Oesophageal Disorders Flashcards
At what vertebral level does the oesophagus begin? End?
Begins at lower level of cricoid cartilage - C6
Terminates at T11-12 where it enters stomach
Describe the epithelium and muscle of the oesophagus
Stratified squamous epithelium
Upper oesophagus skeletal muscle - becomes smooth
Which layer of the muscularis externa powers peristalsis in the oesophagus?
Circular muscle layer
Peristalsis and the lower oesophageal sphincter are controlled by which nerve?
Vagus nerve (the two are coordinated)
Two major symptoms of oesophageal disorders?
Dysphagia and heartburn
Describe the localization of heartburn. What is it caused by?
Heartburn is retrosternal discomfort/burning
Caused by reflux of acidic/bilious contents into oesophagus
Describe the opening to the stomach at the distal end of the oesophagus
LOS above angle of His, at level of diaphragm
Angle of His between oesophageal opening and fundus
Is heartburn a major warning sign?
If consistent, but it is normal if occurring every now and then
Examples of drugs/foods that can cause reflux/heartburn?
Alcohol
Nicotine
Dietary xanthines (caffeine/theophylline)
What is Gastro-oesophageal reflux disease?
Symptoms?
Weakening of LOS - frequent reflux into oesophagus. Causes cell loss and inflammation (erosive oesophagitis)
Symptoms - many asymptomatic, or - heartburn, cough, water brash (saliva and acid mix in throat), sleep disturbance
What is dysphagia?
Subjective sensation of difficulty swallowing foods/liquids
What is odynophagia?
Pain with swallowing - may accompany dysphagia
What enquiries should be made when a patient is experiencing dysphagia?
**Associated features (weight loss/regurgitation/cough)
Type of food (solid/liquid)
Pattern (progressive/intermittent)
Anatomical locations of the dysphagia sensation?
Oropharyngeal
Oesophageal
Causes of dysphagia?
Benign stricture Malignant stricture (oesophageal cancer) Motility disorders (achalasia, presbyoesophagus) Eosinophilic oesophagitis (immune) Extrinsic compression (eg. lung cancer)
Primary investigation for oesophageal disease? Why is it the primary choice?
Endoscopy
OGD - oesophago-gastro-duodenoscopy
UGIE - upper GI endoscopy
Simple, effective, safe and quick
Other investigations for oesophageal disease? When are they likely to be used?
Contrast radiology (barium swallow) - investigation of dysphagia (usually proximally caused dysphagia)
pH probing - nasal catheter with pH sensors at LOS and UOS - measures reflux
Manometry - assesses motility, tonicity and coordination of oesophageal tube by measuring pressure changes due to contractions
Motility disorders of the oesophagus?
Hypermotility
Hypomotility
Achalasia
What is hypermotility of the oesophagus? Symptoms? Appearance on Ba swallow?
Corkscrew appearance on Ba swallow
It is characterized by exaggerated, uncoordinated, hypertonic contractions of the oesophagus
symptoms
- Severe episodic chest pain (+/- dysphagia)
Often confused with angina/MI
Cause of hypermotility of the oesophagus? Treatment? Examples?
Cause is idiopathic
Treat with smooth muscle relaxants (eg. CCB)
Ex. - diffuse oesophageal spasm
Causes of oesophageal hypomotility? What is the effect on oesophagus function?
Associated with CT disease, diabetes, neuropathy
Causes failure of LOS contraction - leads to heartburn and reflux
What is Achalasia?
It is the functional loss of the myenteric plexus in the distal oesophagus and LOS
Failure of LOS to RELAX
Symptoms of achalasia?
Progressive dysphagia for solids and liquids Weight loss Chest pain (30%) Regurgitation Chest infection (?)
Treatment of achalasia?
Smooth muscle relaxants - Nitrates, CCB’s
Endoscopic - botulinum toxin pneumatic balloon dilation (dilation of tube via balloon, inject botox to stop perforation)
Surgical - myotomy (cut the LOS muscles)
Complications of achalasia treatment?
Aspiration pneumonia/lung disease
Increased risk of squamous cell oesophageal carcinoma
Risk factors for gastro-oesophageal reflux disease? (GORD)
Pregnancy Obesity Drugs lowering LOS pressure Smoking Alcohol Hypomotility
What investigations are needed for GORD?
Typical GORD can be diagnosed on symptoms alone
Endoscopy is a poor test
- pH monitoring
- Barium swallow
Aetiology of GORD with normal anatomy?
