoms of GORD?
- Many patients do not get any symptoms
* Symptoms: heartburn, cough, water brash, sleep disturbance
What are the risk factors of GORD?
pregnancy, obesity, drugs lowering LOS pressure, smoking, alcoholism, hypomotility
Explain GORD without any abnormal anatomy
- Increased transient relaxations of the LOS
- Hypotensive LOS
- Delayed gastric emptying
- Delayed oesophageal emptying
- Decreased oesophageal acid clearance
- Decreased tissue resistance to acid/bile
Explain GORD due to hiatus hernia
- Anatomical distortion of the OG junction
- Sliding or para-oesophageal
What is the pathophysiology of GORD?
- Mucosa exposed to acid-pepsin and bile
- Increased cell loss and regenerative activity
- Erosive oesophagus
- Increased cell loss and regenerative activity
What is the treatment of GORD?
- Lifestyle measures
- Pharmacological: Alginates (Gaviscon), H2RA (Ranitidine), proton pump inhibitor (e.g. Omeprazole, Lansoprazole)
- Anti-reflux surgery: Fundoplication (full or partial wrap)
What are the complications of GORD?
- Ulceration
- Stricture
- Glandular metaplasia (Barret’s oesophagus)
- Carcinoma
What is Barrett’s oesophagus?
- Intestinal metaplasia related to prolonged exposure to acid in the distal oesophagus
- Change from squamous to mucous secreting columnar (gastric type) epithelial cells in the lower oesophagus
- Precursor to dysplasia/adenocarcinoma
What is the treatment for Barrett’s oesophagus?
- Endoscopic mucosal resection (EMR)
- Radio frequency ablation (RFA)
- Oesophagostomy (rarely)
Explain oesophageal cancer
- Western Europe/ USA: Adenocarcinoma
- Rest of world: squamous
- Usually presents late
- Tumours have commonly spread through nodes and/or the liver at presentation
- Local invasion: heart, trachea, aorta
- Metastasis: Hepatic, brain, pulmonary, bone
- Poor prognosis
What is the presentation of oesophageal cancer?
- Progressive dysphagia
- Anorexia and weight loss
- Odynophagia
- Chest pain
- Cough
- Pneumonia (trachea-oesophageal fistula)
- Vocal cord paralysis
- Haematemesis
Explain oesophageal squamous cell carcinoma
- Often large exophytic excluding tumours
- Occur in proximal and middle 1/3 of the oesophagus
- Preceded by dysplasia and carcinoma in situ
- Tobacco and alcohol significant risk factors
- Diet related (vitamin deficiency)
- Associated with achalasia (a condition in which the muscles of the lower part of the oesophagus fail to relax), caustic strictures, Plummer Vinson syndrome
Explain oesophageal adenocarcinoma
- Occurs in distal oesophagus
- Associated with Barrett’s oesophagus
- Predisposing factors: obesity male sex, middle age, Caucasian
- Associated with Barrett’s oesophagus
What is the treatment for oesophageal cancer?
- Oesophagostomy +/- adjuvant (after) or neoadjuvant (before) chemotherapy
- Limited to patients with localised disease, without co-morbid disease, usually <70 years of age
- Significant morbidity and mortality associated with oesophagostomy
- Long post-operative recovery
- Required nutritional support
- Combined chemo and radiotherapy now offer some perspective of improving long term survival in patients with locally advanced inoperable disease
- May ultimately offer non-surgical “cure”
- Symptom palliation: Endoscopic (stent, laser/ APC, PEG), chemotherapy, radiotherapy, Brachytherapy
