Oesophageal Disorders Flashcards
What is the main mechanism that prevents the reflux of gastric contents into the oesophagus?
Lower oesophageal sphincter
Which two conditions predispose to GORD?
Pregnancy causing increased intra-abdominal pressure
Low LOS pressure
What is a hiatus hernia?
Part of the stomach moves up into the chest
What is a sliding hiatus hernia?
The oesophageal-gastric junction and part of the stomach ‘slide’ through the hiatus so it lies above the diaphragm
What is a rolling or para-oesophageal hiatus hernia?
Part of the funds of the stomach prolapses through the hiatus alongside the oesophagus, while the LOS remains below the diaphragm
What causes 2/3 of reflux in GORD patients?
Transient relaxations of the LOS
What is the acid pocket and what can be used to target it?
An area of unbuffered gastric acid that accumulates in the stomach and serves as a reservoir for reflux.
Targeted with an antacid-alginate combination
What are the clinical features of GORD?
Heartburn (major feature)
Regurgitation
Laryngo-pharyngeal reflux disease
What is heartburn relieved and exacerbated by?
Relived by oral antacids and alginates
Exacerbated by lying down, stooping or bending
Cold liquids and alcohol can cause pain in GORD
True/False
False
HOT liquids and alcohol
What are some factors associated with GORD?
Pregnancy or obesity Large meals Cigarettes Drugs (anti-muscarinics, calcium channel blockers, nitrates) Treatment for achalasia Systemic sclerosis Hiatus hernia
What are the differences between cardiac and reflux pain?
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
What is laryngo-pharyngeal reflux disease?
The transport of gastric contents into the larynx and pharynx usually seen in the context of GORD
Clinical diagnosis for GORD can be made without investigation
True/false
True, but only for under 45s and if there are no alarm symptoms
What are the two aims of investigation for GORD, if it is required?
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
What is seen on endoscopy in oesophagitis?
Streaking oesophagitis and oesophageal ulcers
What are the 4 grades of oesophagitis in the Los Angeles classification?
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
How can approximately half of patient with reflux symptoms be treated?
Antacids
Loss of weight
Raising the head of the bed at night
Reduction in alcohol and smoking, and cessation of smoking
What are the classes of drugs that can be used to treat reflux symptoms?
Alginate-containing antacids
Dopamine antagonist pro-kinetic agents
H2-receptor antagonists
PPIs
What is the usual dosage of alginate-containing antacids and how can they be obtained?
10ml three times daily
Over the counter
What are possible side effects of alginate-containing antacids?
Magnesium-containing antacids may cause diarrhoea
Aluminium-containing antacids may cause constipation
What are examples of dopamine antagonist pro-kinetic agents?
Metoclopramide
Domperidone
When are dopamine antagonist pro-kinetic agents sometimes helpful in GORD, and why are they not as often used?
Helpful to enhance peristalsis and speed gastric emptying
Domperidone may have serious cardiac side effects
What are examples of H2-receptor antagonists?
Cimetidine
Ranitidiine
Famotidine
Nizatidine
When are H2-receptor antagonists used in GORD?
For acid suppression if antacids fail
What are examples of PPIs?
Omeprazole
Rabeprazole
Lansoprazole
Esomeprazole
What is the function of PPIs?
Inhibit gastric H/K/ATPase to reduce gastric acid secretion
When are PPIs used in GORD?
As the drug of choice for all but mild cases
What are some (uncommon) side effects of PPIs?
Osteoporosis
Rise in GI infections
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
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
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
What is done in laparoscopic Nissen fundoplication?
Gastro-oesophageal junction returned to abdominal cavity
Gastric fungus mobilised and the diaphragmatic crura closed
What is done in the Linx reflux management system?
Row of magnets inserted laparoscopically to increase LOS pressure
Which patients tend to get peptic strictures?
Patients over the age of 60
How does a peptic stricture present?
Intermittent dysphagia for solids that worsens gradually over a long time
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
What is Barrett’s oesophagus?
Part of the normal oesophageal squamous epithelium its replaced by metastatic columnar mucosa
What is almost always present in Barrett’s oesophagus?
Hiatus hernia
How is Barrett’s oesophagus diagnosed?
Endoscopy showing displacement of the squamo-columnar junction and biopsy demonstrating columnar lining above proximal gastric folds
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
Who tends to have Barrett’s oesophagus?
Middle-aged obese men with reflux symptoms
What is Barrett’s oesophagus a precursor to?
Oesophageal adenocarcinoma
What is the treatment of choice for endoscopic treatment of dysplastic Barrett’s oesophagus (after removal of any nodular lesions)?
Radiofrequency ablation
What are complications of GORD?
Peptic stricture
Barrett’s oesophagus
What is achalasia?
An oesophageal motility disorder involving oesophageal aperistalsis and impaired relaxation of the LOS.