Can be due to:
- Increased transient relaxations of LOS
- Hypotensive LOS
- Delayed gastric emptying
- Delayed oesophageal emptying
- Reduced oesophageal acid clearance
- Low tissue resistance to acid/bile
Cause of GORD due to anatomical abnormality?
Hiatus Hernia
What is a hiatus hernia?
Where part of your stomach (+/- gastro-oesophageal junction) penetrates the diaphragm into the chest
Types of hiatus hernia? Description? Prevalence?
Sliding - oesophagus + GOJ + part of fundus penetrates the oesophageal hiatus (80%)
Para-oesophageal - fundus penetrates the hiatus, GOJ remains below (15-20%)
Complications of GORD?
Ulceration (5%)
Stricture (8-15%)
Glandular metaplasia (Barrett’s oesophagus)
Carcinoma
What is Barrett’s oesophagus?
It is a change in the epithelium of the lower oesophagus from stratified squamous to mucin secreting columnar cells due to prolonged acid exposure
(eg. from oesophageal to gastric cells in oesophagus)
What gender is more at risk of Barrett’s oesophagus? What is it a risk factor for?
Men»_space; Women
It is a precursor to dysplasia/adenocarcinoma (6% per year risk of developing cancer if high grade dysplasia)
Treatment for Barrett’s Oesophagus?
Endoscopic mucosal resection (EMR)
Radio-Frequency Ablation (RFA - uses heat from medium frequency alternating current)
Oesophagectomy (rarely)
GORD treatment?
In absence of alarm features:
Lifestyle measures
Pharmacological: Alginates (gaviscon) H2RA, proton pump inhibitor (omeprazole, lansoprazole)
Following investigation of alarming symptoms:
Anti-reflux surgery - funcoplication (full/partial wrap)
Types of oesophageal cancer? Which is more common?
Adenocarcinoma and Squamous cell carcinoma
Western Europe/USA - Adenocarcinoma > Squamous
Rest of world - Squamous»_space; Adenocarcinoma
Presentation of oesophageal cancer?
Progressive dysphagia (90%) Anorexia and Weight Loss (75%)
Odynophagia Chest pain Cough Pneumonia (tracheo-oesophageal fistula) Vocal cord paralysis Haematemesis (vomiting blood)
Where does squamous cell carcinoma occur in the oesophagus? Adenocarcinoma?
SCC - proximal and middle 1/3 of oesophagus
Adenocarcinoma - distal oesophagus
Which gender is more at risk of oesophageal cancer?
Males 3:1 Females
Risk factors for squamous cell carcinoma of the oesophagus?
Tobacco
Alcohol
Vitamin deficiency (?)
Associated with - achalasia, caustic strictures, Plummer-Vinson Syndrome
Risk factors for oesophageal adenocarcinoma?
Barrett's oesophagus Obesity Being male Middle age Caucasian Smoking
Why does oesophageal cancer metastasize easily?
- Usually presents late, more time to spread
- Lamina propria of oesophagus is lymph vessel rich (lymph mainly submucosal in rest of GI) so lymphatic invasion readily occurs
Investigations for diagnosis of oesophageal cancer?
Biopsy
Endoscopy
Investigations for staging of oesophageal cancer?
- CT scan
- Endoscopic ultrasound
- PET scan
- Bone scan
Treatment of oesophageal cancer?
Only cure is:
Oesophagectomy +/- adjuvant/neoadjuvant chemo
In patients with non-operable disease combined chemo + radiotherapy can improve long-term survival
Who is eligible for oesophagectomy? Is it a safe surgery? What is post-operative recovery like?
Only patients with localized tumours, without co-morbid disease are eligible. Usually <70 years old too
It is a risky surgery, 10% mortality
Got a long post operative recovery period, where the patient requires nutritional support
What are the options for palliative treatment for those with oesophageal tumours?
Endoscopic surgery (stenting, lazer/APC, Percutaneous endoscopic gastrostomy)
Chemotherapy
Radiotherapy
Brachytherapy
What is eosinophilic oesophagitis?
An eosinophilic infiltration of the oesophageal epithelium in the absence of secondary causes of inflammation
Allergen/immune mediated
Causes oesophageal dysfunction
How does eosinophilic oesophagitis present? What investigations are useful?
Presents with dysphagia and food bolus obstruction
Endoscopy
Treatment of eosinophilic oesophagitis?
Topical/oral corticosteroids
Elimination of dietary allergens
Endoscopic dilatation
