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Y1 - Gatrointestinal > Oesophageal Disorders > Flashcards

Oesophageal Disorders Flashcards

1
Q

What is the main mechanism that prevents the reflux of gastric contents into the oesophagus?

A

Lower oesophageal sphincter

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2
Q

Which two conditions predispose to GORD?

A

Pregnancy causing increased intra-abdominal pressure

Low LOS pressure

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3
Q

What is a hiatus hernia?

A

Part of the stomach moves up into the chest

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4
Q

What is a sliding hiatus hernia?

A

The oesophageal-gastric junction and part of the stomach ‘slide’ through the hiatus so it lies above the diaphragm

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5
Q

What is a rolling or para-oesophageal hiatus hernia?

A

Part of the funds of the stomach prolapses through the hiatus alongside the oesophagus, while the LOS remains below the diaphragm

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6
Q

What causes 2/3 of reflux in GORD patients?

A

Transient relaxations of the LOS

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7
Q

What is the acid pocket and what can be used to target it?

A

An area of unbuffered gastric acid that accumulates in the stomach and serves as a reservoir for reflux.
Targeted with an antacid-alginate combination

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8
Q

What are the clinical features of GORD?

A

Heartburn (major feature)
Regurgitation
Laryngo-pharyngeal reflux disease

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9
Q

What is heartburn relieved and exacerbated by?

A

Relived by oral antacids and alginates

Exacerbated by lying down, stooping or bending

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10
Q

Cold liquids and alcohol can cause pain in GORD

True/False

A

False

HOT liquids and alcohol

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11
Q

What are some factors associated with GORD?

A 
Pregnancy or obesity
Large meals
Cigarettes
Drugs (anti-muscarinics, calcium channel blockers, nitrates)
Treatment for achalasia
Systemic sclerosis
Hiatus hernia
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12
Q

What are the differences between cardiac and reflux pain?

A

Reflux seldom radiates to arm, worse with hot drinks and alcohol, relieved by antacids
Cardiac ischaemic pain is gripping or crushing, radiates to neck or arm, worse with exercise and is accompanied by dyspnoea

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13
Q

What is laryngo-pharyngeal reflux disease?

A

The transport of gastric contents into the larynx and pharynx usually seen in the context of GORD

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14
Q

Clinical diagnosis for GORD can be made without investigation
True/false

A

True, but only for under 45s and if there are no alarm symptoms

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15
Q

What are the two aims of investigation for GORD, if it is required?

A

Assess oesophagitis and hiatal hernia by endoscopy, and if there is oesophagitis or Barrett’s reflux is confirmed
Document reflux by intra-luminal monitoring using 24hr intra-luminal pH monitoring or impedance combined with manometry

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16
Q

What is seen on endoscopy in oesophagitis?

A

Streaking oesophagitis and oesophageal ulcers

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17
Q

What are the 4 grades of oesophagitis in the Los Angeles classification?

A

Grade A: <5mm mucosal breaks confined to mucosal folds
Grade B: some mucosal folds >5mm, confined to the mucosal folds
Grade C: mucosal breaks that are continuous between the tops of mucosal folds but not circumferential
Grade D: extensive mucosal breaks engaging at least 75% of the oesophageal circumference

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18
Q

How can approximately half of patient with reflux symptoms be treated?

A

Antacids
Loss of weight
Raising the head of the bed at night
Reduction in alcohol and smoking, and cessation of smoking

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19
Q

What are the classes of drugs that can be used to treat reflux symptoms?

A

Alginate-containing antacids
Dopamine antagonist pro-kinetic agents
H2-receptor antagonists
PPIs

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20
Q

What is the usual dosage of alginate-containing antacids and how can they be obtained?

A

10ml three times daily

Over the counter

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21
Q

What are possible side effects of alginate-containing antacids?

A

Magnesium-containing antacids may cause diarrhoea

Aluminium-containing antacids may cause constipation

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22
Q

What are examples of dopamine antagonist pro-kinetic agents?

