Oesophageal Problems Flashcards
What is GORD
Reflux of gastric contents into the oesophagus which irritates squamous lining causing oesophagitis
What causes GORD and what worsens
Increased relaxation of LOS (never full contracts)
Oesophageal dysmotility
Decreased resistance to bile
Worsens Hiatus hernia - size doesn't correlate Delayed gastric emptying Pregnancy Obesity
What can cause oesophagitis (inflammation of oesophagus)
GORD Hernia Alcohol Biphosphonates Steroid NSAID Theophylline Candida Herpes Ulcer Cancer
What are the symptoms of GORD
Dyspepsia Acid brash Odnyophagia Erosive oesophagitis Sleep disturbance
What are the RF for GORD
Male Caucasian Obesity Alcohol Smoking Pregnancy Drugs lower LOS pressure Hypomotility Hypercalcium H.pylori but no role in eradication
What drugs affect motility
CCB
Nitrate
Anti-cholinergic
What drugs cause oesophagitis
Biphosphonate
Steroid
NSAID
Theophylline
What should you do with NSAID
Always prescribe with a PPI esp if >65
How do you Dx GORD
Clinical Dx
Trial PPI if uncertain
Endoscopy if >55 + alarm symptoms / resistant dyspepsia or refractory to Rx
What do you do if endoscopy normal
Manometry
pH studies
Barium swallow
What is necessary before fundolipication
Manometry and pH studies
Barium swallow
What does manometry look at
Lower sphincter tonicity / relaxation
What does barium swallow look for
Motility
Stricture
How do you treat GORD
As per dyspepsia Lifestyle measures Alginates - Gaviscon / Peptac Antacids - PPI - omeprazole = mainstay - 10 or 20mg = starting dose - 40mg = very high dose H2 - ranitidine if refractory (no longer given)
When do you consider fundolipication
Refractory to Rx
Severe reflux
Must perform manometry before to ensure due to low pressure of LOS as can tighten
What are the complications of GORD
Oesophagitis Ulcers Anaemia if bleed Strictures - benign Fibrosis Impaired motility Barret's Adenocarcinoma
What are complications of hernia repair / fundolipication
Dysphagia
Diarrhoea
Cant belch / vomit
Bloating
What does endoscopy involve
Tube down throat
Can have sedation (midazalam)
Can’t drive for 24 hours or stay by yourself
What is Barrets oesophagus
Metaplasia
Transformation of squamous to columnar (glandular)
Pre-malignant change to adenocarcinoma
What causes Barret
Long standing GORD
What are the RF for Barret
Male
Obesity
Smoking
GORD
What is risk of progression to cancer
Long segment >3cm
Age
Dysplasia
How do you Dx Barret
Usually found on endoscopy for upper GI symptoms
How do you treat Barret and what reduces risk of transformation
PPI
2 yearly endoscopy + biopsy as surveillance
When do you treat Barret
If HGD or cancer detected
How do you treat
Endoscopic mucosal resection
Radiofrequency ablation
Oesophagectomy but high mortality
What are the risks of oesophagectomy
Anastomotic leak
High mortality due to mediastinitis
What is dyspepsia
A group of symptoms related to the gut
Non-ulcer if no cause found
Major symptom of GORD
What causes dyspepsia
GORD Ulcers - duodenal / gastric Gastritis Malignancy Drugs
Other Pancreatitis Hepatic / gall bladder IBS Celiac Anxiety Delayed gastric emptying
What symptoms make up dyspepsia
Non-specific term for indigestion Retrosternal discomfort - related to food / hunger (heartburn) Less severe than ulcer Acid regurgitation Cough Water brash Weight loss Early satiety Bloating N+V
What drugs can cause dyspepsia
NSAID Steroid BIphosphonate Theophylline Nitrates CCB Anti-cholinergic
What do you do for dyspepsia <55 and no alarm symptoms
Stop drugs / review
