Oesophageal Disorders Flashcards
At what vertebral level does the oesophagus begin?
C6 and ends at T11-12
What is the epithelium of the oesophagus?
Stratified squamous non keratinised
How does food move through the oesophagus?
Oesophageal peristalsis produced by oesophageal circular muscles and propels swallowed materials distally into the stomach
Coordinates with lower oesophageal sphincter (LOS) relaxation
What nerve is responsible for peristalsis and LOS relaxation?
Vagus nerve
Describe the lower oesophageal sphincter
- High resting pressure in distal smooth muscle
* Striated muscle of right crus of diaphragm
Name two main symptoms of oesophageal disease
Heartburn and dysphagia
Describe heartburn
- Retrosternal discomfort or burning
- May be associated with: Waterbrash, cough
- Consequence of reflux of acidic &/or bilious gastric contents into the oesophagus
Describe the pathology and complications of heartburn
- Reflux occurs physiologically (i.e. after swallowing)
- Certain drugs/oods (i.e. alcohol, nicotine, dietary xanthines) can reduce the LOS pressure resulting in increased reflux/heartburn
- Persistent reflux and heartburn leads to gastro-oesophageal reflux disease (GORD) which can in turn cause long-term complications
What is dysphagia?
- Subjective sensation of difficulty in swallowing foods and/or liquids
- Odynophagia: pain with swallowing (may accompany)
What do you need to ask about in the history of dysphagia?
- Type of food (solid vs. liquid)
- Pattern (progressive, intermittent)
- Associated features (weight loss, regurgitation, cough)
- Location - oropharyngeal or oesophageal
What are five causes of dysphagia?
- Benign stricture
- Malignant stricture (oesophageal cancer)
- Motility disorders (i.e. achalasia, presbyoesophagus)
- Eosinophilic oesophagitis
- Extrinsic compression (i.e. in lung cancer)
Name three different investigations used for oesophageal disease
- Endoscopy
- Contrast radiology (barium swallow)
- Oesophageal pH and Manometry
Name two different types of endoscopies and the general use
- Oesophagi-gastro-duodenoscopy (OGD)
- Upper GI endoscopy (UGIE)
Diagnostic takes 2-3mins, or used therapeutically with sedation
What in contrast radiology (barium swallow) used to investigate?
Dysphagia (but endoscopy preferred)
What does pH and manometry measure?
pH in reflux disease and pressure waves in oesophagus (peristalsis)
Using nasogastric catheter containing sensors placed in oesophagus with probes at level of both sphincters (UOS and LOS)
What is manometry?
Used in investigation of dysphagia/suspected motility disorder (usually after endoscopy). It assesses sphincter tonicity, relaxation of sphincters and oesophageal motility
Name two mobility disorders
Hyper and hypomotility
What is the presentation hypermotility?
- ‘corkscrew appearance’ on Ba swallow
- Severe, episodic chest pain +/- dysphagia
- Often confused with angina/MI
- Idiopathic
- Manometry shows exaggerated, uncoordinated, hypertonic contractions
- Treatment: smooth muscle relaxants
What is the presentation of hypomotility?
- Associated with connective tissue disease, diabetes, neuropathy
- Causes failure of LOS mechanism leading to heartburn and reflux symptoms
What is alchalsia?
Functional loss of myenteric plexus ganglion cells in distal oesophagus and LOS due to degeneration of inhibitory neurons
- Cardinal feature: failure of LOS to relax
- Result: functional distal obstruction of oesophagus
Describe the manometry in alchalsia?
- High pressure in the LOS at rest
- Failure of the LOS to relax after swallowing
- An absence of useful (peristaltic) contraction in the lower oesophagus
What are four symptoms of alchalsia?
- Progressive dysphagia for solids and liquids
- Weight loss (late presentation)
- Chest pain
- Regurgitation and chest infection
What is the treatment of alchalsia?
