Oesophageal Disorders Flashcards by India Dodd

risk factors of GORD

pregnancy
obesity 
excessive alcohol intake 
smoking 
male sex

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define GORD

irritation/damage of the simple squamous epithelium of the oesophagus due to acid reflux through the lower oesophageal sphincter (LOS) into the distal portion

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clinical features of GORD

heartburn, water brash, restrosternal/epigastric pain, bloating, nocturnal cough and hoarse voice

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red flag symptoms that require immediate admission and endoscopy referral

weight loss
age >55 
dysphagia 
melena 
low Hb and high platelet count (anaemia)

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differentials of GORD

eosinophillic or drug induced oesophagitis 
peptic ulcer disease 
achalasia 
oesophageal cancer
cardiac pathology

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conservative management of GORD

advise weight loss if obesity a contributing factor
advise reduced caffeine intake
advise smoking cessation
suggest smaller, lighter meals and avoidance of heavier meals before bed

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medical management of GORD

4wks PPI trial (e.g. omezaprole)

OR H2 receptor antagonist (e.g. ranitidine)

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common complications of GORD

barrett's oesophagus
oesophageal cancer 
oesophageal stricture
peptic ulcer 
peptic ulcer perforation

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define distal oesophageal spasm (DOS)

a hyper-motility disorder of the oesophagus that causes uncoordinated contractions of several sections at once

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risk factors of DOS

anxiety/stress and diabetes

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clinical features of DOS

severe/crushing retrosternal chest pains
intermitting dysphagia
oesophageal pain
heartburn and other reflux-related issues

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differentials of DOS

GORD
myocardial ischaemia/infarction
oesophageal stricture
achalasia

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investigations of DOS

oesophageal manometry - shows exaggerated + uncoordinated hypertonic contractions
barium swallow - shows ‘corkscrew’ appearance
US of oesophagus
cardiac investigations to rule out cardiac issues

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conservative management of DOS

provide reassurance that not cardiac disease
modify the diet - soft food + liquids only
suggest avoiding cold fluids

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medical management of DOS

4 wks PPI trial (rule out GORD)

smooth muscle relaxants (e.g. nifedipine, Ca channel blocker OR nitrates)

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surgical management of DOS

botulinum toxin injection

oesophageal dilation

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define achalasia

a hypo-motility disorder of the oesophagus that causes failure of the LOS to relax resulting in functional stenosis or stricture of the oesophagus

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causes of achalasia

primary cause is unknown (either autoimmune or neurodegenerative) but causes functional degeneration and loss of myenteric plexus ganglion

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risk factors of achalasia

> 50yrs old
autoimmune disease
neurodegenerative disorder

clinical features of achalasia

progressive dysphagia for solid foods but eventually liquids and softs
food bolus impaction
regurgitation
chest pain (after eating)
heart burn
weight loss (minimal but may indicate malignancy)

differentials of achalasia

oesophageal or gastric cancer
GORD
oesophageal stricture

additional investigations of achalasia

CXR
barium swallow - will have characteristic ‘bird beak’ appearance
endoscopy (if rule out malignancy)

gold standard investigation for achalasia

manometry

- shows high resting pressure in cardiac sphincter, incomplete relaxation on swallow and absent peristalsis

management of achalasia

Heller’s myotomy - surgical division of musculature of LOS
pneumatic dilation
botulinum toxin A injection

indications for pneumatic dilation and botulinum toxin injection

pneumatic dilation is preferred in older, unfit patients | injection is used for those who cannot tolerate either dilation or myotomy

complications of achalasia

risk of oesophageal cancer treatment may cause perforation or GORD untreated may lead to aspiration pneumonia

define Barrett's Oesophagus

an oesophagus that has a portion of the normal epithelium replaced with metaplastic columnar epithelium ABOVE the gastro-oesophageal junction

describe the change in epithelium during Barrett's Oesophagus

simple squamous epithelium to columnar gastric epithelium

risk factors of Barrett's

``` older age (50-70yrs) smoking obesity male sex MH of GORD or dysphagia ```

clinical features of Barrett's Oesophagus

``` heartburn waterbrash bloating and belching nausea burning pain when swallowing hot drinks ```

investigations for Barrett's Oesophagus

gastroscopy (with biopsy)

conservative management for Barrett's Oesophagus

``` recommend weight loss smoking cessation reducing alcohol intake raising head during sleep suggest smaller, regular meals avoid hot drinks and drugs that affect oesophageal motility ```

medical management of Barrett's Oesophagus

long term PPI therapy | ablative therapy

surgical management of Barrett's Oesophagus

oesophagectomy (for severe dysplasia) | laparoscopic fundoplication

common complications of Barrett's Oesophagus

development of adenocarcinoma

define squamous cell carcinoma oesophageal cancer

affects upper 2/3rd of oesophagus and is proceeded by dysphasia and carcinoma in situ

define adenocarcinoma oesophageal cancer

affects lower 1/3rd of oesophagus and is proceeded by Barrett's

risk factors of SCC

alcohol, obesity and poor diet

risk factors of AC

obesity, male sex and smoking

clinical features of oesophageal cancer

``` unrelenting and progressive dysphagia weight loss and/or anorexia lymphandenopathy melena hoarseness of voice ```

differentials of oesophageal cancer

oesophageal stricture achalasia gastric cancer metastatic tumours

initial investigations for suspected oesophageal cancer

``` bloods - FBC, U+E, LFT, glucose, CRP + CEA urgent endoscopy (with biopsy if required) ```

additional investigations for oesophageal cancer

CXR - check for metastases | double contrast barium swallow

investigations for staging of cancer

CT/MRI of chest + upper abdomen | FDG-PET

surgical management/treatment of oesophageal cancer

in AC: pre-operative chemoradiotherapy oesophagectomy endoscopic mucosal resection

medical management/treatment of oesophageal cancer

rapid chemotherapy | palliative care

when is surgical treatment considered for oesophageal cancer?

if disease is localised and no co-morbidities are present