Oesophageal Disorders Flashcards
What sphincter is striated muscle of the right crus of the diaphragm?
Lower oesophageal sphincter
What are symptoms of oesophageal disease?
Heartburn
Often associated with waterbrash, cough
- Certain drugs/foods, (e.g. alcohol, nicotine, dietary xanthines) can reduce the LOS pressure resulting in increased reflux / heartburn
Persistent reflux and heartburn leads to gastro-oesophageal reflux disease (GORD) which can in turn cause long-term complications
Dysphagia
Odynophagia
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 investigations for oesophageal disease?
- Oesophago-Gastro-Duodenoscopy (OGD)
- Upper GI Endoscopy (UGIE)
Contrast radiology - barium swallow
Oesophageal pH and manometry
When is endoscopy used in oesophageal disease?
In oesophageal disease used in investigation of dysphagia or reflux symptoms with alarm features
What is manometry used for?
Used in investigation of dysphagia / suspected motility disorder
What does manometry measure?
-assesses sphincter tonicity, relaxation of sphincters and oesophageal motility.
pH studies – used in investigation of refractory heartburn/reflux
What are the motility disorders of the oesophagus?
Hypermotility
Hypomotility
Achalasia
What portion of motility is controlled by the vagus nerve?
Contraction in the oesophageal body and relaxation of the LOS is mediated by the vagus nerve
What is the appearace of hypermotility on a barium swallow?
Corckscrew appearance on the barium swallow
What is hypermotility often confused with and why?
Often confused with angina/MI becaue there is severe episodic chest pain (with or without dysphagia)
What is hypomotility associated with?
Associated with connective tissue disease,
diabetes, neuropathy
Causes failure of the LOS and therefore causes reflux symptoms
What causes achalasia?
Functional loss of myenteric plexus ganglion cells in distal oesophagus and LOS
What is teh cardinal feature of achalasia?
failure of LOS to relax and therefore distal obstruction of the oesophagus
What are symptoms of achalasia?
- progressive dysphagia for solids and liquids
- weight loss
- Chest pain (30%)
- Regurgitation and chest infection
What is the treatment for achalasia?
Pharmacological - Nitrates,
Calcium Channel blockers
Endoscopic - Botulinum Toxin
Pneumatic balloon dilation
Radiological - Pneumatic balloon
dilation
Surgical - Myotomy
What are the complications of achalasia?
Aspiration pneumonia and lung disease
nIncreased risk of squamous cell oesophageal carcinoma
What causes GORD?
Presence of acid and bile exposure in the lower oesophagus
What are the symptoms of GORD?
Many may not experience any symptoms at all
Symptoms include: heartburn, cough, water brash, sleep disturbance
Waterbrash: a sudden flow of saliva associated with indigestion.
What are the risk factors for GORD?
Pregnancy, obesity, drugs lowering LOS pressure (alcohol, nicotine, dietary xanthines), smoking, alcoholism, hypomotility
Why is endoscopy a poor test for GORD?
Most patients (>50%) with reflux symptoms have no visible evidence of oesophageal abnormality when endoscopy is performed
When must endoscopy be performed for GORD?
In the presence of alarm features eg dysphagia, weight loss, vomiting
What are the aetiologies of GORD with normal anatomy?
– Increasing Transient relaxations of the LOS
–Hypotensive LOS
–Delayed gastric emptying
–Delayed oesophageal emptying
– Decreased Oesophageal acid clearance
– Decreased Tissue resistance to acid/bile
What are the 2 main types of hiatus hernia?
Sliding and para-oesophageal
What part of the stomach moves proximally through the diaphtragmatic hiatus?
Fundus
What are two risk factors for hiatus hernia?
Age and obesity
What is the mucosa exposed to in GORD?
Acid-pepsin and bile
What are the complications associated with GORD?
Ulceration (5%)
Stricture (8-15%)
Glandular metaplasia (Barrett’s oesophagus)
Carcinoma
What is the change in epithelium in barrett’s oesophagus?
