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Oesophageal Disorders Flashcards

1
Q

How long is the oesophagus?

A

Approx. 25 cm

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2
Q

Where does the oesophagus begin and end?

A

Lower end of cricoid cartilage (C6)

Ends at T11-12 where it enters the stomach

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3
Q

What muscle is in the oesophagus?

A

Upper 3-4cm striated muscle

Remainder smooth muscle

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4
Q

What is the epithelium of the oesophagus?

A

Stratified squamous epithelial lining

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5
Q

Function of oesophagus

A

Transport food / liquid from mouth to stomach in an active process

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6
Q

How does food get from the mouth to the stomach via 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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7
Q

What innervates peristalsis of the oesophagus and relaxation of the LOS?

A

Vagus nerve

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8
Q

What type of muscle is the LOS?

A

Striated

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9
Q

What is the “mucosal roulette” of the LOS formed by?

A

Acute angle (oh His) at GOJ

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10
Q

When is the only time the LOS should open?

A

When food or liquid pass into the sotmach

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11
Q

What is heartburn?

A

Retrosternal discomfort or burning

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12
Q

Causes of heartburn

A

Physiological e.g. after swallowing
Alcohol
Nicotine
Dietary xanthines

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13
Q

What are dietary xanthines?

A

Chocolate
Coffee
Coke

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14
Q

What can persistent reflux and heartburn lead to?

A

GORD which can in turn lead to long term complications

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15
Q

What does GORD stand for?

A

Gastro-oesophageal reflux disease

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16
Q

Definition of odynophagia

A

Pain with swallowing

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17
Q

Definition of dysphagia

A

Subjective sensation of difficulty in swallowing foods and/or liquids

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18
Q

Causes of oesophageal dysphagia

A

Benign stricture
Malignant stricture (oesophageal cancer)
Motility disorders e.g. achalasia, presbyooesophagus)
Eosinophilic oesophagitis
Extrinsic compression (e.g. in lung cancer)

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19
Q

What is eosinophilic oesophagitis?

A

Inflammatory disorder associated with intense eosinophilia infiltrate into the oesophagus

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20
Q

Investigations of oesophageal disease

A

Endoscopy
Contrast radiography - barium swallow
Oesophageal pH and manometry

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21
Q

How does oesophageal pH work?

A

Naso gastric catheter containing multiple pressure and pH sensors is placed in oesophagus
Probs at both sphincters (UOS and LOS)

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22
Q

When is manometry used?

A

After endoscopy

To investigate dysphagia/motility disorders

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23
Q

When are pH studies used?

