Oesophageal Disorders Flashcards
Gastro-oesophageal reflux disease (GORD) may be defined as
symptoms of oesophagitis secondary to refluxed gastric contents
NICE recommend that GORD which has not been investigated with endoscopy should be treated as per the dyspepsia guidelines
true
GORD - poor correlation between symptoms and endoscopy appearance
true
Indications for upper GI endoscopy >45 years is an indication
FALSE
>55 years
Indications for upper GI endoscopy:
age > 55 years symptoms > 4 weeks or persistent symptoms despite treatment dysphagia relapsing symptoms weight loss
GORD If endoscopy is negative consider
24-hr oesophageal pH monitoring
GORD gold standard test for diagnosis?
24-hr oesophageal pH monitoring
Management of Endoscopically proven oesophagitis
full dose proton pump inhibitor (PPI) for 1-2 months
if response then low dose treatment as required
if no response then double-dose PPI for 1 month
Management of Endoscopically negative reflux disease
full dose PPI for 1 month
if response then offer low dose treatment, possibly on an as-required basis, with a limited number of repeat prescriptions
if no response then H2RA or prokinetic for one month
H2 RA examoles?
Ranitidine
Complications of GORD include?
oesophagitis ulcers anaemia benign strictures Barrett's oesophagus oesophageal carcinoma
Barrett’s refers to the hyperplasia of the lower oesophageal mucosa
false
metaplasia
Barrett’s usual squamous epithelium being replaced by columnar epithelium
true
Barrett’s increased risk of oesophageal adenocarcinoma, estimated at 50-100 fold
true
Barrett’s can be subdivided into short (<3cm) and long (>3cm). The length of the affected segment correlates strongly with the chances of identifying metaplasia
true
Barrets seen in 12% of those undergoing endoscopy for reflux.
true
Barrets Histological features
the columnar epithelium may resemble that of either the cardiac region of the stomach or that of the small intestine (e.g. with goblet cells, brush border)
Barretts risk factors
gastro-oesophageal reflux disease (GORD) is the single strongest risk factor
male gender (7:1 ratio)
smoking
central obesity
alcohol does not seem to be an independent risk factor for Barrett’s
true
Barretts mx
endoscopic surveillance with biopsies
high-dose proton pump inhibitor - evidence base that this reduces the change of progression to dysplasia or induces regression of the lesion is limited
Endoscopic surveillance in barretts is for patients with ? endoscopy is recommended every ? years
for patients with metaplasia (but not dysplasia) endoscopy is recommended every 3-5 years
Barretts If dysplasia of any grade is identified what is offered.
If dysplasia of any grade is identified endoscopic intervention is offered.
endoscopic mucosal resection
radiofrequency ablation
Achalasia is
Failure of oesophageal peristalsis and of relaxation of the lower oesophageal sphincter (LOS) due to degenerative loss of ganglia from Auerbach’s plexus i.e. LOS contracted, oesophagus above dilated
Achalasia typically presents in
middle-age and is equally common in men and women.
Achalasia symptoms
dysphagia of BOTH liquids and solids
typically variation in severity of symptoms
heartburn
regurgitation of food
may lead to cough, aspiration pneumonia etc
Achalasia malignant change in small number of patients
true
Achalasia ix oesophageal manometry shows?
excessive LOS tone which doesn’t relax on swallowing
Achalasia ix barium swallow shows?
shows grossly expanded oesophagus, fluid level
‘bird’s beak’ appearance
Achalasia ix chest x-ray shows?
wide mediastinum
fluid level
What si considered the most important diagnostic test in achalasia?
oesophageal manometry
Achalasia mx recurrent or persistent symptoms?
surgical intervention with a Heller cardiomyotomy
Achalasia mx first-line option
pneumatic (balloon) dilation
Achalasia mx high surgical risk
intra-sphincteric injection of botulinum toxin
most common type of oesophageal cancer
Adenocarcinoma in UK/US
squamous cell most common in developing world
The majority of adenocarcinomas are located near
gastroesophageal junction
squamous cell tumours are most commonly found
in the upper two-thirds of the oesophagus.
Risk factors Adenocarcinoma
GORD Barrett's oesophagus smoking achalasia obesity
Risk factors Squamous cell cancer
smoking alcohol achalasia Plummer-Vinson syndrome diets rich in nitrosamines
Oesophageal cancer - Features
dysphagia: the most common presenting symptom
anorexia and weight loss
vomiting
other possible features include: odynophagia, hoarseness, melaena, cough
Oesophageal cancer - diagnosis
first line test
Upper GI endoscopy
Oesophageal cancer - diagnosis
Staging
CT scanning of the chest, abdomen and pelvis.
If CT does not show metastatic disease, then local stage may be more accurately assessed by use of endoscopic ultrasound
Staging laparoscopy is performed to detect occult peritoneal disease. PET CT is performed in those with negative laparoscopy.
Oesophageal cancer - treatment
surgical resection- vor- Lewis type oesophagectomy
In addition to surgical resection many patients will be treated with adjuvant chemotherapy.
Oesophageal cancer - biggest surgical challenge
anastomotic leak, with an intrathoracic anastomosis this will result in mediastinitis. With high mortality
Upper gastrointestinal bleeding - most likely diagnosis?
Small volume of fresh blood, often streaking vomit. Malaena rare. Often ceases spontaneously. Usually history of antecedent GORD type symptoms.
Oesophagitis
Upper gastrointestinal bleeding - most likely diagnosis?
small volume of blood, symptoms of dysphagia and constitutional symptoms
Cancer
Upper gastrointestinal bleeding - most likely diagnosis?
Typically brisk small to moderate volume of bright red blood following bout of repeated vomiting. Malaena rare. Usually ceases spontaneously.
Mallory Weiss Tear
Upper gastrointestinal bleeding - most likely diagnosis?
Usually large volume of fresh blood. Swallowed blood may cause malaena. Often associated with haemodynamic compromise. May stop spontaneously but re-bleeds are common until appropriately managed.
Varices
history of HIV or other risk factors such as steroid inhaler use suggests
Oesophageal candidiasis
posteromedial herniation between thyropharyngeus and cricopharyngeus muscles is
Pharyngeal pouch
Pharyngeal pouch sx
dysphagia, regurgitation, aspiration and chronic cough. Halitosis may occasionally be seen
large then a midline lump in the neck that gurgles on palpation
Globus hystericus features
history of anxiety
Symptoms are often intermittent and relieved by swallowing
Usually painless
Dysphagia ix
upper GI endoscopy
Motility disorders may be best appreciated by undertaking fluoroscopic swallowing studies.
A full blood count should be performed.
Ambulatory oesophageal pH and manometry studies will be required to evaluate conditions such as achalasia and patients with GORD being considered for fundoplication surgery.
Neurological dysphagia causes
CVA Parkinson's disease Multiple Sclerosis Brainstem pathology Myasthenia Gravis