Change from squamous to mucin-secreting columnar (ie gastric type) epithelial cells in lower oesophagus
What is barretts oesophagus the precursor for?
Precursor to dysplasia/ adenocarcinoma
Dysplasia: Abnormal cells in a tissue which may signify a stage preceding the development of cancer.
What is treatment for Barretts oesphagus?
–Endoscopic Mucosal Resection (EMR)
–Radio-Frequency Ablation (RFA)
–Oesophagectomy rarely (mortality ~10%)
Without alarm features what is the treatment of GORD?
- Lifestyle measures
- Pharmacological
Alginates (Gaviscon)
H2RA (Ranitidine)
Proton Pump Inhibitor (e.g. Omeprazole, Lansoprazole)
For refractory disease following investigation
Anti-reflux surgery (fundoplication)
What is the incidence of benign tumours?
They are rare
What are the two common types of oesphageal cancer?
Squamous Cell Carcinoma
Adenocarcinoma
What is the prevalence of adenocarcinoma and squamous cell carcinoma in Western europe / USA?
Western Europe/USA Adenocarcinoma > Squamous
Rest of World Squamous >> Adenocarcinoma
What is the presentation of oesophageal cancer?
Progressive dysphagia (90%)
Anorexia and Weight loss (75%)
Odynophagia
Chest pain
Cough
Pneumonia (tracheo-oesophageal fistula)
Vocal cord paralysis
Haematemesis
Where does squamous normally occur in the oespohagus?
In the proximal and middle third of the oesophagus
What are the risk factors for squamous cell carcinoma?
High incidence in Southern Africa, China, Iran
Tobacco and alcohol significant risk factors
Diet related (vitamin deficiency)
Associated with Achalasia, Caustic strictures, Plummer-Vinson Syndrome
Where does adenocarcinoma often occur in the oesophagus?
Occurs in distal oesophagus
What are risk factors for adenocarcinoma?
Associated with Barrett’s oesophagus (progresses through dysplasia to cancer)
Predisposing factors: obesity, male sex, middle age, caucasian
Where do oesophageal cancers often spread?
To regional lymph nodes and or liver at
No peritoneal (serosal) lining in mediastinum – local invasion (heart, trachea, aorta) often limits surgery
Metastases - Hepatic, brain, pulmonary, bone
Why does tumour invasion into adjacent structures occur more easily in the oesophagus?
Oesophagus lacks a serous layer
Why does lymph node involvement occur early in oesophageal tumours?
Oespohagus lymphatic vessels are mucosal (lamina propria)
Vs
Rest of the GIT lymphatic vessels are mainly submucosal
How do we diagnose oesphageal cancer?
How do we stage oesphageal cancer?
–CT Scan
–Endoscopic ultrasound
–PET Scan
–Bone Scan
Disease stagin by TNM classification
TNM classification
TNM staging
T1- Tumor invades lamina propria or submucosa
(a-lamina propria, b-submucosa)
T2- Tumor invades muscularis propria
T3- Tumor invades adventitia
T4- Tumor invades adjacent structures
N1- Regional lymph node metastasis
M1- Distant metastasis
Stage I- T1N0M0
Stage IIa- T2T3/N0M0
Stage IIb- T1T2/N1M0
Stage III- T3N1M0, T4, any N, M0
Stage IV- M1
What is treatment for oesophageal cancer?
Only potential cure is surgical oesophagectomy +/- adjuvant (after) or neoadjuvant (before) chemotherapy
Limited to patients with localised disease, without co-morbid disease, usually <70 years of age
Significant morbidity and mortality assoc with oesophagectomy (mortality ~ 10%)
Long post operative recovery
Require nutritional support
Combined chemo and radiotherapy now offer some prospect of improved long-term survival (ie > 1year) in patients with locally advanced inoperable disease - ? may ultimately offer non-surgical “cure”
What is treatment for incurable disease? (most have incurable disease at presentation)
Symptom pallation (dysphagia) is often overriding priority
OPTIONS:
Endoscopic
(stent, laser/APC, PEG)
Chemotherapy
Radiotherapy
Brachytherapy
