Oesophageal Disorders Flashcards
What is heartburn?
Retrosternal discomfort/burning
Waterbrash (acidic taste)
Cough
Consequence of acid reflux
What is dysphagia?
Difficulty swallowing foods and/or liquids
In dysphagia, what things should be enquired about?
Type of food (solid/liquid)
Pattern
Associated features (weight loss, cough)
What are the 2 locations that dysphagia occur?
Oropharyngeal (high)
Oesophageal
What are the causes of oesophageal dysphagia?
Benign stricture Malignant stricture (cancer) Motility disorders Eosinophilic oesophagitis Extrinsic compression (e.g. lung cancer)
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
When is an endoscopy used?
Investigation of dysphagia or reflux symptoms WITH alarm features
When is a barium swallow used?
In high dysphagia to exclude pharyngeal pouch or post-cricoid web prior to endoscopy
What does a pH-metry involve?
Nasal catheter with pH sensors placed at both UOS and LOS to monitor reflux
What is manometry?
Muscle contraction monitoring
Used in investigation of dysphagia or suspected motility disorder
What does manometry do?
Assesses sphincter tonicity, relaxation of sphincters and oesophageal motility
What does hypermotility look like on a barium swallow?
Oesophagus has a corkscrew appearance
What are the symptoms of hypermotility?
Severe, episodic chest pain with or without dysphagia
Can be confused with angina/MI
What does manometry show for hypermotility?
Exaggerated, uncoordinated, hypertonic contractions
What is the treatment for hypermotility?
Smooth muscle relaxants
What is hypomotility associated with?
Connective tissue disease
Diabetes
Neuropathy
What does hypomotility do?
Causes failure of LOS mechanism which leads to heartburn/reflux symptoms
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
What is the incidence of achalasia?
1-2 / 100,000
What are the symptoms of achalasia?
Progressive dysphagia (solids + liquids)
Weight loss
Chest pain (30%)
Regurgitation + chest infection
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
What are the 4 types of treatment for achalasia?
PHARMACOLOGICAL: nitrates, CCBs
ENDOSCOPIC: botulinum toxin pneumatic balloon dilation
RADIOLOGICAL: pneumatic balloon dilation
SURGICAL: myotomy
What are the complications of achalasia?
Aspiration pneumonia/lung disease
Increased risk of squamous cell oesophageal carcinoma
What causes gastro-oesophageal reflux disease (GORD)?
Due to pathological acid (+ bile) exposure to lower oesophagus
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?
- Lifestyle measures
- Pharmacological: alginates (gaviscon), H2RA (ranitidine), proton pump inhibitor (omeprazole, lansoprazole)
- 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?
M1
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
