Oesophageal disorders

Question 1

What is dysphagia?

Answer 1

Subjective sensation of difficulty in swallowing foods and/or liquid

Question 2

What should you enquire about if someone presents with dysphagia?

Answer 2

• Type of food
  
  • Pattern (progressive, intermittent)
  • Associated features: weight loss, regurgitation, cough
    
    • Location: Orophayngeal, Oesophageal

Question 3

What are the causes of dysphagia?

Answer 3

• 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)

Question 4

Explain hypermotility

Answer 4

• 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

Question 5

Explain hypo-motility

Answer 5

• Associated with connective tissue disease, diabetes, neuropathy
  
  • Causes failure of LOS mechanisms leading to heartburn and reflux symptoms

Question 6

Explain achalasia

Answer 6

• 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

Question 7

What are the symptoms of achalasia?

Answer 7

progressive dysphagia for solids and liquids, weight loss, chest pain, regurgitation and chest infection

Question 8

What is the treatment of achalasia? (along with complications of these)

Answer 8

• 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

Question 9

What is GORD?

Answer 9

Due to pathological exposure to acid (and bile) in the lower oesophagus

Question 10

What are the symptoms of GORD?

Answer 10

• Many patients do not get any symptoms

* Symptoms: heartburn, cough, water brash, sleep disturbance

Question 11

What are the risk factors of GORD?

Answer 11

pregnancy, obesity, drugs lowering LOS pressure, smoking, alcoholism, hypomotility

Question 12

Explain GORD without any abnormal anatomy

Answer 12

• Increased transient relaxations of the LOS
  
  • Hypotensive LOS
  • Delayed gastric emptying
  • Delayed oesophageal emptying
  • Decreased oesophageal acid clearance
  • Decreased tissue resistance to acid/bile

Question 13

Explain GORD due to hiatus hernia

Answer 13

• Anatomical distortion of the OG junction

- Sliding or para-oesophageal

Question 14

What is the pathophysiology of GORD?

Answer 14

• Mucosa exposed to acid-pepsin and bile
  
  • Increased cell loss and regenerative activity
    
    • Erosive oesophagus

Question 15

What is the treatment of GORD?

Answer 15

• Lifestyle measures
  
  • Pharmacological: Alginates (Gaviscon), H2RA (Ranitidine), proton pump inhibitor (e.g. Omeprazole, Lansoprazole)
  • Anti-reflux surgery: Fundoplication (full or partial wrap)

Question 16

What are the complications of GORD?

Answer 16

• Ulceration
  
  • Stricture
  • Glandular metaplasia (Barret’s oesophagus)
  • Carcinoma

Question 17

What is Barrett’s oesophagus?

Answer 17

• 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

Question 18

What is the treatment for Barrett’s oesophagus?

Answer 18

• Endoscopic mucosal resection (EMR)
  
  • Radio frequency ablation (RFA)
  • Oesophagostomy (rarely)

Question 19

Explain oesophageal cancer

Answer 19

• 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

Question 20

What is the presentation of oesophageal cancer?

Answer 20

• Progressive dysphagia
  
  • Anorexia and weight loss
  • Odynophagia
  • Chest pain
  • Cough
  • Pneumonia (trachea-oesophageal fistula)
  • Vocal cord paralysis
  • Haematemesis

Question 21

Explain oesophageal squamous cell carcinoma

Answer 21

• 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

Question 22

Explain oesophageal adenocarcinoma

Answer 22

• Occurs in distal oesophagus
  
  • Associated with Barrett’s oesophagus
    
    • Predisposing factors: obesity male sex, middle age, Caucasian

Question 23

What is the treatment for oesophageal cancer?

Answer 23

• 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