Oesophageal Pathology Flashcards
What is Gastro-Oestophageal Reflux Disease (GORD)?
Reflux of gastric contents, acid and bile, through the lower oesophageal sphincter into the oesophagus, due to decreased tone
In what sex is GORD most common?
M>F
What are the causes of GORD?
Pregnancy
Obesity
Drugs that lower LOS pressure
Smoking
Alcohol
Hypomobility
Hiatus Hernia
Name drugs that can lower the LOS pressure
Nitrates
What are causes of hiatus hernia?
>Age
Pregnancy
Obesity
What are the types of hiatus hernia?
Type 1, sliding, in which the gasto-oesophageal junction slides into thorax
Type 2, rolling/para-oesophageal, in which junction remains in abdomen but different part of stomach herniates through oesophageal opening
Type 3, combination of sliding and rolling
Type 4, large opening with additional organs entering thorax
What is a Nissen Fundoplication?
Surgical management of hiatus hernia in which hernia is pulled back and fundus is tied around the lower oesophagus to narrow the LOS
What is the pre-operative workup for Nissens fundoplication?
Manometry studies prior to surgery
How does GORD present?
Heartburn/Burning retrosternal discomfort, exacerbated after meals and lying down
Nocturnal cough
Waterbrash/acid regurgitation
Bloating
Odynophagia if ulceration
What investigations are used in GORD diagnosis and monitoring?
Upper GI Endoscopy
Barium swallow, to bisualise hiatus hernia
Manometry studies
What is the lifestyle management of GORD?
Weight loss
Smoking cessation
Avoid alcohol, tea and coffee
Smaller lighter meals
What is the pharmacological management of GORD (endoscopically proven oesophagitis)?
Full dose PPI for 1-2 months
If response, low dose treatment as required
If no response, double dose PPI for 1 month
What is the pharmacological management of GORD (endoscopically negative oesophagitis)?
Full dose PPI for 1 month
If response, low dose treatment as required
If no response, H2RA or prokinetic for 1 month
Name examples of PPI
Omeprazole
Lomeprazole
Give side effects of PPI
Hyponatraemia
Hypomagnesaemia
Osteoporosis
Microscopic colitis
Clostridium Difficile infection
Name an example of a histamine blocker
Ranitidine
Give complications of GORD
Reflux esophagitis
Ulcers
Barrett’s Oesophagus
Benign stricture
Anaemia
Oesophageal carcinoma
What is Barrett’s oesophagus?
Form of metaplasia in which normal stratified squamous epithelium of the oesophagus is replaced by glandular columnar epithelium
What causes Barrett’s oesophagus?
GORD
Name a complication of Barret’s oesophagus
Oesophageal adenocarcinoma
How is Barret’s oesophagus managed?
GORD management
Endoscopic surveillance with biopsy
Endoscopic intervention
- Offered if dysplasia is identified
- Mucosal resection
- Radiofrequency ablation
Oesophagectomy
How often do patients with Barrett’s oesophagus recieve endoscopic surveillance?
Every 3-5 years for patients with metaplasia
What are the two classifications of oesophageal cancer?
Squamous carcinoma
Adenocarcinoma
What area of the oesophagus does squamous carcinoma affect?
Proximal
(Upper two thirds)
What are of the oesophagus does adenocarcinoma effect?
Distal
(Lower one third)
What sex is oesophageal cancer most common in?
M>F
At what age is oesophageal cancer most common?
Onset at 65
Which oesophageal cancer classification is most common?
Adenocarcinoma > squamous
What is the prognosis for oesophageal cancer?
Poor, 5 year survival <15%
What are the causes of oesophageal cancer (adenocarcinoma)?
Barrett’s oesophagus
Obesity
What are the causes of oesophageal cancer (squamous)?
Smoking
Alcohol
Dietary carcinogens
- Fish
Achalasia
How does oesophageal cancer present?
Progressive dysphagia, beeginning as solids and movig to liquids
Weight loss
Odynophagia
Chest pain/heart burn
Cough
Haematemesis and vomiting
Hoarseness/Vocal cord paralysis
Lymphadenopathy
Give a dermatological manifestation of oesophagus cancer
Acanthosis nigricans
What investigations are used in oesophageal cancer diagnosis?
Upper GI endoscopy and biopsy
- Note, always prioritise endoscope if chronic reflux symptoms that have not responded to PPI
Staging
- CT
- US
What is the management of oesophageal cancer?
Surgical resection with adjuvant chemotherapy
- Ivor-Lewis oesophagectomy
- Total oesophagectomy/McKeown
Palliative
- Endoscopic stent
- Chemotherapy
- Radiotherapy
- Laser ablation
Name complications of oesophageal cancer
Pneumonia, due to tracheo-oesophageal fistula
What sites can oesophageal cancer metastasise to?
