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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
When are H2-receptor antagonists used in GORD?
For acid suppression if antacids fail
26
What are examples of PPIs?
Omeprazole Rabeprazole Lansoprazole Esomeprazole
27
What is the function of PPIs?
Inhibit gastric H/K/ATPase to reduce gastric acid secretion
28
When are PPIs used in GORD?
As the drug of choice for all but mild cases
29
What are some (uncommon) side effects of PPIs?
Osteoporosis | Rise in GI infections
30
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?
Non-erosive reflux disease | Isomers of PPIs, such as dexlanoprazole
31
What is endoluminal gastroplication?
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
32
When is surgery not performed in GORD?
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
33
What is done in laparoscopic Nissen fundoplication?
Gastro-oesophageal junction returned to abdominal cavity | Gastric fungus mobilised and the diaphragmatic crura closed
34
What is done in the Linx reflux management system?
Row of magnets inserted laparoscopically to increase LOS pressure
35
Which patients tend to get peptic strictures?
Patients over the age of 60
36
How does a peptic stricture present?
Intermittent dysphagia for solids that worsens gradually over a long time
37
How are peptic strictures managed?
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
38
What is Barrett's oesophagus?
Part of the normal oesophageal squamous epithelium its replaced by metastatic columnar mucosa
39
What is almost always present in Barrett's oesophagus?
Hiatus hernia
40
How is Barrett's oesophagus diagnosed?
Endoscopy showing displacement of the squamo-columnar junction and biopsy demonstrating columnar lining above proximal gastric folds
41
What are the types of ways Barrett's oesophagus can form?
Continual circumferential sheet Finger-like projections extending upwards from the squamous-columnar junction Islands of columnar mucosal interspersed with areas of squamous mucosa
42
Who tends to have Barrett's oesophagus?
Middle-aged obese men with reflux symptoms
43
What is Barrett's oesophagus a precursor to?
Oesophageal adenocarcinoma
44
What is the treatment of choice for endoscopic treatment of dysplastic Barrett's oesophagus (after removal of any nodular lesions)?
Radiofrequency ablation
45
What are complications of GORD?
Peptic stricture | Barrett's oesophagus
46
What is achalasia?
An oesophageal motility disorder involving oesophageal aperistalsis and impaired relaxation of the LOS.
47
How does achalasia present?
Long history of intermittent dysphagia for both solids and liquids form onset. Regurgitation of food Spontaneous chest pain due to oesophageal spasm
48
What is the histopathology of achalasia?
Inflammation of the myenteric plexus | Reduction of ganglion cell numbers
49
What are the first line investigations for achalasia?
Oesophagoscopy Barium swallow Manometry
50
What are investigations that can be done for achalasia that are not first line and why might they be done?
CXR | CT scan - excludes distal oesophageal cancer
51
What is the initial management for achalasia?
Nifedipine, nitrates or sildenafil
52
What procedures can be done for achalasia?
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
What is the surgical treatment of choice for achalasia and what does it involve?
Heller's operation | Laparoscopic division of LOS
54
What are the oesophageal features of systemic sclerosis?
Diminished peristalsis and oesophageal clearance due to replacement of smooth muscle by fibrous tissue LOS pressure is decreased, allowing reflux Strictures may develop
55
What investigations are used to diagnose oesophageal features of systemic sclerosis?
Manometry or barium swallow
56
What are the symptoms of oesophageal involvement of systemic sclerosis?
Dysphagia and heartburn
57
What is diffuse oesophageal spasm?
Severe form of oesophageal dysmotility that can accompany GORD
58
What are the features and symptoms of diffuse oesophageal spasm?
Swallowing is accompanies by marked contractions of the oesophagus without normal peristalsis Can sometimes produce retrosternal chest pain and dysphagia
59
What investigations are done for diffuse oesophageal spasm?
Barium swallow - 'corkscrew' oesophagus | Manometry
60
What is the management for diffuse oesophageal spasm?
PPIs if reflux is a factor Anti-spasmodics, nitrates, calcium channel blockers Occasionally balloon dilation or longitudinal oesophageal myotomy needed
61
What are abnormalities of motility that can produce dysphagia?
``` Diabetes Myotonic dystrophy Oculo-pharyngeal muscular dystrophy Myasthenia graves Neurological disorders involving the brainstem ```
62
What is a diverticulum that presents immediately above the upper oesophageal sphincter called?
Pharyngeal pouch or Zenker's diverticulum
63
What is a diverticulum that presents near the middle of the oesophagus called?
Traction diverticulum
64
What is a diverticulum that presents just above the LOS called?
