Oesophageal Disorders Flashcards
Where does the oesophagus begin and end?
Begins at lower level of cricoid cartilage (C6), terminates at T11-12 where it enters the stomach
What is its length in cm? How much of that is striated v smooth muscle?
approx 25cm
Upper 3-4cm = striated, rest is smooth
What is the epithelial lining of the oesophagus?
Stratified squmaous
Describe function of the oesophagus and how it acheives this
Transport food/liquid from mouth to stomach; oesophageal peristalsis produced by oesophageal circular muscles + propels swallowed materials distally into the stomach; co-ordinates with LOS relaxation
Contraction in oesophageal body (peristalsis) and relaxation of the LOS is mediated via what nerve?
Vagus
2 key symptoms in oesophageal disease?
- Heartburn*
- Dysphagia*
What is heartburn described as?
Retrosternal discomfort or burning
What can heartburn be associated with?
Waterbrash
Cough
What is heartburn a consequence of? Is it normal to experience it?
Heartburn is a consequence of reflux of acidic and/or bilious gastric contents into the oesophagus
Yes - almost everyone expeeriences it occasionally
What do certain drugs/foods do to LOS to cause increased reflux/heartburn? Give examples of what drugs
Reduce LOS pressure
e.g. alcohol, nicotine, dietary xanthines
What does persistent reflux and heartburn lead to?
Gastro-oesophageal reflux disease (GORD) - can cause long-term complications
What is dysphagia described as?
Subjective sensation of difficulty in swallowing food and/or liquids
What is odynophagia?
PAIN with swalling (may accompany dysphagia)
What 3 things should be inquired about when asking about dysphagia?
- Type of food (solid v liquid)
- Pattern (progressive, intermittent)
- Associated features (weight loss, regurgitation, cough)
What are the 2 locations for dysphagia?
Oropharyngeal or oesophageal
Give 5 causes of oesophageal dysphagia
- Benign stricture
- Malignant stricture
- Motility disorders (e.g. achalasia, presbyoesophagus)
- Eosinophilic oesophagitis
- Extrinsic compression (e.g. in lung cancer)
3 investigations which can be done for oesophageal disease?
Endoscopy (OGD or UGIE) Contrast radiology (barium swallow)
Oesophageal pH; manometry (investigates refractory heartburn/reflux; assesses sphincter tonicity, relaxation of sphincters and oesophageal motility)
2 ends of spectrum for motility disorders?
Hypermotility (e.g. diffuse oesophageal spasm)
Hypomotility (associated w connective tissue disease, diabetes, neuropathy)
How would a hypermotility disorder appear on Ba swallow?
Corkscrew appearance
What symptoms are associated with hypermotility? What does this mean it can be confused with?
Severe, episodic chest pain +/- dysphagia
Can be confused with angina/MI
What would the manometry for hypermotility show?
Exaggerated, uncoordinated, hypertonic contractions
Cause and Rx for hypermotility?
Cause unclear (idiopathic)
Rx smooth muscle relaxants
What does hypomotility cause? Leading to what?
Causes failure of LOS mechanism leading to heartburn and reflux symptoms
What is achalasia? (functional loss of…)
Functional loss of myenteric plexus ganglion cells in distal oesophagus and LOS
Incidence of achalasia?
1-2/100,000
Usually 3rd-5th decade
Cardinal feature of achalasia? Resulting in what?
Failure of LOS to relax resulting in functional distal obstruction of oesophagus
4 symptoms of achalasia
Progressive dysphagia for solids and liquids
Weight loss
Chest pain (30%)
Regurgitation and chest infection
4 modalities of treatment for achalasia are pharmacological, endoscopic, radiological and surgical - give examples for each
Pharmacological - nitrates, CCBs
Endoscopic - botulinum toxin, pneumatic balloon dilatation
Radiological - pneumatic balloon dilatation
Surgical - myotomy
2 possible complications of achalasia?
Aspiration pneumonia and lung disease
Increased risk of SC oesophageal carcinoma
Do patients with frequent, pathological episodes of acid/bile reflux always experience symptoms?
NO! Many do not
4 symptoms of GORD
Heartburn
Cough
Water brash
Sleep disturbance
Give risk factors for GORD
Pregnancy
Obesity
Drugs lowering LOS pressure
Smoking
Alcoholism
Hypomotility
What can the typical reflux syndrome be diagnosed on the basis of?
The characteristic symptoms, without diagnostic testing
Is endoscopy a good diagnostic test for GORD? When would it be used?
No, it is a poor diagnostic test - most patients with reflux symptoms have no visible evidence of oesophageal abnormality when endoscopy is performed
Endoscopy must be performed in presence of ‘alarm’ features suggestive of malignancy (e.g. dysphagia, weight loss, vomiting)
What are the possible aetiologies of GORD without abnormal anatomy?
Increased transient relaxations of the LOS; hypotensive LOS; delayed gastric emptying; delayed oesophageal emptying; decreased oesophageal acid clearance; decreased tissue resistance to acid/bile
What is the aetiology of GORD due to hiatus hernia?
Anatomical distortion of the OG junction
What happens in a hiatus hernia?
Fundus of stomach moves proximally through the diaphragmatic hiatus
2 main types of hiatus hernia?