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
What is the histopathology of achalasia?
Inflammation of the myenteric plexus
Reduction of ganglion cell numbers
What are the first line investigations for achalasia?
Oesophagoscopy
Barium swallow
Manometry
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
What is the initial management for achalasia?
Nifedipine, nitrates or sildenafil
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)
What is the surgical treatment of choice for achalasia and what does it involve?
Heller’s operation
Laparoscopic division of LOS
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
What investigations are used to diagnose oesophageal features of systemic sclerosis?
Manometry or barium swallow
What are the symptoms of oesophageal involvement of systemic sclerosis?
Dysphagia and heartburn
What is diffuse oesophageal spasm?
Severe form of oesophageal dysmotility that can accompany GORD
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
What investigations are done for diffuse oesophageal spasm?
Barium swallow - ‘corkscrew’ oesophagus
Manometry
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
What are abnormalities of motility that can produce dysphagia?
Diabetes Myotonic dystrophy Oculo-pharyngeal muscular dystrophy Myasthenia graves Neurological disorders involving the brainstem
What is a diverticulum that presents immediately above the upper oesophageal sphincter called?
Pharyngeal pouch or Zenker’s diverticulum
What is a diverticulum that presents near the middle of the oesophagus called?
Traction diverticulum
What is a diverticulum that presents just above the LOS called?
Epiphrenic diverticulum
Which oesophageal diverticula are associated with a achalasia?
Epiphrenic diverticula
Which oesophageal diverticula can cause dysphagia and regurgitation?
Pharyngeal pouches
What is an oesophageal web?
A thin membranous flab, covered with squamous epithelium
Where are most oesophageal webs located?
Anteriorly in the post-cricoid region of the cervical oesophagus
What symptom may oesophageal webs produce?
Dysphagia
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
Who is mainly affected by Plummer-Vinson syndrome?
Women
What treatment is given for Plummer-Vinson syndrome?
Dilation of web if necessary
Iron supplements for anaemia
What are the two types of oesophageal ring?
Mucosal (Schatzki’s ring or B ring)
Muscular (A ring)
What are the features of mucosal oesophageal rings?
Located at the squamocolumnar mucosal junction
Common
Associated with history of intermittent bolus obstruction
What are the features of muscular oesophageal rings?
Located more proximal than the mucosal ring
Uncommon
Covered with squamous epithelium
May cause dysphagia
What is the management for oesophageal rings?
Reassurance and dietary advice
Dilation sometimes necessary
May respond to oral PPI
What are the main oesophageal infections?
Candida
Herpes simplex
Cytomegalovirus
TB
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
What features of oesophageal TB can be seen on endoscopy? And what else is associated with it
Deep ulceration
Associated with mediastinal lymphadenopathy
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
What can endoscopy achieve in Mallory-Weiss syndrome?
Diagnosis
Endoscopic clipping for treatment if necessary
What is eosinophilic oesophagitis?
When eosinophils are seen in the oesophageal mucosa where there are usually none
How do patients present in eosinophilic oesophagitis?
Long history of: Dysphagia Food impaction Heartburn Oesophageal pain All caused by eosinophil induced inflammation
How is eosinophilic oesophagitis diagnosed?
Endoscopy with biopsy and calculation of eosinophil numbers
May look normal macroscopically but there are microscopic abnormalities
What is the management for eosinophilic oesophagitis?
- First ,one is topical steroids (fluticasone spread or budesonide syrup)
- Systemic steroids or elimination diet
Some respond to PPis in the absence of GIRD
Dilation sometimes necessary
What is the risk of endoscopic oesophageal dilation, nano-gastric tube insertion, gastroscope or trans-oesophageal echo probe?
Perforation
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
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
How is diagnosis of oesophageal rupture made?
Water-soluble contrast swallow or CT
Where do squamous cell carcinomas, and adenocarcinomas of the oesophagus present?
SCC - upper 2/3
Adenocarcinoma - lower 1/3
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
What are the risk factors for adenocarcinomas of the oesophagus?
Longstanding heartburn Barrett's Tobacco smoking Obesity Breast cancer treated with radiotherapy Older age
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
What are the possible appearances of an oesophageal tumour?
Ulcerative
Proliferative
Scirrhous (extending round oesophageal wall to produce stricture
What are the most common physical signs of oesophageal carcinoma?
Weight loss
Anorexia
Lymphadenopathy
What investigations are used to diagnose oesophageal cancer?
Endoscopy for histological proof
Barium swallow when differential includes motility disorder
What investigations are used for staging of oesophageal carcinoma?
CT of thorax and upper abdomen
Endoscopic US
Laparoscopy
PET
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
When is there a benefit to chemoradiation alone in oesophageal cancer?
Early stage SCC
Nutritional support is vital in oesophageal cancer
True/False
True
