Oesophageal disorders

Question 1

where does the oesophagus begin and end?

Answer 1

C6

T11-T12 where it enters stomach

Question 2

What is the upper 1/3, middle and lower 1/3 made up of? How is the muscle arranged?

Answer 2

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.

Question 3

Function of the oesophagus

Answer 3

transport of food/liquid from mouth to stomach - active

Question 4

how are swallowed materials propelled distally into the stomach?

Answer 4

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.

Question 5

when should the lower oesophageal sphincter open?

Answer 5

Only when food or liquid is passed into the stomach

Question 6

which nerve mediates the contraction in the oesophageal body (peristalsis) and relaxtion of the LOS?

Answer 6

vagus nerve

Question 7

Describe what heartburn is

Answer 7

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

Question 8

Presentation of Oesophageal disease

Answer 8

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

Question 9

what is dysphagia

Answer 9

difficulty swallowing foods and/or liquids

pain may come with this

Question 10

What are some causes of oesophageal dysphagia? (5)

Answer 10

benign stricture (narrowing/tightening)

malignant stricture (cancer of the oesophagus)

motility disorders

eosinophilic oesophagitis

extrinsic compression (from the thoracic cavity eg in lung cancer)

Question 11

Key investigations: oesophageal disease (4)

Answer 11

Endoscopy - best
Contrast radiology (barium swallow - not used much)
pH-metry 
manometry

Question 12

Endoscopy pros

Answer 12

simple, effective, quick procedure

used to investigate dysphagia or reflux symptoms with alarming features

2 types:- upper GI endoscopy and oesophago-gastro-duodenoscopy

Question 13

what is pH-metry?

Answer 13

Nasal catheter containing pH sensors at both sphincters (UOS and LOS) sphincters is placed in oesophagus

tests the pH level of reflux

Question 14

what is manometry

Answer 14

Nasal catheter containing multiple pressure sensors is placed in oesophagus - assesses sphincter tonicity, relaxation of sphincters and oesophageal motility

usually done after endoscopy

Question 15

what is hypermotility in the oesophagus

Answer 15

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

Question 16

What is hypomotility?

Answer 16

slow peristalsis
Causes failure of LOS mechanism leading to heartburn and reflux symptoms

Associated with connective tissue disease,
diabetes, neuropathy

Question 17

What is Achalasia? incidence, symptoms etc

Answer 17

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

Question 18

investigation and treatment of achalasia

Answer 18

nitrates, calcium channel blockers

endoscopy
balloon dilation - radiology
myotomy

Question 19

complications of achalasia (2)

Answer 19

Aspiration pneumonia and lung disease

Increased risk of squamous cell oesophageal carcinoma

Question 20

Risk factors of Gastro-oesophageal reflux disease (6)

Answer 20

Pregnancy
obesity
drugs lowering LOS pressure
smoking
alcoholism
hypomotility

Question 21

Even though it must be performed if presence of alarming features, why is endoscopy a poor diagnostic test for gastro-oesophageal reflux disease

Answer 21

Most patients with reflux symptoms have no visible evidence of oesophageal abnormality when endoscopy is performed

Question 22

What are the 2 types of gastro-oesophageal reflux disease?

Answer 22

GORD without abnormal anatomy

GORD due to hiatus hernia

Question 23

2 main types of hiatus hernia

Answer 23

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

Question 24

Pathophysiology of gastro-oesophageal disease

Answer 24

Mucosa exposed to acid-pepsin and bile

Increased cell loss and regenerative activity (ie inflammation)

Erosive oesophagitis

Question 25

Complications with GORD (4)

Answer 25

Ulceration

Stricture (narrowing)

Glandular metaplasia (Barrett’s oesophagus)

Carcinoma

Question 26

treatment of Barrett’s oesophagus

Answer 26

endoscopic mucosal resection

radio-frequency ablatic

oesophagectomy - rare

Question 27

treatment of GORD

Answer 27

mainly don’t need investigation if there are no alarm features

• lifestyle
• pharmacological eg alginates (gaviscon), H2RA

for refractory disease/symptoms - anti-reflux surgery

Question 28

2 types of oesophageal cancer

Answer 28

squamous cell carcinoma

adenocarcinoma

Question 29

world cancer ranking: oesophageal? incidence?

Answer 29

5th
men>women
adenocarcinoma more common in west

Question 30

Presentation of oesophageal cancer (8)

Answer 30

Progressive dysphagia (swallowing problems)
Anorexia and Weight loss 
Odynophagia (painful swallowing)	
Chest pain
Cough
Pneumonia (tracheo-oesophageal fistula)
Vocal cord paralysis	
Haematemesis (vomiting blood)

Question 31

describe squamous cell carcinoma of the oesophagus

Answer 31

often large exophytic (grow outwards out of epithelium) occluding tumours

occur in proximal and middle 1/3 of oesophagus

RF: tobacco and alcohol

Question 32

describe adenocarcinoma of the oesophagus

Answer 32

occurs in distal oesophagus

associated with Barrett’s oesophagus (progresses through dysplasia to cancer)

RF; male, obesity

Question 33

oesophageal cancer: how is it worse than other cancers within the abdomen

Answer 33

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

Question 34

Investigations for oesophageal cancer

Answer 34

endoscopy and biopsy

staging - CT, endoscopic ultrasound, PET scan, bone scan

Question 35

TNM staging of oesophageal cancer?

Answer 35

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

Question 36

treatment of oesophageal cancer

Answer 36

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

Question 37

what is eosinophilic oesophagitis

Answer 37

chronic immune/allergy mediated condition

It occurs when eosinophils (WBC) accumulate in the oesophagus

This causes injury and inflammation to the oesophagus

Question 38

presentation and treatment of eosinophilic oesophagitis

Answer 38

dysphagia and food bolus obstruction

treatment
children - diet
adults - topical or systemic steroids