Epiphrenic diverticulum
65
Which oesophageal diverticula are associated with a achalasia?
Epiphrenic diverticula
66
Which oesophageal diverticula can cause dysphagia and regurgitation?
Pharyngeal pouches
67
What is an oesophageal web?
A thin membranous flab, covered with squamous epithelium
68
Where are most oesophageal webs located?
Anteriorly in the post-cricoid region of the cervical oesophagus
69
What symptom may oesophageal webs produce?
Dysphagia
70
What is Plummer-Vinson's syndrome?
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
Who is mainly affected by Plummer-Vinson syndrome?
Women
72
What treatment is given for Plummer-Vinson syndrome?
Dilation of web if necessary | Iron supplements for anaemia
73
What are the two types of oesophageal ring?
Mucosal (Schatzki's ring or B ring) | Muscular (A ring)
74
What are the features of mucosal oesophageal rings?
Located at the squamocolumnar mucosal junction Common Associated with history of intermittent bolus obstruction
75
What are the features of muscular oesophageal rings?
Located more proximal than the mucosal ring Uncommon Covered with squamous epithelium May cause dysphagia
76
What is the management for oesophageal rings?
Reassurance and dietary advice Dilation sometimes necessary May respond to oral PPI
77
What are the main oesophageal infections?
Candida Herpes simplex Cytomegalovirus TB
78
What features of oesophageal candidiasis can be seen on endoscopy? And how is it confirmed?
White plaques Examining a smear taken endoscopically Infections can be mixed though so cultures and biopsies must be performed
79
What features of oesophageal TB can be seen on endoscopy? And what else is associated with it
Deep ulceration | Associated with mediastinal lymphadenopathy
80
What is Mallory-Weiss Syndrome?
A tear in the gastro-oesophageal junction that causes bleeding, and is produced by a sudden increase in intra-abdominal pressure
81
What can endoscopy achieve in Mallory-Weiss syndrome?
Diagnosis | Endoscopic clipping for treatment if necessary
82
What is eosinophilic oesophagitis?
When eosinophils are seen in the oesophageal mucosa where there are usually none
83
How do patients present in eosinophilic oesophagitis?
``` Long history of: Dysphagia Food impaction Heartburn Oesophageal pain All caused by eosinophil induced inflammation ```
84
How is eosinophilic oesophagitis diagnosed?
Endoscopy with biopsy and calculation of eosinophil numbers | May look normal macroscopically but there are microscopic abnormalities
85
What is the management for eosinophilic oesophagitis?
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
What is the risk of endoscopic oesophageal dilation, nano-gastric tube insertion, gastroscope or trans-oesophageal echo probe?
Perforation
87
What is the management for oesophageal perforation?
Place an expanding covered oesophageal stent which seals the hole Water-soluble contrast X-ray to check seal
88
What is the presentation of a typical case of oesophageal rupture?
Violent vomiting, producing severe chest pain and collapse May follow alcohol ingestion CXR shows hydropneumothorax
89
How is diagnosis of oesophageal rupture made?
Water-soluble contrast swallow or CT
90
Where do squamous cell carcinomas, and adenocarcinomas of the oesophagus present?
SCC - upper 2/3 | Adenocarcinoma - lower 1/3
91
What are the risk factors for SCC of the oesophagus?
``` Excess alcohol Tobacco smoking Obesity and poor diet Plummer-Vinson syndrome Achalasia Corrosive strictures Coeliac disease Breast cancer treated with radiotherapy Tylosis ```
92
What are the risk factors for adenocarcinomas of the oesophagus?
``` Longstanding heartburn Barrett's Tobacco smoking Obesity Breast cancer treated with radiotherapy Older age ```
93
What are the clinical features of oesophageal carcinoma?
``` 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
What are the possible appearances of an oesophageal tumour?
Ulcerative Proliferative Scirrhous (extending round oesophageal wall to produce stricture
95
What are the most common physical signs of oesophageal carcinoma?
Weight loss Anorexia Lymphadenopathy
96
What investigations are used to diagnose oesophageal cancer?
Endoscopy for histological proof | Barium swallow when differential includes motility disorder
97
What investigations are used for staging of oesophageal carcinoma?
CT of thorax and upper abdomen Endoscopic US Laparoscopy PET
98
What neo-adjuvant therapy is there for oesophageal carcinoma?
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
When is there a benefit to chemoradiation alone in oesophageal cancer?
Early stage SCC
100
Nutritional support is vital in oesophageal cancer | True/False
True

Y1 - Gatrointestinal (31 decks)

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