Lifestyle measure
Antacids
Test for H.pylori - urea breath or stool antigen
When can you not test for H.pyolori
If Ax within 4 weeks or on PPI
When do you do further tests in dyspepsia
If treatment resistant i.e. still symptoms after 4 weeks
Alarm symptoms
- Do abdo exam for Virchow’s node / mass / weight loss
Requires endoscopy with rapid urease CLO and FBC to look for anaemia suggesting bleed
What bloods should you get for dyspepsia
FBC, U+E, LFT Ferritin if anaemia Lactate if suspect perforation Amylase Calcium Glucose Coeliac Troponin if abdominal pain
What are lifestyle measures
Diet Alcohol Stop smoking Exercise more Eat 2 hours before sleep Lose weight Stop drugs that could cause
How do you eradicate H.pylori if +ve
Triple therapy
Ax - clarithromycin (500mg) + Amox (1g) for 7 days or Metronidazole if no response
PPI
H2 antagonist - not always needed
When do you check for cure
3 months
Usually urea breath
Will also have +ve serology
Can do stool antigen test
What do you do if H.pylori -ve
H2 or PPI for 4 weeks
If no improvement = endoscopy
When do you treat H.plyori
Even if asymptomatic as carcinogen
What are SE of PPI
Microscopic colitis
C.diff
Osteoporosis
Hyponatraemia and Mg - muscle aches
What is dysphagia
Trouble swallowing
What is odynophagia
Painful swallowing
What does odynophagia suggest
Oesophagitis
Ulceration - malignancy / GORD / candida
Spasm
What causes dysphagia
Extra-mural
- Neck mass - goite
- Lung cancer
- Any mediastinal mass
- Vascular malformation
- SVC obstruction
Intra-mural Achalasia Spasm Sysemic sclerosis Stricture Bulbar palsy Pharyngeal pouch Neuromuscular - MS / myasthenia gravis / Parkinson
Intra-luminal Barret's Oesophageal cancer Oesophagiitis - eosinophilic or GORD Benign or malignan stricture FB Candidiasis - HIV / steroid Plumer-Winson
Wha is important in the history and exam
Solids or liquids Same from start or getting worse Progressive or constant Intermittent or constant Where in the chest - Difficulty initiating swallow - Or after swallow does it get stuck - Any regurg Any pain Associated Sx - Odynophagia / otalgia / regurg / weight loss / signs of GI bleed - blood / change in bowel habit / chest infections as may aspirate RF - smoking / alcohol
Mass - para-aortic Ln / gastric acner Dysphonia - laryngeal palsy Cough - if trachea invaded Swelling - SVC obstruction Neuro features
How do you investigate dysphagia
ENDOSCOPY + BIOPSY = gold standard Do contrast swallow before if any risk of condition that scope could perforate e.g. diverticulum FBC + U+E CXR if suspect lung cancer Manometry / pH VIdeo fluroscopy for motility disorder CT if suspecting neurological
How do you treat
Treat cause
SALT review
Benign = balloon dilatation
CNS = specialist
What is suggestive of oesophagitis
Heartburn after eating
Odynophagia
Systemically wel
What suggest pharyngeal pouch (out-pouching of mucosa and submucosa in the pharynx)
- Thyropharyngeus and cricopharyngeus inferior constrict muscle and what can it cause
Elderly male tend to be affected Can be asymptomatic if small Progressive dysphagia Regurg Aspiration Cough Halitosis Recurrent chest infection due to aspiration Neck swelling Gurgling on palpation
Can lead to
- Oesopheageal perforation = mediasinitis / surgical emphysema
- Pneumothorax
- Hoarse voice
- Fistula
- Stricture
How do you Dx and Rx pouch
ENT exam usually normal
Contrast swallow = definite
Consider MRI if -ve to look for malignancy
Conservative if small
Botox to muscle
Surgery - stapling or diverticulotomy
