Oesophageal Disorders Flashcards
1
Q
What is the length of the oesophagus?
A
25cm
2
Q
Where does the oesophagus begin and end?
A
Begins at lower level of cricoid cartilage (C6)
Terminates at T11-T12 where it enters the stomach
3
Q
What kind of muscle is present in the oesophagus?
A
Upper 1/3 is skeletal muscle
Lower 2/3 is smooth muscle
4
Q
What is the classification of the epithelium in the oesophagus?
A
Stratified squamous non-keratinised epithelium
5
Q
What is the function of the oesophagus?
A
Transport food/liquid from the mouth to the stomach which is an active process
6
Q
What propels swallowed materials into the stomach?
A
Oesophageal peristalsis
7
Q
What produces oesophageal peristalsis?
A
Oesophageal circular muscles
8
Q
What must the oesophageal circular muscles coordinate with so that food can enter the stomach?
A
Lower oesophageal sphincter (LOS)
9
Q
What must the LOS do to allow food to enter the stomach?
A
Relax
10
Q
What is contraction in the oesophageal body (peristalsis) and relaxation of the LOS mediated by?
A
Vagus nerve
11
Q
What forms the LOS?
A
Striated muscle of the right crus of diaphragm
12
Q
What is formed by the acute angle of His at gastro-oesophageal junction?
A
Mucosal rosette (Redundant mucosal folds)
13
Q
What does GOJ stand for?
A
Gastro-oesophageal junction
14
Q
What is the resting pressure like in distal smooth muscle of oesophagus?
A
High resting pressure due to LOS
15
Q
What are key symptoms of oesophageal disease?
A
Heartburn
Dysphagia
16
Q
What is heartburn?
A
Retrosternal discomfort or burning
17
Q
What can heartburn be associated with?
A
Waterbrash (sudden flow of saliva)
Cough
18
Q
What is a sudden flow of saliva called?
A
Waterbrash
19
Q
What is heartburn a consequence of?
A
Reflux of acidic and/or bilious gastric contents into oesophagus
20
Q
What do things that reduce LOS pressure result in?
A
Increased reflux/heartburn
21
Q
What are examples of things that can reduce LOS pressure?
A
Drugs (dietary xanthines, alcohol, nicotine)
Food
22
Q
What does persistent reflux and heartburn lead to?
A
Gastro-oesophageal Reflux disease (GORD)
23
Q
What does GORD stand for?
A
Gastro-oesophageal reflex disease
24
Q
What is dysphagia?
A
Subjective sensation of difficulty in swallowing foods and/or liquids
25
What often accompanies dysphagia?
Odynophagia (pain when swallowing)
26
What is pain when swallowing called?
Odynophagia
27
What should you enquire about when a patient presents with dysphagia?
Type of food (solid v liquid)
Pattern (progressive, intermittent)
Associated features (weight loss, regurgitation, cough)
28
Where can the location of dysphagia be?
Oropharyngeal (part of throat behind the mouth)
Oesophageal
29
What is the part of the throat behind the mouth called?
Oropharyngeal
30
What are some possible causes of dysphagia?
Benign stricture
Malignant stricture (oesophageal cancer)
Motility disorders
Eosinophilic oesophagitis
Extrinsic compression (such as lung cancer0
31
What is eosinophilic oesophagitis?
Allergic inflammatory condition of the oesophagus
32
What are examples of motility disorders?
Achalasia
Presbyoesophagus
33
What are the main investigations done for oesophageal disease?
Endoscopy
Contrast radiology
Oesophageal pH and manometry
34
What is an endoscopy?
Procedure where the inside of the body is examined using an endoscope (long, thin, flexible tube) that has a light source and camcer at one end
35
What are examples of different endoscopies that can examine the oesophagus?
Oesophago-gastro-duodenoscopy (OGD)
Upper GI endoscopy
36
What does OGD stand for?
Oesophageal-gastro-duodenalscopy
37
What does UGIE stand for?
Upper GI endoscopy
38
What is an exampe of a contrast radiology that can be used to examine the oesophagus?
Barium swallow
39
What is an oesophageal pH and manometry?
Naso-gastric catheter containing pressure and pH sensors placed in oesophagus
40
Where are the probs for a oesophageal pH and manometry placed?
At both UOS and LOS
41
Why is manometry used in investigations of dysphagia?
To assess sphincter tonicity, relaxation of sphincters and oesophagus
42
What does manometry messure?
Pressure
43
What are pH studies of the oesophagus used to investigate?
Refractory hearburn/reflux
44
What is manometry of the oesophagus used to investigate?
Dysphagia/suspected motility disorder
45
What are the 2 categories of motility disorders?
Hypermotility
Hypomotility
46
What is an example of hypermotility disorder?
