Oesophageal Disorders Flashcards by Rebecca Anderson

What is heartburn?

Retrosternal discomfort/burning
Waterbrash (acidic taste)
Cough
Consequence of acid reflux

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What is dysphagia?

Difficulty swallowing foods and/or liquids

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In dysphagia, what things should be enquired about?

Type of food (solid/liquid)
Pattern
Associated features (weight loss, cough)

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What are the 2 locations that dysphagia occur?

Oropharyngeal (high)

Oesophageal

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What are the causes of oesophageal dysphagia?

Benign stricture
Malignant stricture (cancer)
Motility disorders
Eosinophilic oesophagitis
Extrinsic compression (e.g. lung cancer)

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What type of investigations can be done for oesophageal disease?

Oesophago-gastro-duodenoscopy (OGD)
Upper GI endoscopy
Contrast radiology (barium swallow)
pH-metry (for heartburn/reflux)
Manometry

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When is an endoscopy used?

Investigation of dysphagia or reflux symptoms WITH alarm features

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When is a barium swallow used?

In high dysphagia to exclude pharyngeal pouch or post-cricoid web prior to endoscopy

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What does a pH-metry involve?

Nasal catheter with pH sensors placed at both UOS and LOS to monitor reflux

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What is manometry?

Muscle contraction monitoring

Used in investigation of dysphagia or suspected motility disorder

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What does manometry do?

Assesses sphincter tonicity, relaxation of sphincters and oesophageal motility

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What does hypermotility look like on a barium swallow?

Oesophagus has a corkscrew appearance

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What are the symptoms of hypermotility?

Severe, episodic chest pain with or without dysphagia

Can be confused with angina/MI

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What does manometry show for hypermotility?

Exaggerated, uncoordinated, hypertonic contractions

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What is the treatment for hypermotility?

Smooth muscle relaxants

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What is hypomotility associated with?

Connective tissue disease
Diabetes
Neuropathy

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What does hypomotility do?

Causes failure of LOS mechanism which leads to heartburn/reflux symptoms

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What is achalasia?

Degeneration of inhibitory neurons in the myenteric plexus in the oesophagus
Causes failure of LOS to relax which results in functional distal obstruction of oesophagus

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What is the incidence of achalasia?

1-2 / 100,000

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What are the symptoms of achalasia?

Progressive dysphagia (solids + liquids)
Weight loss
Chest pain (30%)
Regurgitation + chest infection

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What does manometry in achalsia look like?

High pressure in LOS at rest
Failure of LOS to relax after swallowing
Absence of useful contractions in lower oesophagus

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What are the 4 types of treatment for achalasia?

PHARMACOLOGICAL: nitrates, CCBs
ENDOSCOPIC: botulinum toxin pneumatic balloon dilation
RADIOLOGICAL: pneumatic balloon dilation
SURGICAL: myotomy

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What are the complications of achalasia?

Aspiration pneumonia/lung disease

Increased risk of squamous cell oesophageal carcinoma

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What causes gastro-oesophageal reflux disease (GORD)?

Due to pathological acid (+ bile) exposure to lower oesophagus

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What are the symptoms of GORD?

Heartburn Cough Waterbrash Sleep disturbance

What are the risk factors of GORD?

``` Pregnancy Obesity Drugs lowering LOS pressure Smoking Alcoholism Hypomotility ```

What is the role of endoscopy in GORD?

Generally, a poor diagnostic test - most patients have no visible evidence of abnormality Must be done if ALARM features suggest malignancy

What causes GORD without abnormal anatomy?

``` Increased transient relaxations of LOS Hypotensive LOS Delayed gastric and/or oesophageal emptying Decreased oesophageal acid clearance Decreased tissue resistance to acid/bile ```

What causes GORD with an abnormal anatomy?

Hiatus hernia - distortion of the OG junction

What are the 2 main types of hiatus hernia?

Sliding | Para-oesophageal

What is hiatus hernia?

Fundus of stomach moves through diaphragmatic hiatus

What happens to oesophagus due to GORD?

Mucosa is exposed to acid-pepsin and bile Increased cell loss + regenerative activity (inflammation) Erosive oesophagitis

What are the complications of GORD?

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

What are the treatments for Barrett's oesophagus?

Endoscopic Mucosal Resection (EMR) Radio-frequency ablation (RFA) Oesophagectomy (rarely) = mortality ~10%

What are the treatments for GORD?

1. Lifestyle measures 2. Pharmacological: alginates (gaviscon), H2RA (ranitidine), proton pump inhibitor (omeprazole, lansoprazole) 3. Anti-reflux surgery (fundoplication - full/partial wrap)

What are the signs of oesophageal cancer?

``` Progressive dysphagia (90%) Anorexia + weight loss (75%) Odynophagia (pain) Chest pain Cough Pneumonia Vocal cord paralysis Haematemesis ```

Where does squamous cell carcinoma occur?

Proximal and middle third of oesophagus

What is squamous cell carcinoma associated with?

Achalasia Caustic strictures Plummer-Vinson syndrome

Where does adenocarcinoma occur?

Distal oesophagus

What is adenocarcinoma associated with?

Barrett's oesophagus

What is the prognosis for oesophageal cancer?

5 year survival <10% | Usually caught late (mostly palliative care)

What are the metastases that can occur from oesophageal cancer?

Hepatic Brain Pulmonary Bone

Why does lymph node involvement occur early in oesophageal tumours?

Mucosal layer has a rich lymphatic supply whereas the rest of the GIT lymphatic vessels are in the submucosal layer

Why does tumour invasion of surrounding structures (e.g. heart, trachea, aorta) occur more easily?

Oesophagus has no serosal layer making tumour invasion into local structures easier

How is oesophageal cancer diagnosed?

By endoscopy and biopsy

How is staging of oesophageal cancer discovered?

CT scan Endoscopic ultrasound PET scan Bone scan

What is T1 in cancer staging?

Tumour invades lamina propria (a) or submucosa (b)

What is T2 in cancer staging?

Tumour invades muscularis propria

What is T3 in cancer staging?

Tumour invades adventitia

What is T4 of cancer staging?

Tumour invades adjacent structures

What is N1 in cancer staging?

Regional lymph node metastasis

What is M1 in cancer staging?

Distant metastasis

What is stage 1 cancer?

T1N0M0

What is stage 2a cancer?

T2T3/N0M0

What is stage 2b cancer?

T1T2/N0M0

What is stage 3 cancer?

T3N1M0, T4, any N, M0

What is stage 4 cancer?

What is the treatment for oesophageal cancer?

Oesophagectomy +/- adjuvant/neoadjuvant chemotherapy Surgery only in patients with localised disease without comorbid disease Palliative treatment: - endoscopic (stent, laser/APC, PEG) - chemotherapy - radiotherapy - brachytherapy (specified radiotherapy)

What is eosinophilic oesophagitis?

Chronic immune/allergen-mediated condition

How is eosinophilic oesophagitis defined clinically?

Symptoms of oesophageal dysfunction

How is eosinophilic oesophagitis defined pathologically?

Eosinophilic infiltration of the oesophageal epithelium in the absence of secondary causes of local or systemic eosinophilia

What are the signs of eosinophilic oesophagitis?

Dysphagia | Food bolus obstruction

What is the treatment for eosinophilic oesophagitis?

Topical/swallowed corticosteroids or systemic steroids Dietary elimination Endoscopic dilatation