Oesophageal Disorders Flashcards
where does the oesophagus start and end?
Begins at lower level of cricoid cartilage (C6), terminates at T11-12 where it enters the stomach
is the oesophagus striated or smooth muscle?
Upper 3-4 cm striated muscle, remainder is smooth muscle
what type of epithelium is the oesophagus?
stratified squamous epithelium
what is the function of the oesophagus?
Transport of food/liquid from mouth to stomach – active process
how are oesophageal peristalsis produced?
by oesophageal circular muscles and propels swallowed materials distally into the stomach
true or false?
Contraction in the oesophageal body (peristalsis) and relaxation of the LOS is mediated via the vagus nerve
true
what are the symptoms of heartburn?
Retrosternal discomfort or burning
May be associated with: Waterbrash, Cough
Heartburn is a consequence of reflux of acidic &/or
bilious gastric contents into the oesophagus
how can the LOS be reduced?
certain drugs/food can reduce it, resulting in increased reflux/ heartburn
what does Persistent reflux and heartburn lead to?
gastro-oesophageal reflux disease (GORD) which can in turn cause long-term complications
what is dysphagia?
Subjective sensation of difficulty in swallowing foods and/or liquids
what do you enquire about for someone who has dysphagia?
Type of food (solid vs liquid) - Pattern (progressive, intermittent)
- Associated features (weight loss, regurgitation, cough
where would the possible locations be for dysphagia?
Oropharyngeal -Oesophageal
causes of dysphagia?
benign stricture
- malignant stricture (oesophageal cancer) - motility disorders (eg achalasia, presbyoesophagus) - eosinophilic oesophagitis - extrinsic compression (eg in lung cancer
investigations of dysphagia
ENDOSCOPY
Oesophago-Gastro-Duodenoscopy (OGD)
Upper GI Endoscopy (UGIE)
what is hypermotility
Corkscrew appearance” on Ba swallow
-Severe, episodic chest pain +/- dysphagia
-Often confused with angina/MI
-Cause unclear (idiopathic)
-Manometry shows exaggerated,
uncoordinated, hypertonic contractions
-Rx smooth muscle relaxants
what is hypomotility
Associated with connective tissue disease,
diabetes, neuropathy
-Causes failure of LOS mechanism leading to
heartburn and reflux symptoms
what is achalasia?
Degeneration of inhibitory neurons (ganglion cells) in the myenteric plexus in the oesophagus
Often surrounded by lymphocytes- so an inflammatory aetiology is suspected
what are symptoms of achalasia?
progressive dysphagia for solids and liquids
weight loss
Chest pain (30%)
Regurgitation and chest infection
what is the treatment for achalasia?
Pharmacological - Nitrates,
Calcium Channel blockers
Endoscopic - Botulinum Toxin
Pneumatic balloon dilation
Radiological - Pneumatic balloon
dilation
Surgical - Myotomy
what are complications of achalasia?
Aspiration pneumonia and lung disease
Increased risk of squamous cell oesophageal carcinoma
what are the symptoms of gastro-oesophageal reflux disease?
heartburn, cough, water brash, sleep disturbance
may not experience any symptoms
what are the risk factors for gastro-oesophageal refluc disease?
Pregnancy, obesity, drugs lowering LOS pressure, smoking, alcoholism, hypomotility
who is more likely to get gastro-oesophageal reflux disease?
men, caucasian
true or false:
The typical reflux syndrome can be diagnosed on the basis of the characteristic symptoms, without diagnostic testing.
true
why is endoscopy a poor diagnostic test but still performed?
. Most patients (>50%) with reflux symptoms have no visible evidence of oesophageal abnormality when endoscopy is performed.
However endoscopy must be performed in the presence of ‘alarm’ features suggestive of malignancy (eg dysphagia, weight loss, vomiting)
what is GORD without abnormal anatomy?
increased Transient relaxations of the LOS
Hypotensive LOS
Delayed gastric emptying
Delayed oesophageal emptying
decreased Oesophageal acid clearance
decreased Tissue resistance to acid/bile
what is GOD due to hiatus hernia?
Anatomical distortion of the OG junction
what are the two main types of hiatus hernia?
Sliding and Para-oesophageal
GORD pathophysiology
Mucosa exposed to
acid-pepsin and bile
Increased cell loss
and regenerative activity
(ie inflammation)
Erosive oesophagitis
GORD complications
Ulceration (5%)
Stricture (8-15%)
Glandular metaplasia (Barrett’s oesophagus)
Carcinoma
whos more likely to get barretts oesophagus?
men
what is barretts oesophagus a precurser to?
dysplasia
adenocarcinoma
what is barretts oesophagus?
Intestinal metaplasia related to prolonged acid exposure in distal oesophagus
what type of epithelium is in the lower oesophagus?
Change from squamous to mucin-secreting columnar (ie gastric type)
what is the risk of developing oesophageal cancer ?
6% year
what is the treatment of barrettsoesophagus?
Endoscopic Mucosal Resection (EMR) Radio-Frequency Ablation (RFA) Oesophagectomy rarely (mortality ~10%)
GORD treatment?
Lifestyle measures
Pharmacological
Alginates (Gaviscon)
H2RA (Ranitidine)
Proton Pump Inhibitor (e.g. Omeprazole, Lansoprazole)
For refractory disease/symptoms
following investigation
Anti-reflux surgery
(Fundoplication – full / partial wrap)
oesophageal cancer presentation
Progressive dysphagia (90%)
Anorexia and Weight loss (75%)
Odynophagia
Chest pain
Cough
Pneumonia (tracheo-
oesophageal fistula)
Vocal cord paralysis
Haematemesis
where does squamous cell carcinoma happen in the oesophagus?
Occur in proximal and middle third of oesophagus
risk factors for squamous cell carcinoma
tobacco and alcohol
where does adenocarcinoma happen in the oesophagus?
distal oesophagus
what are the predisposing factors for adenocrcinoma?
obesity, male sex, middle age, caucasian
metastases of oesophageal cancer
Hepatic, brain, pulmonary, bone
oesophageal cancer investigations
Diagnosis by Endoscopy & Biopsy
Staging: CT Scan Endoscopic ultrasound PET Scan Bone Scan
Disease staging by
TNM classification
oesophageal cancer treatment
Only potential cure is surgical oesophagectomy +/- adjuvant (after) or neoadjuvant (before) chemotherapy
Endoscopic (stent, laser/APC, PEG) Chemotherapy Radiotherapy Brachytherapy
what is Eosinophilic Oesophagitis
Chronic immune-/allergen-mediated condition defined clinically by symptoms of oesophageal dysfunction, and pathologically by an eosinophilic infiltration of the oesophageal epithelium (≥15 eosinophils per high-power microscopy field on oesophageal biopsy) in the absence of secondary causes of local or systemic eosinophilia.
who is more likely to have Eosinophilic Oesophagitis
children and young adults of males
presentation of Eosinophilic Oesophagitis
Dysphagia & Food bolus obstruction
treatment of Eosinophilic Oesophagitis
topical/swallowed corticosteroids
- dietary elimination - endoscopic dilatation