Diffuse oesophageal spasm
47
What can be seen on a barium swallow for oesophageal spasm?
Corkscrew appearance
48
What is the common presentation of oesophageal spasms?
Severe, episodic chest pain with or without dysphagia
49
What is oesophageal spasm often confused with?
Angina/MI
50
What does a manometry for oesophageal spasms show?
Exaggerated, uncoordinated, hypertonic contractions
51
What are hypermotility disorders?
Abnormal or excessive movement of the oesophagus
52
What are hypomotility disorders?
Abnormal deficiency of movement of the oesophagus
53
What are hypomobility disorders associated with?
Connective tissue disease
Diabetes
Neuropathy
54
What do hypomobility disorders lead to?
Failure of LOS leading to heartburn and reflux symptoms
55
What is achalasia?
Functional loss of myenteric plexus ganglion cells in distal oesophagus and LOS
56
What is the incidence of achalasia?
1-2/100000
57
What is the male:female incidence of achalasia?
1:1
58
What age does achalasia usually onset?
30-50
59
How does achalasia affect the LOS?
Causes failure of the LOS to relax, resulting in obstruction of the distal oesophagus
60
What are symptoms of achalasia?
Progressive dysphagia for solids and liquids
Weight loss
Chest pain
Regurgitation and chest infection
61
What investigations are done for achalasia?
Manometry
62
What does a manometry show for achalasia?
High pressure at LOS (usually 45mmHg above normal, normal being 10mmHg)
Failure of LOS to relax after swallowing
Absence of peristaltic contractions in lower oesophagus
63
What is the normal pressure of the LOS?
10mmHg
64
What is the treatment for achalasia?
Pharmacological - nitrates, calcium channel blockers
Endoscopic - botulinum toxin, pneumatic balloon dilation
Radiological - pneumatic balloon dilatin
Surgical - myotomy
65
What is a myotomy?
Cut away outer layers of tissue from lower oesophagus
66
What are possible complications of achalasia\>
Aspiration pneumonia and lung disease
Increased risk of squamous cell oesophageal carcinoma
67
What causes GORD?
Pathological acid and bile exposure in lower oesophagus
68
What are symptoms of GORD?
Heartburn
Cough
Water brash
Sleep disturbances
69
What are risk factors for GORD?
Pregnancy
Obesity
Drugs lowering LOS pressure
Smoking
Alcoholism
Hypomotility
70
What is the male:female ratio for GORD?
Men are affected more than woman
71
How does ethnicity change risk of GORD?
Caucasians more than black more than asian
72
What can GORD be diagnosed on?
Basis of characteristic symptoms without diagnosed testing
73
What can be said about endoscopies and diagnosing GORD?
Poor diagnostic test due to \>50% having no visible evidence of oesophageal abnormalities
But it must be performed in presence of alarming features suggesting malignancy
74
What are alarming features that could suggest malignancy and so an endoscopy must be performed?
Dysphagia
Weight loss
Vomiting
75
What is GORD aeitology?
Increase in transient relaxations of LOS
Hypotensive LOS
Delayed gastric emptying
Delayed oesophageal emptying
Decreased oesophageal acid clearance
Decreased tissue resistance to acid/bile
Anatomical distortion of the OGJ
76
What are the 2 types of hiatus hernia?
Sliding
Para-oesophageal
77
What happens in a hiatus hernia?
Stomach moves proximally through the diaphragmatic hiatus
78
What does a hiatus hernia likely occur due to?
Obesity and aging
79
Explain GORD pathophysiology?
Mucosa exposed to acid-pepsin and bile
Increased cell loss and regenerative ability (ie inflammation)
Erosive oesophagitis
80
What are examples of GORD complications?
Ulceration (5%)
Stricture (8-15%)
Glandular metaplasia (Barrett's oesophagus)
Carcinoma
81
82
Does treatment occur with or without investigation for GORD in the absence of alarming features?
Without investigation
83
What is the treatment for GORD?
Lifestyle measures
Pharmacological - alginates (gaviscon), H2RA (Ranitidine), proton pump inhibitor (such as omeprazole or lansoprazole)
Surgery - anti reflux surgery (fundoplication)
84
What is fundoplication?
Full or partial wrap of stomach around the oesophagus
85
What is Barrett's oesophagus?
Metaplasia related to prolonged acid exposure in distal oesophagus
86
What changes in Barrett's oesophagus?
Stratified squamous epithelium of oesophagus changes to glandular
87
What is Barrett's oesophagus a precurser for?
Dysplasia/adenocarcinoma
88
What is the male:female ratio of Barrett's oesophagus?
Males are affected more than females
89
What is the treatment for Barrett's oesophagus?
Endoscopic mucosal resection (EMR)
Radio-frequency ablation (RFA)
Oesophagectomy rarely
90
What is endoscopic mucosal resection (EMR)?
