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Gastrointestinal Pathology > Oesophageal Disorders > Flashcards

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
Q

Example of hypermotility of the oesophagus

A

Diffuse oesophageal spasm

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26
Q

What can be seen on barium swallow in hypermotility of the oesophagus?

A

“Corkscrew appearance”

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27
Q

Presentation of oesophageal hypermotility

A

Severe episodic chest pain

+/- dysphagia

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28
Q

What is oesophageal hypermotility often confused with?

A

Angina

MI

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29
Q

Causes of oesophageal hypermotility

A

Idiopathic

Sometimes spasms secondary to acid reflux

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30
Q

Oesophageal hypermotility on manometry

A

Exaggerated, uncoordinated, hypertonic contractions

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31
Q

Treatment of oesophageal hypermotility

A

Muscle relaxants

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32
Q

Associations of oesophageal hypomotility

A

Connective tissue disease
Diabetes
Neuropathy

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33
Q

Pathology of achalasia

A

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

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34
Q

What is there a risk of in achalasia?

A

Aspiration

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35
Q

Definition of achalasia

A

LOS fails to open up during swallowing and therefore leads to a backup of food within the oesophagus

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36
Q

What is seen on scans in achalasia?

A

Rat tail appearance of distal oesophagus and LOS

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37
Q

Which gender gets achalasia more?

A

M = F

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38
Q

What age is onset of achalasia?

A

3 rd - 5th decade

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39
Q

What is the cardinal feature of achalasia?

A

Failure of LOS to relax

40
Q

Symptoms of achalasia

A 
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
Q

What is seen on mammography on achalasia?

A

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
Q

What is the normal pressure of the LOS at rest?

43
Q

Treatment of achalasia

A 
Nitrates 
CCBs
Endoscopic botulinum toxin 
Pneumatic balloon dilation 
Myotomy surgery
44
Q

Complications of achalasia

A

Aspiration pneumonia
Lung disease
Squamous cell oesophageal carcinoma

45
Q

What % of adults experience daily GORD symptoms?

46
Q

Pathology of GORD

A

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
Q

Symptoms of GORD

A

Heartburn
Cough
Water brash
Sleep disturbance

48
Q

What is water brash?

A

Causes sour taste in mouth due to excess saliva and acid mixing in the mouth

49
Q

Risk factors for GORD

A 
Pregnancy 
Obesity
Drugs lowering LOS pressure
Smoking
Alcoholism 
Hypomotility
50
Q

Who gets GORD?

A

M > F

Caucasian > Black > Asian

51
Q

How can the typical reflux syndrome be diagnosed?

A

On basis of characteristic symptoms, without diagnostic testing

52
Q

Should an endoscopy be used to investigate reflux?

A

ONLY in the presence of alarm features suggestive of malignancy

  • dysphagia
  • weight loss
  • vomiting
53
Q

Possible pathologies causing GORD

A 
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
Q

2 main types of hiatus hernia

A

Sliding

Para oesophageal

55
Q

What happens in a hiatus hernia?

A

Fundus of the stomach moves proximally through the diaphragmatic hiatus

56
Q

Risk factors for hiatus hernia

A

Obesity

Ageing (>30% over 50 y/o)

57
Q

GORD complications

A

Ulceration 5%
Stricture 8 - 15%
Glandular metaplasia (Barrett’s oesophagus)
Carcinoma

58
Q

What is Barrett’s oesophagus?

A

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
Q

What is Barrett’s oesophagus a precursor for?

A

Dysplasia / Adenocarcinoma

60
Q

Which gender gets barrett’s oesophagus?

A

M&raquo_space;> F

61
Q

Cancer rate of barrett’s oesophagus

A

0.3% per year

62
Q

Cancer rate of high grade dysplasia

63
Q

Treatment of high grade dysplasia of barrett’s oesophagus

A

Endoscopic mucosal reception (EMR)
Radio-frequency ablation (RFA)
Oesophagectomy rarely

64
Q

Mortality of Oesophagectomy

65
Q

Treatment of GORD

A

Lifestyle measures
Alginates (Gaviscon)
H2RA (ranitidine)
PPI (omeprazole)

66
Q

What does Gaviscon do?

A

Forms a raft on top of acid contents of the stomach to prevent the acid coming up

67
Q

Treatment of GORD refractory disease

A

Anti reflux surgery

  • fundoplication
  • full / partial wrap
68
Q

Types of oesophageal cancer

A

Adenocarcinoma

Squamous cell carcinoma

69
Q

Who gets oesophageal cancer?

A

M > F 3:1

Median age 65 but decreasing

70
Q

Presentation of oesophageal cancer

A 
Progressive dysphagia (90%)
Anorexia and weight loss (75%)
Odynophagia
Chest pain 
Cough 
Pneumonia (trachea-oesophageal fistula)
Vocal cord paralysis
Haematemesis
71
Q

Where does SCC occur on the oesophagus?

A

Proximal and middle third of oesophagus

72
Q

What is SCC in the oesophagus preceded by?

A

Dysplasia

Carcinoma in situ

73
Q

Where are there high incidences of SCC of oesophagus?

A

Southern Africa
China
Iran

74
Q

Associations of SCC of oesophagus

A

Smoking
Achalasia
Casutic strictures
Plummer- vinson syndrome

75
Q

Where does adenocarcinoma occur in the oesophagus?

A

Distal oesophagus

76
Q

What is adenocarcinoma of the oesophagus associated with?

A

Barrett’s oesophagus

77
Q

Risk factors for adenocarcinoma of the oesophagus

A

Obesity
Male
Middle Age
Caucasian

78
Q

When does oesophageal cancer usually present?

79
Q

Metastases / spread of oesophageal cancer

A

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
Q

Prognosis of oesophageal cancer

A

5 year survival < 10%

81
Q

Investigations for oesophageal cancer

A

Endoscopy
Barium swallow
Biopsy
Staging scans

82
Q

Treatment of oesophageal cancer

A

Oesophagectomy +- adjuvant or neoadjuvant chemotherapy

Palliation

83
Q

Definition of adjuvant

A

After therapy

84
Q

Definition of neoadjuvant

A

Before therapy

85
Q

Palliation options for oesophageal cancer

A 
Endoscopic stent / laser / PEG
Chemotherapy 
Radiotherapy
Brachytherapy 
Nutritional support
86
Q

What can reflux lead to?

A

Benign strictures

87
Q

Staging investigations of oesophageal cancer

A

CT chest + abdo

88
Q

Where do cancers of the oesophagus start?

89
Q

Oesophageal cancer commonly spreads to where?

A

Liver

Lungs

90
Q

How long does radiotherapy take to improve dysphagia in oesophageal cancer?

A

3 - 4 weeks

91
Q

If there is nodal disease along with the oesophageal cancer, what can be done?

A

Give chemotherapy at front to mop up micromets

If very early could start surgery immediately

92
Q

Who is a pharyngeal pouch common in?

93
Q

What is a pharyngeal pouch?

A

Posteromedial herniation between thyropharyngeus and cricopharyngeus muscles

94
Q

Presentation of pharyngeal pouch

A 
Dysphagia
Regurgitation 
Aspiration 
Chronic cough 
Halitosis 
Usually not visible but if large then midline lump in the neck that gurgles on palpation
95
Q

Gold standard investigation for oesophageal cancer

96
Q

What is globus pharyngis?

A

Persistent sensation of having a ‘lump in the throat’ when there is not.

97
Q

Presentation of globus pharyngis

A

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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