Gastro-oesophageal reflux disease - gastric acid from stomach leaks back up into the oesophagus - lower oesophageal spincter relaxes more frequently than it should

Oesophageal Problems Flashcards by Megan McLaren

what vertebral level does the oesophagus originate

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What are the symptoms of oesophageal disease?

Dysphagia

Dyspepsia (Heartburn)

Regurgitation

Painful swallow

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What is dysphagia?

DIFFICULTY swallowing

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What does a short history of progressive dysphagia first to solids and then liquids suggest? What is the most appropriate investigation?

Mechanical stricture

Urgent ODG (endoscopy)

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What does a long history of slow onset dysphagia to both solids and liquids suggest? What is the most appropriate investigation?

Motility disorder

OGD to exclude cancer
Barium swallow rarely performed now

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What is heartburn?

Retrosternal/Epigastric burning sensation due to acid reflux. Pain is made worse by lying down

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What is regurgitation? What conditions does it occur in?

Reflux of oesophageal contents into the mouth/pharynx Occurs in reflux disease + oesophageal strictures

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What is odynophagia? What condition does it indicate?

Painful swallow

Oesphagitis caused by GORD/infection

candida in HIV patients

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what is GORD?

Gastro-oesophageal reflux disease

gastric acid from stomach leaks back up into the oesophagus
lower oesophageal spincter relaxes more frequently than it should

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What is the major symptom of GORD?

Heartburn- burning retrosternal pain

worse after meals
worse lying down / bending over

May also present with regurgitation + odynophagia.

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How is the diagnosis of GORD made?

The history

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risk factors for GORD

male

age

obesity

smoking

alcohol

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When is an endoscopy (OGD) indicated?

New onset GORD > 55 years old or worsening despite PPI

patients with ALARM Symptoms

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What are the ALARM Symptoms?

Anaemia

Loss of weight

Anorexia

Recent onset of progressive symptoms

Malena or haematemesis

Swallowing difficulty

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what is the gold standard investigation for GORD?

when is it required?

24 hour pH monitoring

patients where medical treatment fails and are being considered for surgery
should be combined with oesophageal manometry to exclude motility disorders

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What non-pharmacological management is indicated in GORD?

Weight loss

Smoking cessation

Avoidance of aggravating foods (e.g. coffee, fatty foods) + excess alcohol

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What is the first line treatment for mild GORD?

Antacids, e.g. gavascon

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What is the first line treatment for severe GORD or patients with complications?

PPIs e.g. omeprazole

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surgical options for GORD

Fundoplication

fundus is wrapped around gastro-oesophageal junction to create lower sphincter
indicated for patients who dont respond to treatment / patient preference to avoid life long medication

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What do H2 receptor antagonists do?

Relieve the symptoms of GORD. e.g. ranitidine

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What are some of the complications of GORD?

Stricture formation

Barret oesophagus

Aspiration pneumonia

Oesophageal cancer

Schatski ring

How is an oesophageal stricture treated?

PPIs + endoscopic dilatation

What is Barrets oesophagus?

Metaplastic change from squamous epithelium to columnar epithelium.

It is an irreversible premalignant change

majority of cases caused by chronic GORD

investigation of Barrets oesophagus

OGD + biopsy

it is a histological diagnosis

appearance of the oesophagus in a patient with Barrets oesophagus on OGD

red + velvety appearance

How is Barrets oesophagus treated?

PPIs + endoscopic surveillance due to risk of progression to adenocarcinoma

What is a schatski ring?

Localised mucosal stricture at the gastro-oesophageal junction

what is the difference between the upper and lower oesophageal sphincter? what are their functions?

**upper = skeletal muscle** - prevents air from entering GI tract **lower = smooth muscle** - prevents reflux from the stomach

What is achalasia?

Failure of the lower oesophageal sphincter to relax, preventing food from passing into the stomach

What is the pathology behind achalasia?

Degeneration of the vagus nerve - progressive destruction of the ganglion cells in the myenteric plexus

symptoms of achalasia

**progressive dysphagia to both solids + liquids** vomiting regurgitation of food chest discomfort weight loss

What is the buzz word seen on a barium swallow for achalasia?

Birds beak oesophagus

What else does a barium swallow show that indicates achalasia?

Dilatation of the oesophagus + no peristalsis

What investigation confirms achalasia?

Oesophageal manometry _3 key features:_ - absence of peristalsis - failure of relaxation of LOS - high LOS resting tone

How do you treat achalasia?

_surgical:_ - endoscopic dilation - heller myotomy Nitrates/Ca channel blockers (nifedipine) can be given to relax LOS but effects are short lived

What is an oesophageal spasm? What is seen on a barium swallow?

Simultaneous contractions in the distal oesophagus - dysfunction in oesophageal inhibitory nerves CORKSREW OESOPHAGUS

presentation of oesophageal spasm

Dysphagia + chest pain

what does the pain in oesophageal spasm respond to

nitrates / calcium channel blockers - relax the smooth muscle

manometry finding in oesophageal spasm

repetitive, simultaneous, ineffective contractions

what autoimmune conditions can cause oesophageal dysmotility

systemic sclerosis polymyositis / dermatomyositis

What is allergic eosinophilic oesophagits?

Inflammation of the oesophagus caused by reaction to food. Immune complex mediated + eosinophilic infiltrates present

How does oesophageal perforation present? How is it diagnosed?

Severe chest pain, Fever, Hypotension, Emphysema Diagnosis: erect CXR for peritoneal air + **CT** gold standard for any perforation (shows presence + location)

What are the most common malignant oesophageal tumours and where do they occur?

Squamous cell - usually middle 3rd of oesophagus Adenocarcinoma- usually lower 3rd of oesophagus

What are the risk factors for Squamous cell carcinoma?

Smoking, Alcohol, Achalasia, Coeliac disease

What causes adenocarcinoma?

Barrets oesophagus GORD, smoking + obesity are also risk factors

How does oesophageal cancer present?

Progressive dysphagia to solids then liquids. Weight loss Hoarseness / odynophagia may also occur

How is oesophageal cancer diagnosed?

OGD + biopsy

What is the treatment for oesophageal cancer?

70% require palliative therapy and are unfit for treatment - oesophageal stent for dysphagia Chemo-radiotherapy +/- oesophagectomy

Are benign oesophageal tumours common or rare?

Rare

What is the most common benign oesophageal tumour?

Squamous papilloma