What suggests myasthenia gravis
Tend to be acute onset
Ptosis
Extraocular weakness
Swallowing difficulty
How do you treat
Acetylcholinesterase inhibitor
What suggest bulbar palsy
Difficult to initiate swallow Dysphagia Weakness Drooling Waste tongue Dysphonia
What suggest systemic sclerosis and how do you Rx
Calcinosis Raynaud Eoshageal issue / decreased pressure LOS S - sclerodactly Telengtasia
PPI
Surgery as last resort
What is globus hysterics
Dysphagia caused by anxiety
Relieved by swallow
What is globus pharynges ‘FOSIT’ and how do you Dx
Feeling of lump in throat / FB due to cricopharyngeal spasm
Relieved by food
Worse swallowing saliva
Linked to reflux / spasm
Form of somatisation - linked to stress / anxiety
Dx of exclusion
Flexible nasa-endoscopy to rule out other causes
If smoking / alcohol Hx then consider barium swallow / upper GI endoscopy
What suggest oral candidiasis
HIV / inhaler / steroid/ haemophiliac / Ax
Endoscopy to confirm
What does constant and progressive dysphagia suggest e.g. from solid-liquid
Malignancy / benign stricture
- Often Hx smoking / alcohol or GORD
What is alchalsia
Motlity disorder where LOS doesn’t relax so increased pressure
Loss of peristalsis
How does alchasia present
Dysphagia - solid and liquid from start Weight loss Regurg Aspiration Vomit CHoking Chest pain Systemically well
How do you Dx achalasia and what do they show
Endoscopy 1st line to exclude cancer
Manometry - sustained higher pressure
Barium swallow - dilated tight sphincter + bird peak
CXR - wide mediastinum +
How do you Rx achalasia
Balloon dilatation of LOS
Cardiomyotomy
PPI after as balloon can cause heart burn
CCB / nitrate if no surgical or botulism toxin
Ax if aspiration + CXR
What are complications of achalasia
SCC of the lung
Aspiration pneumonia
What does oesophageal spasm present like
Intermittent chest pain and dysphagia
Like angina
Odynophagia
How do you Dx spasm
Contrast swallow - cork screen
Manometry - exaggerated contraction
How do you Rx spasm
Nitrates and CCB to relax
What causes hypo motility
Failed relaxation of LOS sphincter
DM
Neuropathy
Connective tissue disease
How do hypo motility present
Dysphagia
Regurg
Dyspepsia
What is a sliding hiatus hernia
Gastro-oesophageal junction slides into chest
Acid reflux / GORD as no sphincter
What is a para oesophageal hernia
Junction stays below diaphragm
Part of stomach into chest
GORD less common
Who is at risk of hernia
Age
Obese
Female
How do you dx hernia
Endoscopy for GORD
Contrast swallow for reflux - gastric seen above diaphragm
CXR shows gastric funds above diaphragm
How do you treat hernia
Lose weight
Treat GORD
FUndolipication for severe complications / strangulated
What is a strangulated hernia
Necrosis = urgent surgery
What are other complications
Incarcerated - stuck and unable to reduce
Abscess in sac
What are other indications for endoscopy apart from dysphagia / ALARM
Haematemesis Treatment resistant dyspepsia H.pylori -ve Abdo pain and low Hb Raised platelet + N+V, weight loss, dyspepsia, abdominal pain
What causes oesophageal rupture
Iatrogenic after endoscopy Trauma Carcinoma Boerhaave - rupture due to violent vomit Corrosive
What are clinical features
Odynophagia Tachypnoea Fever Shcok Surgical emphysema
How do you Rx
Fluid resus
PPI
Ax / anti-fungal
Surgery
What are risks
Mediastinitis and sepsis
What do you do have to be of before endoscopy
PPI for 2 weeks as may mask
What are alarm Sx
Anaemia Loss of weight Anorexia Recent onset Melena / haematemesis Swallowing difficulty (dysphagia)
