Oesophageal disorders Flashcards
where does the oesophagus begin and end?
C6
T11-T12 where it enters stomach
What is the upper 1/3, middle and lower 1/3 made up of? How is the muscle arranged?
Upper 1/3 = striated muscle
Middle 1/3 = mix of striated and smooth muscle
Lower 1/3 = smooth muscle
There are 2 layers - circular and longitudinal.
Function of the oesophagus
transport of food/liquid from mouth to stomach - active
how are swallowed materials propelled distally into the stomach?
Smooth muscles contract behind the bolus to prevent it from being squeezed back into the mouth.
Then rhythmic, unidirectional waves of contractions work to rapidly force the food into the stomach.
when should the lower oesophageal sphincter open?
Only when food or liquid is passed into the stomach
which nerve mediates the contraction in the oesophageal body (peristalsis) and relaxtion of the LOS?
vagus nerve
Describe what heartburn is
Retrosternal discomfort or burning
consequence of reflux of acid or bilious gastric contents (alkaline) into the oesophagus
Heartburn is only considered pathalogical if it is more frequent and severe
Presentation of Oesophageal disease
degree of reflux physiologically e.g after swallowing
certain drugs/foods (alcohol, nicotine, dietary xanthines) can reduce LOS pressure resulting in increased reflux which can present as heartburn
persistent reflux + heartburn => GI reflux disease - long term complications
what is dysphagia
difficulty swallowing foods and/or liquids
pain may come with this
What are some causes of oesophageal dysphagia? (5)
benign stricture (narrowing/tightening)
malignant stricture (cancer of the oesophagus)
motility disorders
eosinophilic oesophagitis
extrinsic compression (from the thoracic cavity eg in lung cancer)
Key investigations: oesophageal disease (4)
Endoscopy - best Contrast radiology (barium swallow - not used much) pH-metry manometry
Endoscopy pros
simple, effective, quick procedure
used to investigate dysphagia or reflux symptoms with alarming features
2 types:- upper GI endoscopy and oesophago-gastro-duodenoscopy
what is pH-metry?
Nasal catheter containing pH sensors at both sphincters (UOS and LOS) sphincters is placed in oesophagus
tests the pH level of reflux
what is manometry
Nasal catheter containing multiple pressure sensors is placed in oesophagus - assesses sphincter tonicity, relaxation of sphincters and oesophageal motility
usually done after endoscopy
what is hypermotility in the oesophagus
diffuse oesophageal spasm (fast peristalsis)
gives it a “Corkscrew appearance” on Ba swallow
Severe, episodic chest pain +/- dysphagia
Often confused with angina/MI
idiopathic
treated with smooth muscle relaxants
What is hypomotility?
slow peristalsis
Causes failure of LOS mechanism leading to heartburn and reflux symptoms
Associated with connective tissue disease,
diabetes, neuropathy
What is Achalasia? incidence, symptoms etc
a type of motility disorder - functional distal obstruction of the oesophagus
Degeneration of inhibitory neurons (ganglion cells) in the myenteric plexus in the oesophagus
Often surrounded by lymphocytes- so an inflammatory aetiology is suspected
symptoms - chest pain, weight loss, dysphagia, C.I, regurgitation
investigation and treatment of achalasia
nitrates, calcium channel blockers
endoscopy
balloon dilation - radiology
myotomy
complications of achalasia (2)
Aspiration pneumonia and lung disease
Increased risk of squamous cell oesophageal carcinoma
Risk factors of Gastro-oesophageal reflux disease (6)
Pregnancy obesity drugs lowering LOS pressure smoking alcoholism hypomotility
Even though it must be performed if presence of alarming features, why is endoscopy a poor diagnostic test for gastro-oesophageal reflux disease
Most patients with reflux symptoms have no visible evidence of oesophageal abnormality when endoscopy is performed
What are the 2 types of gastro-oesophageal reflux disease?
GORD without abnormal anatomy
GORD due to hiatus hernia
2 main types of hiatus hernia
Sliding - stomach and the section of the esophagus that joins the stomach slide up into the chest through the hiatus.
Para-oesophageal - upper part of the stomach pushes through an opening in the diaphragm and up into the chest. More concerning but less common.
Obesity and old age tend to be RF’s
Pathophysiology of gastro-oesophageal disease
Mucosa exposed to acid-pepsin and bile
Increased cell loss and regenerative activity (ie inflammation)
Erosive oesophagitis
Complications with GORD (4)
Ulceration
Stricture (narrowing)
Glandular metaplasia (Barrett’s oesophagus)
Carcinoma
treatment of Barrett’s oesophagus
endoscopic mucosal resection
radio-frequency ablatic
oesophagectomy - rare
treatment of GORD
mainly don’t need investigation if there are no alarm features
- lifestyle
- pharmacological eg alginates (gaviscon), H2RA
for refractory disease/symptoms - anti-reflux surgery
2 types of oesophageal cancer
squamous cell carcinoma
adenocarcinoma
world cancer ranking: oesophageal? incidence?
5th
men>women
adenocarcinoma more common in west
Presentation of oesophageal cancer (8)
Progressive dysphagia (swallowing problems) Anorexia and Weight loss Odynophagia (painful swallowing) Chest pain Cough Pneumonia (tracheo-oesophageal fistula) Vocal cord paralysis Haematemesis (vomiting blood)
describe squamous cell carcinoma of the oesophagus
often large exophytic (grow outwards out of epithelium) occluding tumours
occur in proximal and middle 1/3 of oesophagus
RF: tobacco and alcohol
describe adenocarcinoma of the oesophagus
occurs in distal oesophagus
associated with Barrett’s oesophagus (progresses through dysplasia to cancer)
RF; male, obesity
oesophageal cancer: how is it worse than other cancers within the abdomen
oesophageal cancer presents late
invasion into adjacent structures is easier than rest of GIT due to having no serosal layer
there is also a rich lymphatic sypply in the lamina propria - lymph node involvement often occurs earlier in oesophageal tumours
Investigations for oesophageal cancer
endoscopy and biopsy
staging - CT, endoscopic ultrasound, PET scan, bone scan
TNM staging of oesophageal cancer?
T1- Tumor invades lamina propria or submucosa (a-lamina propria, b-submucosa)
T2- Tumor invades muscularis propria/externa T3- Tumor invades adventitia T4- Tumor invades adjacent structures N1- Regional lymph node metastasis M1- Distant metastasis
treatment of oesophageal cancer
Only potential cure is surgical oesophagectomy +/- adjuvant (after) or neoadjuvant (before) chemotherapy. Neo given to try shrink tumour and make surgery more likely to be successful
endoscopic stent, laser etc
chemo
radiotherapy
brachytherapy
what is eosinophilic oesophagitis
chronic immune/allergy mediated condition
It occurs when eosinophils (WBC) accumulate in the oesophagus
This causes injury and inflammation to the oesophagus
presentation and treatment of eosinophilic oesophagitis
dysphagia and food bolus obstruction
treatment
children - diet
adults - topical or systemic steroids