A

Metoclopramide

Domperidone

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23
Q

When are dopamine antagonist pro-kinetic agents sometimes helpful in GORD, and why are they not as often used?

A

Helpful to enhance peristalsis and speed gastric emptying

Domperidone may have serious cardiac side effects

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24
Q

What are examples of H2-receptor antagonists?

A

Cimetidine
Ranitidiine
Famotidine
Nizatidine

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25
Q

When are H2-receptor antagonists used in GORD?

A

For acid suppression if antacids fail

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26
Q

What are examples of PPIs?

A

Omeprazole
Rabeprazole
Lansoprazole
Esomeprazole

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27
Q

What is the function of PPIs?

A

Inhibit gastric H/K/ATPase to reduce gastric acid secretion

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28
Q

When are PPIs used in GORD?

A

As the drug of choice for all but mild cases

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29
Q

What are some (uncommon) side effects of PPIs?

A

Osteoporosis

Rise in GI infections

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30
Q

What are GORD patients who do not respond to PPIs and have continuing symptoms with a normal endoscopy described as having? And what is used for treatment?

A

Non-erosive reflux disease

Isomers of PPIs, such as dexlanoprazole

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31
Q

What is endoluminal gastroplication?

A

An endoscopic procedure where multiple plications or pleats are made below the gastro-oesophageal junction
Causes a benefit in reducing heartburn, acid reflux episodes and PPI usage

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32
Q

When is surgery not performed in GORD?

A

Never for a hiatus hernia alone
Patients with oesophageal dysmotility unrelated to acid reflux
Patients with no response to PPIs
Patients with underlying functional bowel disease

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33
Q

What is done in laparoscopic Nissen fundoplication?

A

Gastro-oesophageal junction returned to abdominal cavity

Gastric fungus mobilised and the diaphragmatic crura closed

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34
Q

What is done in the Linx reflux management system?

A

Row of magnets inserted laparoscopically to increase LOS pressure

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35
Q

Which patients tend to get peptic strictures?

A

Patients over the age of 60

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36
Q

How does a peptic stricture present?

A

Intermittent dysphagia for solids that worsens gradually over a long time

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37
Q

How are peptic strictures managed?

A

Mild cases may respond to PPIs alone
Severe cases need endoscopic dilation and long term PPI therapy
Surgery may be needed if medical treatment fails

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38
Q

What is Barrett’s oesophagus?

A

Part of the normal oesophageal squamous epithelium its replaced by metastatic columnar mucosa

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39
Q

What is almost always present in Barrett’s oesophagus?

A

Hiatus hernia

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40
Q

How is Barrett’s oesophagus diagnosed?

A

Endoscopy showing displacement of the squamo-columnar junction and biopsy demonstrating columnar lining above proximal gastric folds

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41
Q

What are the types of ways Barrett’s oesophagus can form?

A

Continual circumferential sheet
Finger-like projections extending upwards from the squamous-columnar junction
Islands of columnar mucosal interspersed with areas of squamous mucosa

42
Q

Who tends to have Barrett’s oesophagus?

A

Middle-aged obese men with reflux symptoms

43
Q

What is Barrett’s oesophagus a precursor to?

A

Oesophageal adenocarcinoma

44
Q

What is the treatment of choice for endoscopic treatment of dysplastic Barrett’s oesophagus (after removal of any nodular lesions)?

A

Radiofrequency ablation

45
Q

What are complications of GORD?

A

Peptic stricture

Barrett’s oesophagus

46
Q

What is achalasia?

A

An oesophageal motility disorder involving oesophageal aperistalsis and impaired relaxation of the LOS.

47
Q

How does achalasia present?

A

Long history of intermittent dysphagia for both solids and liquids form onset.
Regurgitation of food
Spontaneous chest pain due to oesophageal spasm

48
Q

What is the histopathology of achalasia?

A

Inflammation of the myenteric plexus

Reduction of ganglion cell numbers

49
Q

What are the first line investigations for achalasia?

A

Oesophagoscopy
Barium swallow
Manometry

50
Q

What are investigations that can be done for achalasia that are not first line and why might they be done?

