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Year 3 General Surgery > Oesophageal Disorders > Flashcards

Oesophageal Disorders Flashcards

1
Q

what are the risk factors for GORD?

A
  • increasing age
  • obesity
  • male
  • diet high in fat and spicy foods
  • alcohol
  • smoking
  • caffeinated drinks
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2
Q

what is the presentation of GORD?

A
  • burning retrosternal pain - worse after meals, lying down or bending over, relieved baby antacids
  • excessive belching
  • odynophagia (painful swallowing)
  • chronic cough or nocturnal cough
  • *always check red flags for possible underlying malignancy**
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3
Q

what investigations re carried out for GORD?

A
  • usually a clinical diagnosis
  • upper GI endoscopy (to exclude malignancy and investigate for complications of GORD)
  • 24hr pH monitoring (when medical treatment has failed and surgery is being considered)
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4
Q

what is barett’s oesophagus?

A

metaplasia of the oesophageal epithelial lining

normal stratified squamous epithelium is replaced by columnar epithelium

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5
Q

what is the risk of barett’s oesophagus?

A

it can progress to adenocarcinoma

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6
Q

what are the risk factors for developing barett’s oesophagus?

A
  • GORD
  • Caucasian
  • Male
  • > 50
  • Smoking
  • Hiatus hernia
  • Positive family history
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7
Q

how does barett’s oesophagus present?

A

history of chronic GORD

  • retrosternal chest pain
  • excessive bbelching
  • chronic cough
  • hoarseness
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8
Q

what investigations are carried out when suspecting Barett’s oesophagus?

A
  • OGD - oesophagus appears red, velvety, with some preserved squamous cell islands
  • Histology (biopsy at OGD)
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9
Q

what is the management of Barett’s oesophagus?

A
  • high-dose PPI (omeprazole) - 2x daily
  • stopping any medication that can impact the stomach protective barrier
  • regular endoscopy to monitor progression to adenocarcinoma
  • high-grade dysplasia has a higher risk of progressing to cancer - resect using endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD)
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10
Q

what are the two main types of oesophageal cancer?

A
  • squamous cell carcinoma

- adenocarcinoma

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11
Q

what parts of the oesophagus are affected by squamous cell carcinoma and what are the risk factors for developing SSC?

A
  • middle and upper 1/3rd of oesophagus
  • smoking
  • excessive alcohol
  • chronic achalasia
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12
Q

what parts of the oesophagus are affected by adenocarcinoma?

A
  • lower 1/3rd of the oesophagus
  • arise due to Barett’s oesophagus
  • GORD, obesity and high dietary fat intake
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13
Q

what is the presentation of oesophageal cancer?

A
  • dysphagia - progressive
  • significant weight loss
  • odynophagia (painful swallowing)
  • hoarseness (recurrent laryngeal nerve injury)
  • signs of dehydration
  • supraclavicular lymphadenopathy
  • signs of metastatic disease (jaundice, hepatomegaly, ascites)
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14
Q

what are the red-flag symptoms for oesophageal cancer?

A
  • dysphagia

- patient >55 with weight loss AND upper abdominal pain, dyspepsia or reflux

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15
Q

what investigations are carried out if suspecting oesophageal cancer?

A
  • urgent OGD within 2 weeks
  • biopsy and histology of any lesions
  • CT chest-abdomen-pelvis and PET-CT scan (to investigate metastasis)
  • endoscopic ultrasound (to measure depth of penetration into oesophageal wall and to assess and biopsy suspicious mediastinal lymph nodes)
  • staging laparoscopy (to look for intra-peritoneal metastases)
  • fine needle aspiration of any palpable cervical lymph nodes
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16
Q

what is the management of oesophageal cancer?

A
  • Palliative care
  • Upper oesophagus - chemo-radiotherapy
  • Lower oesophagus - neoadjuvant chemo-radiotherapy followed by surgery

surgical options:

  • oesophagectomy (removal of tumour, top of stomach and surrounding lymph nodes followed by the stomach being made into a tube and brought up into the chest to replace the oesophagus)
  • endoscopic mucosal resection (for very early disease or high grade barett’s oesophagus)

palliative management:

  • oesophageal stent placed (to aid in swallowing)
  • radiotherapy/chemotherapy (to reduce tumour size and bleeding)
  • nutritional support (thickened fluids and supplements)
  • radiologically-inserted gastrostomy (RIG) tube
17
Q

what are the two main types of oesophageal tear?

A
  • mallory-weirs tears (superficial mucosal tears)

- full-thickness ruptures (perforation)

18
Q

what are the causes of oesophageal perforation (full-thickness tears)?

