Oesophageal Motility Disorders Flashcards

1
Q

What are OMDs?

A

A group of conditions characterised by abnormalities in oesophageal peristalsis.

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2
Q

Epidemiology

A

Less common than mechanical and inflammatory diseases of oesophagus

Typically manifest with dysphagia of solids and liquids together.

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3
Q

What are the two major causes of oesophageal dysmotility?

A

Achalasia

Diffuse oesophageal spasm

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4
Q

Explain the oesophageal anatomy

A

25cm divided into thirds:

Upper third = skeletal muscle

Middle third = transition zone of both skeletal and smooth muscle

Lower third = composed of just smooth muscle

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5
Q

What is the upper oesophageal sphincter comprised of?

A

Skeletal msucle to prevent air from entering the GI tract

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6
Q

What is the LOS comprised of?

A

Smooth muscle to prevent reflux from the stomach

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7
Q

Explain the peristaltic waves

A

Controlled by oesophageal myenteric neurones.

They propel ingested food downwards.

Primary wave = is under control of the swallowing centre

Secondary wave = activated in response to distention

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8
Q

Dx of OMD

A

GORD

Oesophageal malignancy

Angina pectories

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9
Q

What is achalasia?

A

A primary motility disorder of the oesophagus.

Failure of relaxation of the LOS and progressive failure of contraction of the oesophageal smooth muscle

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10
Q

Epidemiology of achalasia

A

Quite rare

1 per 100000

Mean age of diagnosis at 50 yo

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11
Q

Histological feature of achalasia

A

Progressive destruction of ganglion cells in the myenteric plexus

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12
Q

Explain pathophysiology

A

High resting tone and failure of relaxation of LOS -> food gets stuck and can’t reach the stomach.

It also causes further dysfunction of the more proximal oesophagus.

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13
Q

Clinical features of achalasia

A

Progressive dysphagia when ingesting both solids and liquids

Vomiting and chest discomfort

Regurgitation of food

Coughing (especially at night)

Chest pain

Weight loss

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14
Q

Examination findings

A

Usually null

Might see visible weight loss in longstanding or severe cases

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15
Q

Ix

A

Oesophageal cancer always need to be excluded -> Urgent endoscopy

Gold standard for diagnosis = Oesophageal manometry

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16
Q

Endoscopy findings of achalasia

A

Should be normal but a tight LOS might be seen.

17
Q

Explain oesophageal manometry.

A

A pressure sensitive probe is inserted into the oesophagus

It measures the pressure of the sphincter and the surrounding muscle

18
Q

Three key features of achalasia on manometry.

A

Absence of oesophageal peristalsis

Failure of relaxation of the LOS

High resting LOS tone

19
Q

When is barium swallows done in achalasia?

A

Rarely performed anymore.

They may show proximal dilation of the oesophagus with a characteristic bird’s beak appearance distally.

20
Q

Conservative management of achalasia

A

Sleeping with many pillows to minimise regurgitation

Eating slowly and chew thoroughly

Plenty of fluids with meals

CCBs or nitrates can give temporary relief but action is typically short-lived.

Botox injections into LOS by endoscopy can help for a few months.

21
Q

Types of surgical management of achalasia

A

Endoscopic balloon dilatation

Laparoscopic Heller myotomy

22
Q

Explain endoscopic balloon dilatation

A

Insertion of a balloon in the LOS which is then dilated to stretch the muscle fibres.

23
Q

Complications of endoscopic balloon dilatation

A

Good response in 75% of patients

Carriers the risk of perforation

24
Q

Explain laparoscopic heller myotomy

A

Division of the specific fibres of the LOS which fail to relax.

A long-term improvement in swallowing is seen in 85% of patients

Less side-effects than endoscopic treatment.

25
Q

Prognosis of achalasia

A

Long standing have an 8-16x increased risk of oesophageal cancer

26
Q

What is diffuse oesophageal spasm DOS?

A

Characterised by multi-focal high amplitude contractions of the oesophagus (spasms)

27
Q

Cause of DOS

A

Dysfunction of oesophageal inhibitory nerves

DOS can progress to achalasia

28
Q

Clinical features of DOS

A

Severe dysphagia to both solids and liquids

Central chest pain (exacerbated by foods)

Pain from DOS can respond to nitrates (making it hard to distinguish from stable angina)

Examination is normal

29
Q

Ix of DOS

A

Needs urgent endoscopy to rule out malignancy

Definitive diagnosis is the same as achalasia by manometry.

Barium swallow is rarely performed but cahn show a corkscrew appearance

30
Q

Endoscopy findings in DOS

A

Usually normal

31
Q

Manometry in DOS

A

Repetitive, simultaneous and ineffective contractions of oesophagus.

May also be dysfunction of LOS

32
Q

Management of DOS

A

Nitrates or CCBs are first line to relax oesophageal smooth muscle.

DOS + hypertension may benefit from pneumatic dilatation.

Myotomy can be done in the most severe cases.

33
Q

Myotomy in DOS

A

Incision involving the entire spasmodic segment and the LOS

34
Q

Other causes of oesophageal dysmotility.

A

Autoimmune and connective tissue disorders like systemic sclerosis, polymyositis and dermatomyositis.