Oesophageal disorders Flashcards
At what veretbral levels does the oesophagus start and finish?
Begins at lower level of cricoid cartilage (C6), terminates at T11-12 where it enters the stomach
What are the varying muscle types of muscle in the oesophagus?
Upper 3/4cm is striated (skeletal) muscle
Remainder is smooth muscle
(although other lectures say its the top 1/3rd that is skeletal)
What type of lining is in the oesophagus?
Non-keritanised stratified squamous
What muscles produce peristaltic movement for food in the oesophagus?
Circular muscles in Muscularis externa
What mediates peristaltic contractions in the oesophagus and relaxation of the Lower oesophageal sphincter?
The vagus nerve
Peristalsis and LOS relaxation are coordinated
What ligament attaches the oesophagus to the diaphragm?
Phreno-oesophageal ligament
What is the name given to this area in the stomach?
(blocked out label)
Mucosal rosette
Formed by the ‘Angle of His’
What is heartburn?
Retrosternal discomfort or burning
How would heartburn present?
- Retrosternal discomfort or burning feeling
- Sometimes experienced with:
- Waterbrash (sudden rush of saliva)
- Cough
What causes heartburn?
Consequence of reflux of acidic &/or bilious gastric contents into the oesophagus
What causes reflux?
Certain drugs/foods:
- Alcohol
- nicotine
- dietary xanthines (caffeine etc I think)
These lower the LOS pressure leading to increased reflux
However, there is a degree of reflux that takes place normally (after swallowing etc)
What is the problem with having persistant relfux/heartburn?
Gastro-oesophageal reflux disease (GORD) can develop
This can in turn cause long-term complications
What is dysphagia?
Subjective sensation of difficulty in swallowing foods and/or liquids
What is the difference between Dysphagia and Odynophagia?
Dysphagia - Difficulty swallowing
Odynophagia - Pain with swallowing
(often accompany eachother)
What aspects of a a patient’s dysphagia is it important to ask about in histories?
- Type of food (solid vs liquid)
- Pattern (progressive, intermittent)
- Associated features (weight loss, regurgitation, cough
What are the possible locations of dysphagia?
Oropharyngeal
Oesophageal
What are the causes of oesophageal dysphagia?
- Benign stricture
- Malignant stricture (oesophageal cancer)
- Motility disorders (eg achalasia, presbyoesophagus)
- Eosinophilic oesophagitis
- Extrinsic compression (eg in lung cancer)
What are the investigations for oesophageal disease (Reflux etc)
Endoscopy:
- Oesophago-Gastro-duodenoscopy (OGD)
- Upper GI endoscopy (UGIE)
Imaging:
- Barium swallow
Other:
- pH monitoring
- Manometry
When is Endoscopy used for investigation in oesophageal disease?
used in investigation of dysphagia or reflux symptoms with alarm features
Endoscopy is pretty much always first line for this (preferred to Barium swallows)
How does pH monitoring of the oesophagus work and when is it done?
Nasal catheter containing pH sensors at both sphincters (UOS and LOS) sphincters is placed in oesophagus
used in investigation of refractory heartburn/reflux
How does Manometry work and when is it used?
Nasal catheter containing multiple pressure sensors is placed in oesophagus to assess its motility
used in investigation of dysphagia / suspected motility disorder (usually after endoscopy)
What are the different types of motility disorders?
Hypermotility (oesophageal spasm)
Hypomotility
Achalasia
How does Hypermotility of the oesophagus present?
Severe episodic chest pain +/- dysphagia
(Easily confused with angina/MI)
How is hypermotility of the oesophagus investigated?
Barium swallow - will show corkscrew appearance
Manometry - exaggerated, uncoordinated, hypertonic contractions
How is hypermotility treated?
Smooth muscle relaxants
What conditions is hypomotility associated with?
Associated with connective tissue disease, diabetes, neuropathy
How does hypomotility present?
Retrosternal pain +/- dysphagia
Hypomotility causes the LOS to fail, meaning the symptoms are similar to reflux/heartburn
What is achalasia?
Functional loss of myenteric plexus ganglion cells in distal oesophagus and LOS
This means the LOS can not relax resulting in functional distal oesophagus obstruction (stays shut)
How does achalasia present?
Symptoms:
- progressive dysphagia for solids and liquids
- weight loss
- Chest pain (30%)
- Regurgitation and chest infection
Epidem:
- 30-50s is usual age
- M = F
What causes Achalasia?
Dont really know but in sites of nerve destruction, there is often Lymphocytic infiltration
An inflammatory aetiology is suspected…
How is achalasia treated?
Drugs:
- Nitrates, Calcium channel blockers
Endoscopic:
- Botulinum Toxin/Pneumatic balloon dilation
Radiological:
- Pneumatic balloon dilation
Surgical:
- Myotomy
What are the complications of achalasia?
Higher risk of:
- Aspiration pneumonia & Lung disease
- Squamous cell oesophageal carcinoma
What is GORD?
Gastro-oesophageal reflux disease
Caused by weakening of LOS due to pathological acid (and bile) exposure in lower oesophagus
What are the symptoms of GORD?
- Heartburn
- cough
- waterbrash
- sleep disturbance
What are the risk factors for GORD?
- Pregnancy
- obesity
- drugs lowering LOS pressure (smooth muscle relaxants?)
- smoking
- alcoholism
- hypomotility
Describe the epidemiology of GORD?
- Men > Women
- Caucasian > Black > Asian
How is GORD investigated?
Diagnosis of GORD can be made based on symptoms alone
Endoscopy is a poor diagnostic tool for GORD, and should only be performed if there are ALARM features suggestive of malignancy etc
Describe the aetiology of GORD without anatomical abnormalities
- 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 anatomical abnormality can cause GORD?
Hiatus Hernia
What predisposes someone to developing a hiatus hernia?
Obesity
Older age
