Oesophageal Disorders Flashcards
What is heartburn and what is it caused by?
Retrosternal discomfort or burning caused by reflux of acid and/or bilious contents into the oesophagus
What first line and second line tests should be conducted in cases of dysphagia?
First an upper GI endoscopy, or a barium swallow in cases of severe dysphagia to exclude a pharyngeal pouch or post-cricoid web
Secondly, oesophageal manometry or pH studies can be conducted
How would hypermotility present on a barium swallow and in manometry?
Barium swallow- oesophagus would have a “cork-screw” appearance
Manometry- shows exaggerated, uncoordinated, hypertonic contractions
What are the symptoms of hypermotility?
Severe, episodic chest pain with or without dysphagia
What are the causes of hypermotility and hypomotility?
Hypermotility- idiopathic
Hypomotility- associated with connective tissue disease, diabetes and neuropathy
What are the symptoms of hypomotility?
Heartburn and reflux symptoms
Describe the pathology of achalasia
Degeneration of inhibitory neurons in the myenteric plexus in the distal oesophagus and LOS
What is the cardinal feature of achalasia, and what effect does this have on the oesophagus?
Cardinal feature- failure of LOS to relax
Effect- functional distal obstruction of oesophagus
What are the symptoms of achalasia?
Progressive dysphagia for solids and liquids
Weight loss
Regurgitation and chest infection
Chest pain (30%)
What abnormalities would be found during manometry in cases of achalasia?
Failure of the LOS to relax after swallowing
Absence of peristaltic contractions in the lower oesophagus
High pressure in the LOS at rest (usually above 45mmHg(normal being 10mmHg))
First two required to make diagnosis
What are the pharmacological treatments of achalasia?
Nitrates and calcium channel blockers
What are the radiological, endoscopic and surgical treatments of achalasia?
Radiological- Pneumatic balloon dilatation
Endoscopic- Botulinum Toxin pneumatic balloon dilatation
Surgical- myotomy
What are the symptoms of gastro-oesophageal reflux disease?
Heartburn
Water brash
Cough
Sleep disturbance
What are the risk factors for GORD?
Pregnancy Smoking Drugs lowering LOS pressure Obesity Alcoholism Hypomotility Men more at risk than women Caucasian > black > asian
Should endoscopy be performed in cases of GORD?
Poor diagnostic test as most patients with reflux symptoms have no visible evidence
Must be performed if ALARM features are present
What are the two types of hiatus hernia?
Sliding and para-oesophageal
What are the risk factors for hiatus hernias?
Ageing and obesity
Describe the pathophysiology of GORD
Mucosa is exposed to acid-pepsin and bile causing increased cell loss and regenerative activity, causing erosive oesophagitis
What are the possible complications of GORD?
Ulceration
Stricture
Glandular metaplasia (Barrett’s oesophagus)
Carcinoma
What is Barrett’s oesophagus?
Intestinal metaplasia caused by prolonged acid exposure in distal oesophagus causes change from squamous to mucous-secreting columnar epithelial cells
The condition is a precursor to dysplasia/adenocarcinoma
What is the cancer rate of Barrett’s Oeosophagus?
~0.3% per year
Describe the treatment of GORD
Lifestyle measures
Pharmacological:
-Alginates (gaviscon)
-H2RA (Ranitidine)
-Proton pump inhibitor (Omeprazole, lansoprazole)
Anti-reflux surgery may be necessary for refractory disease following investigation, this can be a full or partial wrap fundoplication
Where in the world is adenocarcinoma and squamous cell carcinoma of the oeosphagus more common?
Western Europe and USA- adenocarcinoma more common
Rest of the world- squamous cell carcinoma more common
What are the symptoms of oesophageal cancer?
Progressive dysphagia Anorexia and weight loss Odynophagia Chest pain Cough Pneumonia Vocal cord paralysis Haematemesis
Where in the oesophagus is adenocarcinoma and squamous cell carcinoma more common?
Adenocarcinoma- distal oesophagus
Squamous cell carcinoma- Proximal and middle oesophagus
What are the risk factors for squamous cell carcinoma of the oesophagus?
Achalasia
Caustic strictures
Plummer-Vinson syndrome
Possibly diet related (vitamin deficiency)
What are the risk factors for adenocarcinoma of the oesophagus?
Obesity Male sex Middle aged Caucasian Barrett's Oesophagus
Why is spread of oesophageal cancer relatively easy?
There is no serosal lining in the oesophagus so local invasion is common
What are the common metastases of oesophageal cancer?
Hepatic, pulmonary, brain and bone
What investigations are used for the diagnosis and staging of oesophageal cancer?
Diagnosis- endoscopy with biopsy
Staging- CT, endoscopic ultrasound, PET scan, bone scan
Describe the TNM staging of oesophageal cancer
T1- Tumour invades lamina propria (T1a) or submucosa (T1b)
T2- Tumour invades muscularis propria
T3- Tumour invades adventitia
T4- Tumour invades adjacent structures
N1- regional lymph node metastasis
M1- Distant metastasis
What is the only potential cure for oesophageal cancer, and what are its limits?
Surgical oesophagectomy with or without adjuvant or neoadjuvant chemotherapy
Limited to patients with localised disease, no co-morbidities and usually <70 years of age
What is the mortality rate of an oesophagectomy?
10%
What palliative measures can be put in place in cases of oesophageal cancer?
Combined chemo and radiotherapy may add some time to patients life but won’t cure
Endoscopy can be used to insert a stent to prevent dysphagia, PEG insertion if oral intake is impossible, or for laser treatment
What is eosinophilic oesophagitis?
A chronic immune/allergen mediated condition characterised by symptoms of oeosphageal dysfunction and eosinophilic infiltration of the oesophageal epithelium
Who is most at risk of eosinophilic oesophagitis?
Males > females
More common in children and young adults
How does eosinophilic oesophagitis present?
Dysphagia and food bolus obstruction
How is eosinophilic oesophagitis treated?
Topical/swallowed corticosteroids
Dietary elimination
Endoscopic dilatation