Sliding - stomach and section of the esophagus that joins the stomach slide up into the chest through the hiatus (more common)
Para-oesophageal - OG junction remains where it belongs, but part of the stomach is squeezed up into the chest beside the esophagus (more concerning - needs surgery when causing symptoms)
What 2 factors predispose hiatus hernia?
Obesity
Age
What happens during GORD at the mucosal level and what does it lead to?
Mucosa exposed to acid-pepsin and bile
Increased cell loss and regenerative activity (i.e. inflammation)
Leads to erosive oesophagitis
4 complications of GORD?
Ulceration (5%)
Stricture (8-15%)
Glandular metaplasia (Barrett’s oesophagus)
Carcinoma
What is Barrett’s oesophagus?
Intestinal metaplasia related to prolonged acid exposure in distal oesophagus
What do the squamous cells in the lower oesophagus change to in Barrett’s?
Mucin-secreting columnar (i.e. gastric type) epithelial cells
What is Barrett’s a precursor to?
Dysplasia/adenocarcinoma
(cancer rate ~0.3% per year)
Is Barrett’s more common in men or women?
Men
Overall risk of progression from Barrett’s is 0.3%, but patients with high grade dysplasia the risk is 6%, so how is this treated? (3 ways)
- Endoscopic Mucosal Resection (EMR)
- Radio-Frequency Ablation (RFA)
- Oesophagectomy (rarely as mortality ~10%)
GORD is usually treated empirically (w/o investigation) by lifestyle measures and pharmacological measures - what are 3 drugs used?
- Alginates (Gaviscon)
- H2RA (Ranitidine)
- Proton Pump Inhibitor (e.g. Omeprazole, Lansoprazole)
What is the treatment for GORD for refractory disease/symptoms following investigation?
Anti-reflux surgery (fundoplication - full/partial wrap)
What are the 2 types of oesophageal cancer?
- Squamous Cell Carcinoma*
- Adenocarcinoma*
(benign tumours rare)
Who is oesophageal cancer more common in men v women? Which type is most common in western europe/USA?
Men:Women 3:1
Adenocarcinoma more common europe and USA; rest of the world - squamous much more common
Presentation of oesophageal cancer? (2 key features then others)
Progressive dysphagia (90%)
Anorexia and weight loss (75%)
Odynophagia
Chest pain
Cough
Pneumonia
Vocal cord paralysis
Haematemesis
Which type of oesophageal cancer occurs in proximal and middle thirds of oesophagus?
Squamous cell carcinoma
What is SCC oesophagus preceded by?
Dysplasia and carcinoma in situ
2 significant risk factors for SCC oesophagus? (common ones)
Tobacco
Alcohol
3 conditions SCC oesophagus is associated with?
Achalasia
Caustic strictures
Plummer-Vinson syndrome
Which type of oesophageal cancer occurs in distal oesophagus?
Adenocarcinoma
What condition is adenocarcinoma oesophagus associated with?
Barretts oesophagus
4 predisposing factors for adencarcinoma oesophagus?
Obesity
Male sex
Middle age
Caucasian
Does oesophageal cancer usually present early or late?
LATE - tumours have commonly spread to regional nodes and/or liver at presentation
What often limits oesophageal cancer surgery?
Local invasion to heart, trachea, aorta (due to no peritoneal (serosal) lining in mediastinum meaning invasion is easier)
Where does oesophageal cancermetastasise to?
Liver, brain, lungs, bone
Prognosis for oesophageal cancer?
Poor; 5 yr survival <10%
What investigations are used to diagnose oesophageal cancer?
Endoscopy and biopsy
What 4 modalities are used to stage oesophageal cancer?
CT scan
Endoscopic ultrasound
PET scan
Bone scan
How is oesophageal cancer treated?
Surgical oesophagectomy +/- adjuvant or neoadjuvant chemo = only potential cure
(limited to patients with localised disease, without co-morbid disease, usually <70yrs; long post-op recovery; significant mortality ~10%; requires nutritional support)
Chemo + radio now offers prospect of improved long-term survival in patients with locally advanced inpoerable disease
Most patients with oesophageal cancer present with incurable disease, in this case what is the priority?
Symptom palliation (mainly dysphagia)
4 methods for symptoms palliation in oesophageal cancer?
Endoscopic - stent, laser/APC, PEG
Chemo
Radiotherapy
Brachytherapy
What type of condition is eosinphilic oesophagitis?
Chronic immune/allergen-mediated condition
How is eosinophillic oesophagitis defined clinically v pathologically?
Clinically by symptoms of oesophageal dysfunction
Pathologically by an eosinophilic infiltration of the oesophageal epithelium (≥15 eosinophils per high-power microscopy field on oesophageal biopsy) in the absence of secondary causes of local or systemic eosinophilia
Who is eosinophilic oesophagitis more commonly seen in?
Children and young adults
Males > females
Presentation of eosinophilic oesophagitis?
Dysphagia and food bolues obstruction
Endoscopic findings
3 methods of treatment of eosinophillic oesophagitis?
- Topical/swallow corticosteroids
- Dietary elimination to reduce symptoms and inflammation
- Endoscopic dilatation