A

CXR

CT scan - excludes distal oesophageal cancer

51
Q

What is the initial management for achalasia?

A

Nifedipine, nitrates or sildenafil

52
Q

What procedures can be done for achalasia?

A

Endoscopic dilation of the LOS using a pneumatic balloon under x-ray to weaken the sphincter
Intra-sphincteric injection of botulinum toxin A (safer and simpler than dilation)

53
Q

What is the surgical treatment of choice for achalasia and what does it involve?

A

Heller’s operation

Laparoscopic division of LOS

54
Q

What are the oesophageal features of systemic sclerosis?

A

Diminished peristalsis and oesophageal clearance due to replacement of smooth muscle by fibrous tissue
LOS pressure is decreased, allowing reflux
Strictures may develop

55
Q

What investigations are used to diagnose oesophageal features of systemic sclerosis?

A

Manometry or barium swallow

56
Q

What are the symptoms of oesophageal involvement of systemic sclerosis?

A

Dysphagia and heartburn

57
Q

What is diffuse oesophageal spasm?

A

Severe form of oesophageal dysmotility that can accompany GORD

58
Q

What are the features and symptoms of diffuse oesophageal spasm?

A

Swallowing is accompanies by marked contractions of the oesophagus without normal peristalsis
Can sometimes produce retrosternal chest pain and dysphagia

59
Q

What investigations are done for diffuse oesophageal spasm?

A

Barium swallow - ‘corkscrew’ oesophagus

Manometry

60
Q

What is the management for diffuse oesophageal spasm?

A

PPIs if reflux is a factor
Anti-spasmodics, nitrates, calcium channel blockers
Occasionally balloon dilation or longitudinal oesophageal myotomy needed

61
Q

What are abnormalities of motility that can produce dysphagia?

A 
Diabetes
Myotonic dystrophy
Oculo-pharyngeal muscular dystrophy
Myasthenia graves
Neurological disorders involving the brainstem
62
Q

What is a diverticulum that presents immediately above the upper oesophageal sphincter called?

A

Pharyngeal pouch or Zenker’s diverticulum

63
Q

What is a diverticulum that presents near the middle of the oesophagus called?

A

Traction diverticulum

64
Q

What is a diverticulum that presents just above the LOS called?

A

Epiphrenic diverticulum

65
Q

Which oesophageal diverticula are associated with a achalasia?

A

Epiphrenic diverticula

66
Q

Which oesophageal diverticula can cause dysphagia and regurgitation?

A

Pharyngeal pouches

67
Q

What is an oesophageal web?

A

A thin membranous flab, covered with squamous epithelium

68
Q

Where are most oesophageal webs located?

A

Anteriorly in the post-cricoid region of the cervical oesophagus

69
Q

What symptom may oesophageal webs produce?

A

Dysphagia

70
Q

What is Plummer-Vinson’s syndrome?

A

An oesophageal web is associated with chronic iron deficiency anaemia, glossitis and angular stomatitis.
The web may be difficult to see on endoscope and endoscope may unintentionally rupture it

71
Q

Who is mainly affected by Plummer-Vinson syndrome?

A

Women

72
Q

What treatment is given for Plummer-Vinson syndrome?

A

Dilation of web if necessary

Iron supplements for anaemia

73
Q

What are the two types of oesophageal ring?

A

Mucosal (Schatzki’s ring or B ring)

Muscular (A ring)

74
Q

What are the features of mucosal oesophageal rings?

A

Located at the squamocolumnar mucosal junction
Common
Associated with history of intermittent bolus obstruction

75
Q

What are the features of muscular oesophageal rings?

A

Located more proximal than the mucosal ring
Uncommon
Covered with squamous epithelium
May cause dysphagia

76
Q

What is the management for oesophageal rings?

A

Reassurance and dietary advice
Dilation sometimes necessary
May respond to oral PPI

77
Q

What are the main oesophageal infections?

A

Candida
Herpes simplex
Cytomegalovirus
TB

78
Q

What features of oesophageal candidiasis can be seen on endoscopy? And how is it confirmed?