Hepatic
Brain
Pulmonary
Bone
Give complication of chemoradiotherapy in oesophageal cancer survivors?
Dysphagia due to post radiotherapy fibrosis
What is oesophageal hypomotility?
Abnormal deficiency of movement
What causes oesophageal hypomotility?
Connective tissue disease
Diabetes
Neuropathy
How does oesophageal hypomotility present?
Heartburn
What investigations are used in oesophageal motility disorder diagnosis?
Manometry
Barium swallow
Upper GI endoscopy
What is oesophageal hypermotility?
Abnormal excessive movement
What causes oesophageal hypermotility?
Idiopathic
How does oesophageal hypermotility present?
Severe episodic retrosternal chest pain
Dysphagia
What sign is seen on a Barium swallow suggestive of oesophageal hypermotility?
Corkscrew appearance
How is oesophageal hypermotility managed?
Smooth muscle relaxants
- Nitrates
- CCB
What is Achlasia?
Neuromuscular disorder characterised by functional loss of the myenteric plexus ganglion cells in the distal oesophagus, resulting in the LOS failing to relax/open, with the absence of oesophageal peristalsis
How does achlasia present?
Progressive dysphagia
- Equal to both solids and liquids from the outset
Weight loss
Chest pain/heart burn
Regurgitation of food
- May lead to cough and aspiration pneumonia
What barium swallow signs are seen in achlasia?
Proximal dilation and tapering of the distal oesophagus known as ‘bird beak’ sign
What is the surgical management of achlasia?
Endoscopic pneumatic balloon dilation
- First line
Heller’s Cardiomyotomy
- Used if recurrent symptoms
What is Heller’s Cardiomyotomy?
Procedure in which muscles of cardia are cut to allow passage to the stomach
Name complications of achlasia
Aspiration pneumonia
Oesophageal squamous cell carcinoma
Describe the difference in dysphagia between oesophageal conditions
Achlasia
- Begins with solids and progresses to liquids
Oesophageal cancer
- Solids and liquids from the onset
Motility
- Variable between solids and liquids
What is Zenker’s diverticulum?
Also known as pharyngeal pouch, protrusion of the mucosa and submucosa of the inferior pharyngeal constrictor muscle
How does Zenker’s present?
Progressive dysphagia
Regurgitation of undigested food
Chronic cough
Hoarseness
Palpable lump in throat
Halitosis
What is the area of weakness in Zenker’s known as?
Killian’s Dehiscence
How is Zenker’s diverticulum managed?
Surgical excision of pouch, plus repair of defect in inferior constrictor
What is Eosinophillic oesophagus?
Chronic allergic/immune mediated inflammatory disorder causing oesophageal dysfunction, occuring in childhood
How does eosinophilic oesophagus present?
Dysphagia
Food bolus obstruction
Vomiting
Heart burn
How is eosinophilic oesophagus managed?
Topical/oral corticosteroids
Dietary elimination
Endoscopic dilation
What is a Walloru-Weiss tear?
Linear tear at oesophageal-gastric junction due to forceful vomiting
How is walloru-weiss tear managed?
Heals itself
Endoscopic treatment
Describe the pathophysiology of oesophageal varices
Portal hypertension results in dilation of veins at sites of portal-systemic anastomosis, projecting into the oesophagus
What are the sites of portal-systemic anastomosis?
Lower oesophagus
Rectum
Umbilicus (caput medusae)
How does oesophageal varices present?
Haematemesis/melaena, suggesting upper GI bleed
Evidence of chronic liver disease
Splenomegaly and thrombocytopenia, as portal HTN results in splenic enlargement and hyperfunction
What is the acute management of oesophegal varice bleed?
Resuscitate
Correct possible clotting abnormalities
IV Terlipressin or somatostatin analogue
Upper GI Endoscopy and sclerotherapy/banding of varices
If unsuccessful, pass a Sengstaken-Blakemore tube
If continued bleeding, surgical decompression
What is a Sengstaken-Blakemore tube?
Contains a inflatable balloon used to compress varices
What is the prophylaxis management of oesophageal varices?
B Blockers to reduce portal pressure
Upper GI Endoscopy and sclerotherapy/banding of varices
Transjugular intra-hepatic portosystemic shunting (TIPSS)
What is Plummer-Vinson syndrome?
Web thin eccentric extension of normal oesophageal tissue
How does Plummer-Vinson syndrome present?
Dysphagia, secondary to oesophageal webs
Iron deficiency anaemia
Glossitis
What drug can cause odynophagia?
Steroids, due to candidasis
Give features of Boerhaave Syndrome
Alcohol use
Vomiting
Thoracic pain
Subcutaneous emphysema, shown as crepitus in epigastric region