Procedure to remove early stage cancer from lining of digestive tract
91
What does EMR stand for?
Endoscopic mucosa resection
92
What is radio-frequency ablation?
Tumour is ablated using the heat generated from medium frequency alternating current
93
What does RFA stand for?
Radiofrequency ablation
94
What is the procedure called where part or all of the oesophagus is removed?
Oesophagectomy
95
How common are benign tumours for oesophageal cancer?
Rare, are usually malignant
96
What are the two histological types of oesophageal cancer?
Squamous cell carcinoma
Adenocarcinoma
97
Where is oesophageal cancer in the world cancer mortality rankings?
5th
98
What is the male:female ratio of oesophageal cancer?
3:1
99
What is more common out of adenocarcinoma and squamous cell carcinoma?
Adenocarcinoma in Western Europe and USA, squamous cell carcinoma everywhere else
100
What is the presentation of oesophageal cancer?
**Progressive dysphagia (90%)**
**Anorexia and weight loss (75%)**
Odynophagia
Chest pain
Cough
Pneumonia (due to trachea-oesophageal fistula)
Vocal cord paralysis
Haematemesis
101
Where in the oesophagus do squamous cell carcinomas usually occur?
Proximal and middle third of oesophagus
102
What are squamous cell carcinomas preceded by?
Dysplasia and carcinoma in situ
103
What is carcinoma in situ?
Group of abnormal cells that are considered to be pre-cancer
104
What are significant risk factors for squamous cell carcinoma?
Tobacco
Alcohol use
Diet is potentially related (vitamin deficiencys
105
What is squamous cell carcinoma associated with?
Achalasia
Caustic strictures
Plummer-Vinson syndrome
106
Where do adenocarcinoma usually occur?
Distal oeophagus
107
What is adenocarcinoma associated with?
Barrett's oesophagus
108
What are risk factors for adenocarcinoma?
Obesity
Male sex
Middle age
Caucasian
109
What is the physical appearance of squamous cell carcinomas normally?
Large exophytic (grows outwards) occluding tumour
110
Where do tumours of oesophageal cancer commonly spread to?
Regional lymph nodes (due to lamina propria having rich lymphatic supply)
Liver
111
Why does oesophageal invasion to the heart, trachea or aorta often limit surgery?
No peritoneal (serosal) linking in mediastinum
112
What does no serosal layer make more likely in terms of cancer?
Tumour invasion into adjacent structures occur more easily
113
Where are metastatis of oesophageal cancer common?
Liver
Brain
Pulmonary
Bone
114
What is the prognosis of oesophageal cancer?
Very poor with 5 year survival less than 10%
115
What investigations are done for oesophageal cancer?
Diagnosis by endoscopy and biopsy
Staging by CT scan, endoscopic ultrasound, PET scan, bone scan
116
What is required for the diagnosis of oesophageal cancer?
Endoscopy and biopsy
117
What classification is used for staging of oesophageal cancer?
TNM classification
118
What are treatments for oesophageal cancer?
Oesophagectomy with or without adjuvant or neoadjuvant chemotherapy
Combined chemotherapy and radiotherapy
119
What does adjuvant mean?
After
120
What does neoadjuvant mean?
Before
121
Who is oesophagectomy limited to?
Patients with local disease, without comorbid disease who are usually \<70 years old
122
What is the morbidity and mortality of oesophagectomy like?
Significant, moraltity is 10%
123
What do people who recieve an oesophagectomy require post-operation?
Nutritional support
124
What does treatment of oesophageal cancer usually aim to do?
Provide palliative care as most people present with incurable disease
125
What are some symptom palliation options for oesophageal cancer?
Endoscopic (stent, laser, PEG)
Chemotherapy
Radiotherapy
Brachytherapy
126
What is brachytherapy?
Kind of radiation treatment where a sealed radiation source is placed next to the area requiring treatment
127
What is eosinophillic oesophagitis?
Chronic immune/allergen mediated condition defined clinically by symptoms of oesophageal dysfunction and pathologically by eosinophillic infiltration of the eosophageal epithelium in the absence of secondary causes of local or systemic eosinophilia
128
What eosinophil count is required to pathologically be consider eosinophillic oesophagitis?
More than or equal to 15 eosinophils per high power microscopic fields on oesophageal biopsy
129
How is the incidence and prevalence of eosinophillic oesophagitis changing?
Both are rising
130
What is the male:female ratio of eosinophillic oesophagitis?
Males affected more than females
131
What is the presentation of eosinophillic oesophagitis?
Dysphagia
Food bolus obstruction
132
What is the treatment of eosinophillic oesophagitis?
Topical/swallowed corticosteroids
Dietary elimination
Endoscopic dilation
133
What is endoscopic dilation?
Procedure that inflates a region of the oesophagus