A

White plaques
Examining a smear taken endoscopically
Infections can be mixed though so cultures and biopsies must be performed

79
Q

What features of oesophageal TB can be seen on endoscopy? And what else is associated with it

A

Deep ulceration

Associated with mediastinal lymphadenopathy

80
Q

What is Mallory-Weiss Syndrome?

A

A tear in the gastro-oesophageal junction that causes bleeding, and is produced by a sudden increase in intra-abdominal pressure

81
Q

What can endoscopy achieve in Mallory-Weiss syndrome?

A

Diagnosis

Endoscopic clipping for treatment if necessary

82
Q

What is eosinophilic oesophagitis?

A

When eosinophils are seen in the oesophageal mucosa where there are usually none

83
Q

How do patients present in eosinophilic oesophagitis?

A 
Long history of:
Dysphagia
Food impaction
Heartburn
Oesophageal pain
All caused by eosinophil induced inflammation
84
Q

How is eosinophilic oesophagitis diagnosed?

A

Endoscopy with biopsy and calculation of eosinophil numbers

May look normal macroscopically but there are microscopic abnormalities

85
Q

What is the management for eosinophilic oesophagitis?

A
  1. First ,one is topical steroids (fluticasone spread or budesonide syrup)
  2. Systemic steroids or elimination diet
    Some respond to PPis in the absence of GIRD
    Dilation sometimes necessary
86
Q

What is the risk of endoscopic oesophageal dilation, nano-gastric tube insertion, gastroscope or trans-oesophageal echo probe?

A

Perforation

87
Q

What is the management for oesophageal perforation?

A

Place an expanding covered oesophageal stent which seals the hole
Water-soluble contrast X-ray to check seal

88
Q

What is the presentation of a typical case of oesophageal rupture?

A

Violent vomiting, producing severe chest pain and collapse
May follow alcohol ingestion
CXR shows hydropneumothorax

89
Q

How is diagnosis of oesophageal rupture made?

A

Water-soluble contrast swallow or CT

90
Q

Where do squamous cell carcinomas, and adenocarcinomas of the oesophagus present?

A

SCC - upper 2/3

Adenocarcinoma - lower 1/3

91
Q

What are the risk factors for SCC of the oesophagus?

A 
Excess alcohol
Tobacco smoking
Obesity and poor diet
Plummer-Vinson syndrome
Achalasia
Corrosive strictures
Coeliac disease
Breast cancer treated with radiotherapy
Tylosis
92
Q

What are the risk factors for adenocarcinomas of the oesophagus?

A 
Longstanding heartburn
Barrett's
Tobacco smoking
Obesity
Breast cancer treated with radiotherapy
Older age
93
Q

What are the clinical features of oesophageal carcinoma?

A 
Dysphagia - progressive, for solids first then liquids a few weeks later
Pain caused by impaction of food
Weight loss
Difficulty in swallowing saliva
Cough
Difficulty in aspiration into lungs
94
Q

What are the possible appearances of an oesophageal tumour?

A

Ulcerative
Proliferative
Scirrhous (extending round oesophageal wall to produce stricture

95
Q

What are the most common physical signs of oesophageal carcinoma?

A

Weight loss
Anorexia
Lymphadenopathy

96
Q

What investigations are used to diagnose oesophageal cancer?

A

Endoscopy for histological proof

Barium swallow when differential includes motility disorder

97
Q

What investigations are used for staging of oesophageal carcinoma?

A

CT of thorax and upper abdomen
Endoscopic US
Laparoscopy
PET

98
Q

What neo-adjuvant therapy is there for oesophageal carcinoma?

A

Pre-operative chemoradiation therapy may benefit patients with stage 2b and 3 disease.
Combination of endoscopic dilation with laser or bradytherapy prolongs luminal patency

99
Q

When is there a benefit to chemoradiation alone in oesophageal cancer?

A

Early stage SCC

100
Q

Nutritional support is vital in oesophageal cancer

True/False

A

True

Y1 - Gatrointestinal (31 decks)

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