- Pharmacological: nitrates, CCB
- Endoscopic: Botox, pneumatic balloon dilation
- Radiological: pneumatic balloon dilation
- Surgical: Myotomy (best long-term effect)
Name two possible complications of alchalsia
- Aspiration pneumonia and lung disease
* Increased risk of squamous cell oesophageal carcinoma
What are the symptoms of gastro-oesophageal reflux disease?
Many patients with frequent, pathological episodes of acid/bile reflux do not experience any symptoms
Symptoms: heartburn, cough, water brash, sleep disturbance
What are risk factors for GORD?
Pregnancy, obesity, drugs lowering LOS pressure, smoking, alcoholism, hypomotility anything that increases pressure
o Men > women
o Caucasian > Black > Asian
How is GORD diagnosed?
Usually on the basis of the characteristic symptoms
• Endoscopy is a poor diagnostic test as usually have no visible oesophageal abnormality
When should an endoscopy be performed in GORD?
In the presence of alarm features suggestive of malignancy (i.e. dysphagia, weight loss, vomiting).
What is the aetiology of GORD?
With abnormal anatomy
• Increase transient relaxations of the LOS
• Hypotensive LOS
• Delayed gastric emptying
• Delayed oesophageal emptying
• Decreased oesophageal acid clearance
• Decreased tissue resistance to acid/bile
What are the two types of hiatus hernias?
- Sliding
* Para-oesophageal
Describe the GORD pathophysiology
- Mucosa exposed to acid-pepsin and bile
- Increased cell loss and regenerative activity (i.e. inflammation)
- Erosive oesophagitis
What are the different treatment options for GORD?
Mainly empirical (i.e. without investigation) in absence of alarm features
- Lifestyle measure: weight & diet
- Pharmacological:
a. alginates (gaviscon)
b. H2RA (ranitidine)
c. Proton pump inhibitor (i.e. omeprazole)
For refractory disease/symptoms following investigation
3. Anti-reflux surgery (fundoplication – full / partial wrap)
What’s Barrett’s Oesophagus?
- Intestinal metaplasia related to prolonged acid exposure in distal oesophagus
- Change from squamous to mucin-secreting columnar (i.e. gastric type) epithelial cells in lower oesophagus
- Precursor to dysplasia/adenocarcinoma
What is the treatment of high grade dysplasia?
Risk of developing oesophageal cancers
To prevent cancer:
• Endoscopic mucosal resection (EMR)
• Radiorefquency ablation (RFA) of epithelium to allow new cells to grow
• Oesophagectomy (rare)
What are the most common types of oesophageal cancer?
Squamous cell carcinoma and adenocarcinoma
What are the features of squamous cell carcinoma oesophageal cancers?
- Occurs in proximal and middle third of oesophagus
* Tobacco and alcohol significant risk factors
What are the features of adenocarcinoma?
- Occurs in distal oesophagus
- Associated with Barrett’s oesophagus (progresses through dysplasia to cancer)
- Predisposing factors: obesity, male, middle age, Caucasian
What are the features of oesophageal cancer metastases
• Tumours have commonly spread to regional nodes and/or liver at presentation
• No peritoneal (serosal) lining in mediastinum
o Due to lack of serosal layer, tumour invasion into adjacent structures easier
o Lamina propria has a rich lymphatic supply, so lymph node involvement occurs early in oes. Tumours
• Metastases – hepatic, brain, pulmonary, bone
How is oesophageal cancer diagnosed?
Endoscopy and biopsy
How is oesophageal cancer staged?
- CT scan: chest, abdomen and pelvis
- Endoscopic USS (T and N staging)
- PET scan
- Bone scan
What is oesophageal cancer treated?
Only possible cure: surgical oesophagetomy +/- adjuvant (after) or neoadjuvant (before) chemotherapy
What are treatment options for oesophageal cancer?
- Endoscopic (stent, laser/APC, PEG)
- Chemotherapy
- Radiotherapy
- Brachytherapy (radiotherapy where a sealed radiation source is placed inside or next to the area requiring treatment)
