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GI System > Oesophageal Disorders > Flashcards

Oesophageal Disorders Flashcards

1
Q

At what vertebral level does the oesophagus begin?

A

C6 and ends at T11-12

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2
Q

What is the epithelium of the oesophagus?

A

Stratified squamous non keratinised

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3
Q

How does food move through the oesophagus?

A

Oesophageal peristalsis produced by oesophageal circular muscles and propels swallowed materials distally into the stomach

Coordinates with lower oesophageal sphincter (LOS) relaxation

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4
Q

What nerve is responsible for peristalsis and LOS relaxation?

A

Vagus nerve

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5
Q

Describe the lower oesophageal sphincter

A
  • High resting pressure in distal smooth muscle

* Striated muscle of right crus of diaphragm

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6
Q

Name two main symptoms of oesophageal disease

A

Heartburn and dysphagia

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7
Q

Describe heartburn

A
  • Retrosternal discomfort or burning
  • May be associated with: Waterbrash, cough
  • Consequence of reflux of acidic &/or bilious gastric contents into the oesophagus
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8
Q

Describe the pathology and complications of heartburn

A
  • 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
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9
Q

What is dysphagia?

A
  • Subjective sensation of difficulty in swallowing foods and/or liquids
  • Odynophagia: pain with swallowing (may accompany)
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10
Q

What do you need to ask about in the history of dysphagia?

A
  • Type of food (solid vs. liquid)
  • Pattern (progressive, intermittent)
  • Associated features (weight loss, regurgitation, cough)
  • Location - oropharyngeal or oesophageal
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11
Q

What are five causes of dysphagia?

A
  • Benign stricture
  • Malignant stricture (oesophageal cancer)
  • Motility disorders (i.e. achalasia, presbyoesophagus)
  • Eosinophilic oesophagitis
  • Extrinsic compression (i.e. in lung cancer)
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12
Q

Name three different investigations used for oesophageal disease

A
  • Endoscopy
  • Contrast radiology (barium swallow)
  • Oesophageal pH and Manometry
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13
Q

Name two different types of endoscopies and the general use

A
  • Oesophagi-gastro-duodenoscopy (OGD)
  • Upper GI endoscopy (UGIE)

Diagnostic takes 2-3mins, or used therapeutically with sedation

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14
Q

What in contrast radiology (barium swallow) used to investigate?

A

Dysphagia (but endoscopy preferred)

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15
Q

What does pH and manometry measure?

A

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)

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16
Q

What is manometry?

A

Used in investigation of dysphagia/suspected motility disorder (usually after endoscopy). It assesses sphincter tonicity, relaxation of sphincters and oesophageal motility

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17
Q

Name two mobility disorders

A

Hyper and hypomotility

18
Q

What is the presentation hypermotility?

A
  • ‘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
19
Q

What is the presentation of hypomotility?

A
  • Associated with connective tissue disease, diabetes, neuropathy
  • Causes failure of LOS mechanism leading to heartburn and reflux symptoms
20
Q

What is alchalsia?

A

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
21
Q

Describe the manometry in alchalsia?

A
  • 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
22
Q

What are four symptoms of alchalsia?

A
  • Progressive dysphagia for solids and liquids
  • Weight loss (late presentation)
  • Chest pain
  • Regurgitation and chest infection
23
Q

What is the treatment of alchalsia?

A
  • Pharmacological: nitrates, CCB
  • Endoscopic: Botox, pneumatic balloon dilation
  • Radiological: pneumatic balloon dilation
  • Surgical: Myotomy (best long-term effect)
24
Q

Name two possible complications of alchalsia

A
  • Aspiration pneumonia and lung disease

* Increased risk of squamous cell oesophageal carcinoma

25
Q

What are the symptoms of gastro-oesophageal reflux disease?

A

Many patients with frequent, pathological episodes of acid/bile reflux do not experience any symptoms

Symptoms: heartburn, cough, water brash, sleep disturbance

26
Q

What are risk factors for GORD?

A

Pregnancy, obesity, drugs lowering LOS pressure, smoking, alcoholism, hypomotility anything that increases pressure
o Men > women
o Caucasian > Black > Asian

27
Q

How is GORD diagnosed?

A

Usually on the basis of the characteristic symptoms

• Endoscopy is a poor diagnostic test as usually have no visible oesophageal abnormality

28
Q

When should an endoscopy be performed in GORD?

A

In the presence of alarm features suggestive of malignancy (i.e. dysphagia, weight loss, vomiting).

29
Q

What is the aetiology of GORD?

A

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

30
Q

What are the two types of hiatus hernias?

A
  • Sliding

* Para-oesophageal

31
Q

Describe the GORD pathophysiology

A
  • Mucosa exposed to acid-pepsin and bile
  • Increased cell loss and regenerative activity (i.e. inflammation)
  • Erosive oesophagitis
32
Q

What are the different treatment options for GORD?

A

Mainly empirical (i.e. without investigation) in absence of alarm features

  1. Lifestyle measure: weight & diet
  2. 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)

33
Q

What’s Barrett’s Oesophagus?

A
  • 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
34
Q

What is the treatment of high grade dysplasia?

A

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)

35
Q

What are the most common types of oesophageal cancer?

A

Squamous cell carcinoma and adenocarcinoma

36
Q

What are the features of squamous cell carcinoma oesophageal cancers?

A
  • Occurs in proximal and middle third of oesophagus

* Tobacco and alcohol significant risk factors

37
Q

What are the features of adenocarcinoma?

A
  • Occurs in distal oesophagus
  • Associated with Barrett’s oesophagus (progresses through dysplasia to cancer)
  • Predisposing factors: obesity, male, middle age, Caucasian
38
Q

What are the features of oesophageal cancer metastases

A

• 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

39
Q

How is oesophageal cancer diagnosed?

A

Endoscopy and biopsy

40
Q

How is oesophageal cancer staged?

A
  • CT scan: chest, abdomen and pelvis
  • Endoscopic USS (T and N staging)
  • PET scan
  • Bone scan
41
Q

What is oesophageal cancer treated?

A

Only possible cure: surgical oesophagetomy +/- adjuvant (after) or neoadjuvant (before) chemotherapy

42
Q

What are treatment options for oesophageal cancer?

A
  • Endoscopic (stent, laser/APC, PEG)
  • Chemotherapy
  • Radiotherapy
  • Brachytherapy (radiotherapy where a sealed radiation source is placed inside or next to the area requiring treatment)

GI System (28 decks)

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