A
  • spontaneous (vomiting)

- iatrogenic (endoscopy)

19
Q

what are the consequences of oesophageal perforation?

A

leakage of stomach contents into the mediating and pleural cavity.
this causes a severe inflammatory response, leading to physiological collapse, multiorgan failure and death

20
Q

what is the presentation of oesophageal perforation?

A
  • severe sudden-onset retrosternal pain
  • respiratory distress
  • subcutaneous emphysema
    (above three = Mackler’s triad)
  • usually following severe vomiting or retching
  • often septic and haemodynamically unstable
21
Q

what investigations are carried out when suspecting oesophageal rupture?

A
  • urgent routine bloods
  • group and save
  • chest xray (pneumomediastinum)
  • CT chest-abdomen-pelvis with IV and oral contrast (imaging modality of choice)
  • urgent endoscopy in theatre
22
Q

what is the management of spontaneous oesophageal perforation?

A
  • IV access
  • Urgent and aggressive fluid resuscitation
  • high-flow oxygen
  • broad spectrum antibiotics
  • immediate surgery to control the leak and wash out chest via thoracotomy (OGD used during surgery to determine the site of perforation and therefore site of incision)
  • CT scan with contrast 10-14 days post-op to assess for leakage, before starting oral intake
  • feeding jejunostomy inserted for nutrition
23
Q

why are iatrogenic oesophageal perforations more stable then spontaneous?

A

they occur due to OGD and therefore patient was already NBM before the procedure - less contamination

24
Q

what is the management of iatrogenic oesophageal perforations?

A
  • initial suitable resuscitation and transfer to intensive care
  • antibiotic and anti fungal cover
  • NBM for 1-2 weeks
  • Endoscopic insertion of NG tube
  • Large-bore chest drain insertion
  • total parenteral nutrition or feeding jejunostomy inserted
25
Q

what are mallory-weiss tears?

A

lacerations in the oesophageal mucosa, usually at the gastro-oesophageal junction.

26
Q

why do mallory-weirs tears occur?

A

usually after a period of profuse vomiting

27
Q

what is the presentation of mallory-weirs tears?

A
  • haematemesis
  • light-headedness/dizziness
  • postural hypotension
  • dysphagia (rare)
  • shock (rare)
28
Q

what investigations are carried out when suspecting a mallory-weiss tear?

A
  • routine bloods
  • erect chest xray
  • OGD
  • Group and save
  • Glascow-blatchford bleeding score
  • CT abdomen with IV contrast
29
Q

what is the management of mallory-weiss tears?

A
  • if presenting with hypotensive shock (rare):
  • urgent fluid resuscitation
  • urgent bloods
  • group and save (+/- cross match if needed)
  • elective endotracheal intubation if continued haematemesis or altered respiratory or mental status
  • fluid replacement to treat electrolyte abnormalities
  • prolonged PT/INR should be corrected with FFP or vitamin K
  • endoscopy +/- haemoclip placement +/- adrenal ine +/- thermoregulation
30
Q

what are oesophageal motility disorders?

A

abnormalities in oesophageal peristalsis

31
Q

what is achalasia?

A

primary motility disorder of the oesophagus, characterised by failure of relaxation of the lower oesophageal sphincter and progressive failure of contraction of the oesophageal smooth muscle.

32
Q

what is the presentation of achalasia?

A
  • progressive dysphagia when ingesting both solids and liquids
  • eventually leads to vomiting and chest discomfort
  • regurgitation of food
  • chest pain
  • coughing
  • weight loss
33
Q

what investigations are carried out when suspecting an oesophageal motility disorder?

A
  • urgent endoscopy (to exclude cancer (dysphagia is a red flag))
  • oesophageal manometry (pressure sensitive probe measures pressure in oesophagus)
34
Q

what is the management of achalasia?

A
  • conservative management (sleeping with many pillows, eating slowly and chewing food thoroughly, plenty of fluids with meals)
  • calcium channel blockers or nitrates for temporary relief
  • botox injections into lower oesophageal sphincter by endoscopy
  • endoscopic balloon dilatation (dilates lower oesophageal sphincter)
  • laparoscopic Heller myotomy (division of the specific muscle that fail to relax)
35
Q

what is diffuse oesophageal spasm?

A

disease characterised by multi-focal high-amplitude contractions of the oesophagus

36
Q

what is the presentation of diffuse oesophageal spasm?

A
  • severe dysphagia to both solids and liquids
  • central chest pain, usually exacerbated by food
  • pain responds to nitrates
37
Q

what is the management of diffuse oesophageal spasm?

A
  • nitrates or calcium channel blockers
  • endoscopic balloon dilatation
  • myotomy for the most severe cases

Year 3 General Surgery (9 decks)

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