Oesophageal Disorders Flashcards
what are the risk factors for GORD?
- increasing age
- obesity
- male
- diet high in fat and spicy foods
- alcohol
- smoking
- caffeinated drinks
what is the presentation of GORD?
- 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**
what investigations re carried out for GORD?
- 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)
what is barett’s oesophagus?
metaplasia of the oesophageal epithelial lining
normal stratified squamous epithelium is replaced by columnar epithelium
what is the risk of barett’s oesophagus?
it can progress to adenocarcinoma
what are the risk factors for developing barett’s oesophagus?
- GORD
- Caucasian
- Male
- > 50
- Smoking
- Hiatus hernia
- Positive family history
how does barett’s oesophagus present?
history of chronic GORD
- retrosternal chest pain
- excessive bbelching
- chronic cough
- hoarseness
what investigations are carried out when suspecting Barett’s oesophagus?
- OGD - oesophagus appears red, velvety, with some preserved squamous cell islands
- Histology (biopsy at OGD)
what is the management of Barett’s oesophagus?
- 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)
what are the two main types of oesophageal cancer?
- squamous cell carcinoma
- adenocarcinoma
what parts of the oesophagus are affected by squamous cell carcinoma and what are the risk factors for developing SSC?
- middle and upper 1/3rd of oesophagus
- smoking
- excessive alcohol
- chronic achalasia
what parts of the oesophagus are affected by adenocarcinoma?
- lower 1/3rd of the oesophagus
- arise due to Barett’s oesophagus
- GORD, obesity and high dietary fat intake
what is the presentation of oesophageal cancer?
- 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)
what are the red-flag symptoms for oesophageal cancer?
- dysphagia
- patient >55 with weight loss AND upper abdominal pain, dyspepsia or reflux
what investigations are carried out if suspecting oesophageal cancer?
- 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
what is the management of oesophageal cancer?
- 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
what are the two main types of oesophageal tear?
- mallory-weirs tears (superficial mucosal tears)
- full-thickness ruptures (perforation)
what are the causes of oesophageal perforation (full-thickness tears)?
- spontaneous (vomiting)
- iatrogenic (endoscopy)
what are the consequences of oesophageal perforation?
leakage of stomach contents into the mediating and pleural cavity.
this causes a severe inflammatory response, leading to physiological collapse, multiorgan failure and death
what is the presentation of oesophageal perforation?
- 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
what investigations are carried out when suspecting oesophageal rupture?
- 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
what is the management of spontaneous oesophageal perforation?
- 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
why are iatrogenic oesophageal perforations more stable then spontaneous?
they occur due to OGD and therefore patient was already NBM before the procedure - less contamination
what is the management of iatrogenic oesophageal perforations?
- 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
what are mallory-weiss tears?
lacerations in the oesophageal mucosa, usually at the gastro-oesophageal junction.
why do mallory-weirs tears occur?
usually after a period of profuse vomiting
what is the presentation of mallory-weirs tears?
- haematemesis
- light-headedness/dizziness
- postural hypotension
- dysphagia (rare)
- shock (rare)
what investigations are carried out when suspecting a mallory-weiss tear?
- routine bloods
- erect chest xray
- OGD
- Group and save
- Glascow-blatchford bleeding score
- CT abdomen with IV contrast
what is the management of mallory-weiss tears?
- 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
what are oesophageal motility disorders?
abnormalities in oesophageal peristalsis
what is achalasia?
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.
what is the presentation of achalasia?
- progressive dysphagia when ingesting both solids and liquids
- eventually leads to vomiting and chest discomfort
- regurgitation of food
- chest pain
- coughing
- weight loss
what investigations are carried out when suspecting an oesophageal motility disorder?
- urgent endoscopy (to exclude cancer (dysphagia is a red flag))
- oesophageal manometry (pressure sensitive probe measures pressure in oesophagus)
what is the management of achalasia?
- 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)
what is diffuse oesophageal spasm?
disease characterised by multi-focal high-amplitude contractions of the oesophagus
what is the presentation of diffuse oesophageal spasm?
- severe dysphagia to both solids and liquids
- central chest pain, usually exacerbated by food
- pain responds to nitrates
what is the management of diffuse oesophageal spasm?
- nitrates or calcium channel blockers
- endoscopic balloon dilatation
- myotomy for the most severe cases
