Oesophageal Disorders Flashcards
Oesophageal peristalsis produced by
Oesophageal circular muscles
Oesophageal peristalsis coordinates with
Lower oesophageal sphincter (LOS) relaxation
Contraction in the oesophageal body
Peristalsis
Peristalsis and LOS relaxation mediated by
Vagus nerve
Symptoms of oesophageal disease
Heartburn
Dysphagia
Heartburn
Retrosternal discomfort or burning sensation
consequence of reflux of acidic and/or bilious gastric contents into the oesophagus
A degree of reflux occurs physiologically (eg after swallowing)
Certain drugs/foods, (e.g. alcohol, nicotine, dietary xanthines) can reduce the LOS pressure resulting in increased reflux / heartburn
Persistent reflux and heartburn leads to GORD
GORD
Gastro-oesophageal reflux disease
Due to pathological acid (and bile) exposure in lower oesophagus or abnormal anatomy (eg hiatus hernia)
Dysphagia
Difficulty swallowing foods and/or liquids
Pain swallowing foods
Odynophagia
Causes of oesophageal dysphagia
Benign stricture
Malignant stricture (oesophageal cancer)
Motility disorders (eg achalasia, presbyoesophagus)
Eosinophilic oesophagitis
Extrinsic compression (eg in lung cancer)
Oesophageal disease investigations
Endoscopy Contrast radiography (barium swallow) Oesophageal pH and manometry
Motility disorders
Hypermotility
Hypermobility
Achalasia
Hypermotility
Corkscrew appearance on barium swallow
Severe, episodic chest pain +/- dysphagia
Cause unclear (idiopathic)
Manometry shows exaggerated, uncoordinated, hypertonic contractions
Hypomotility
Associated with connective tissue disease, diabetes, neuropathy
Causes failure of LOS mechanism leading to heartburn and reflux symptoms
Achalasia pathology
Degeneration of inhibitory neurons (ganglion cells) in the myenteric plexus in the oesophagus
Often surrounded by lymphocytes- so an inflammatory aetiology is suspected
Main feature and result of achalasia
Failure of LOS to relax - causes functional distal obstruction of oesophagus
Symptoms of achalasia
Progressive dysphagia for solids and liquids
Weight loss
Chest pain
Regurgitation and chest infection
Pharmacological treatment of achalasia
Nitrates
Calcium channel blockers
Endoscopic treatment of achalasia
Botulinum Toxin
Pneumatic balloon dilation
Radiological treatment of achalasia
Pneumatic balloon dilation
Surgical treatment of achalasia
Myotomy
Complications of achalasia
Aspiration pneumonia and lung disease
Increased risk of squamous cell oesophageal carcinoma
Types of hiatus hernia
Fundus of stomach moves proximally through the diaphragmatic hiatus
Sliding - still one tube
Para-oesophageal - with a wee sac sticking out to the side
GORD complications
Ulceration
Stricture
Carcinoma
Glandular metaplasia (Barrett’s oesophagus)
Barrett’s oesophagus
Intestinal metaplasia related to prolonged acid exposure in distal oesophagus
Change from squamous to mucin-secreting columnar (ie gastric type) epithelial cells in lower oesophagus
Precursor to dysplasia/ adenocarcinoma
Barrett’s oesophagus treatment
Endoscopic Mucosal Resection (EMR)
Radio-Frequency Ablation (RFA)
Oesophagectomy rarely
GORD treatment
Mainly empirical in absence of alarm features
Empirical treatment of GORD
Without investigation
Lifestyle measures
Pharmacological
GORD treatment for refractory disease/symptoms following investigation
Anti-reflux surgery
Oesophageal cancer types
Benign tumours rare
Squamous cell carcinoma
Adenocarcinoma
Pesentation of oesophageal cancer
Progressive dysphagia Anorexia and Weight loss Odynophagia Chest pain Cough Pneumonia (tracheo-oesophageal fistula) Vocal cord paralysis Haematemesis
Adenocarcinoma located
Distal oesophagus
Squamous cell carcinoma located
Proximal and middle third of oesophagus
Adenocarcinoma associated with
Barrett’s oesophagus
Squamous cell carcinoma associated with
Achalasia
Caustic strictures
Plummer-Vinson syndrome
Risk factors for adenocarcinoma
Obesity
Male
Middle aged
Caucasian
Risk factors for squamous cell
Tobacco
Alcohol
Squamous cell carcinoma preceded by
Dysplasia
Forms large, exophytic occluding tumours
Oesophagus lacks a _____ allowing tumour invasion to adjacent structures to occur more easily
Serosal layer
Tumours at presentation
Late
Normally regional node/liver metastases
Oesophageal metastases
Hepatic
Brain
Pulmonary
Bone
Oesophageal cancer investigation
Diagnosis by endoscopy & biopsy
Staging:
CT Scan
Endoscopic ultrasound
PET Scan
Bone ScanOesophageal cancer treatment
Only potential cure is surgical oesophagectomy +/- adjuvant (after) or neoadjuvant (before) chemotherapy
Palliative care
Eosinophilic oesophagitis
Chronic immune-/allergen-mediated condition Eosinophilic infiltration of the oesophageal epithelium
in the absence of secondary causes of local or systemic eosinophilia
Presentation of eosinophilic oesophagitis
Dysphagia and food bolus obstruction
Treatment of eosinophilic oesophagitis
Topical/swallowed corticosteroids
Dietary elimination
Endoscopic dilatation