A

Investigation of refractory heartburn/reflux

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24
Q

Motility disorders of the oesophagus

A

Hypermotility
Hypomotility
Achalasia

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25
Example of hypermotility of the oesophagus
Diffuse oesophageal spasm
26
What can be seen on barium swallow in hypermotility of the oesophagus?
"Corkscrew appearance"
27
Presentation of oesophageal hypermotility
Severe episodic chest pain | +/- dysphagia
28
What is oesophageal hypermotility often confused with?
Angina | MI
29
Causes of oesophageal hypermotility
Idiopathic | Sometimes spasms secondary to acid reflux
30
Oesophageal hypermotility on manometry
Exaggerated, uncoordinated, hypertonic contractions
31
Treatment of oesophageal hypermotility
Muscle relaxants
32
Associations of oesophageal hypomotility
Connective tissue disease Diabetes Neuropathy
33
Pathology of achalasia
Functional loss of myenteric plexus ganglion in distal oesophagus and LOS Degeneration of inhibitory neurones (ganglion cells) in the myenteric plexus in oesophagus Often surrounded by lymphocytes Leading to 1. Hypertrophy of LOS (high pressure) 2. Failure of peristalsis
34
What is there a risk of in achalasia?
Aspiration
35
Definition of achalasia
LOS fails to open up during swallowing and therefore leads to a backup of food within the oesophagus
36
What is seen on scans in achalasia?
Rat tail appearance of distal oesophagus and LOS
37
Which gender gets achalasia more?
M = F
38
What age is onset of achalasia?
3 rd - 5th decade
39
What is the cardinal feature of achalasia?
Failure of LOS to relax
40
Symptoms of achalasia
``` Progressive dysphagia for solids and liquids (difficulty in BOTH solids and liquids onset at same time) Weight loss Chest pain (30%) Regurgitation Chest infection ```
41
What is seen on mammography on achalasia?
High pressure in the LOS at rest (usually above 45mmHg) Failure of LOS to relax after swallowing Absence of useful peristaltic contractions in the lower oesophagus
42
What is the normal pressure of the LOS at rest?
10mmHg
43
Treatment of achalasia
``` Nitrates CCBs Endoscopic botulinum toxin Pneumatic balloon dilation Myotomy surgery ```
44
Complications of achalasia
Aspiration pneumonia Lung disease Squamous cell oesophageal carcinoma
45
What % of adults experience daily GORD symptoms?
7%
46
Pathology of GORD
Pathological acid and bile exposure in lower oesophagus - mucosa exposed to acid-pepsin and bile Increased cell loss and regenerative activity (i.e. inflammation) Erosive oesophagitis
47
Symptoms of GORD
Heartburn Cough Water brash Sleep disturbance
48
What is water brash?
Causes sour taste in mouth due to excess saliva and acid mixing in the mouth
49
Risk factors for GORD
``` Pregnancy Obesity Drugs lowering LOS pressure Smoking Alcoholism Hypomotility ```
50
Who gets GORD?
M > F | Caucasian > Black > Asian
51
How can the typical reflux syndrome be diagnosed?
On basis of characteristic symptoms, without diagnostic testing
52
Should an endoscopy be used to investigate reflux?
ONLY in the presence of alarm features suggestive of malignancy - dysphagia - weight loss - vomiting
53
Possible pathologies causing GORD
``` Without abnormal anatomy - increased transient relaxations of LOS - hypotensive LOS - delayed gastric emptying - delayed oesophageal emptying - delayed oesophageal acid clearance - decreased tissue resistance to acid/bile Due to hiatus hernia - anatomical distortion of the OG junction ```
54
2 main types of hiatus hernia
Sliding | Para oesophageal
55
What happens in a hiatus hernia?
Fundus of the stomach moves proximally through the diaphragmatic hiatus
56
Risk factors for hiatus hernia
Obesity | Ageing (>30% over 50 y/o)
57
GORD complications
Ulceration 5% Stricture 8 - 15% Glandular metaplasia (Barrett's oesophagus) Carcinoma
58
What is Barrett's oesophagus?
Intestinal metaplasia related to the prolonged acid exposure in distal oesophagus Changes from squamous to mucin secreting columnar (i.e. gastric type) epithelial cells in the lower oesophagus)
59
What is Barrett's oesophagus a precursor for?
Dysplasia / Adenocarcinoma
60
Which gender gets barrett's oesophagus?
M >>> F
61
Cancer rate of barrett's oesophagus
0.3% per year
62
Cancer rate of high grade dysplasia
6% / year
63
Treatment of high grade dysplasia of barrett's oesophagus
Endoscopic mucosal reception (EMR) Radio-frequency ablation (RFA) Oesophagectomy rarely
64
Mortality of Oesophagectomy
10%
65
Treatment of GORD
Lifestyle measures Alginates (Gaviscon) H2RA (ranitidine) PPI (omeprazole)
66
What does Gaviscon do?
Forms a raft on top of acid contents of the stomach to prevent the acid coming up
67
Treatment of GORD refractory disease
Anti reflux surgery - fundoplication - full / partial wrap
68
Types of oesophageal cancer
Adenocarcinoma | Squamous cell carcinoma
69
Who gets oesophageal cancer?
M > F 3:1 | Median age 65 but decreasing
70
Presentation of oesophageal cancer
``` Progressive dysphagia (90%) Anorexia and weight loss (75%) Odynophagia Chest pain Cough Pneumonia (trachea-oesophageal fistula) Vocal cord paralysis Haematemesis ```
71
Where does SCC occur on the oesophagus?
Proximal and middle third of oesophagus
72
What is SCC in the oesophagus preceded by?
Dysplasia | Carcinoma in situ
73
Where are there high incidences of SCC of oesophagus?
Southern Africa China Iran
74
Associations of SCC of oesophagus
Smoking Achalasia Casutic strictures Plummer- vinson syndrome
75
Where does adenocarcinoma occur in the oesophagus?
Distal oesophagus
76
What is adenocarcinoma of the oesophagus associated with?
Barrett's oesophagus
77
Risk factors for adenocarcinoma of the oesophagus
Obesity Male Middle Age Caucasian
78
When does oesophageal cancer usually present?
Late
79
Metastases / spread of oesophageal cancer
Commonly spread to regional nodes and or liver at presentation No peritoneal/serosal lining in the mediastinum (unlike the rest of GIT) and so local invasion into the heart, trachea, aorta can occur more easily and this limits surgery The lamina propria/mucosal layer has rich lymphatic supply and therefore lymph node involvement occurs early in oesophageal tumours
80
Prognosis of oesophageal cancer
5 year survival < 10%
81
Investigations for oesophageal cancer
Endoscopy Barium swallow Biopsy Staging scans
82
Treatment of oesophageal cancer
Oesophagectomy +- adjuvant or neoadjuvant chemotherapy | Palliation
83
Definition of adjuvant
After therapy
84
Definition of neoadjuvant
Before therapy
85
Palliation options for oesophageal cancer
``` Endoscopic stent / laser / PEG Chemotherapy Radiotherapy Brachytherapy Nutritional support ```
86
What can reflux lead to?
Benign strictures
87
Staging investigations of oesophageal cancer
CT chest + abdo
88
Where do cancers of the oesophagus start?
Mucosa
89
Oesophageal cancer commonly spreads to where?
Liver | Lungs
90
How long does radiotherapy take to improve dysphagia in oesophageal cancer?
3 - 4 weeks
91
If there is nodal disease along with the oesophageal cancer, what can be done?
Give chemotherapy at front to mop up micromets | If very early could start surgery immediately
92
Who is a pharyngeal pouch common in?
Older men
93
What is a pharyngeal pouch?
Posteromedial herniation between thyropharyngeus and cricopharyngeus muscles
94
Presentation of pharyngeal pouch
``` Dysphagia Regurgitation Aspiration Chronic cough Halitosis Usually not visible but if large then midline lump in the neck that gurgles on palpation ```
95
Gold standard investigation for oesophageal cancer
Endoscopy
96
What is globus pharyngis?
Persistent sensation of having a 'lump in the throat' when there is not.
97
Presentation of globus pharyngis
Persistent sensation of lump in throat Intermittent Relieved by foods and liquids Swallowing of saliva often more difficult

Gastrointestinal Pathology (26 decks)

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