Oesophageal Problems Flashcards
what vertebral level does the oesophagus originate
C6
What are the symptoms of oesophageal disease?
Dysphagia
Dyspepsia (Heartburn)
Regurgitation
Painful swallow
What is dysphagia?
DIFFICULTY swallowing
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)
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
What is heartburn?
Retrosternal/Epigastric burning sensation due to acid reflux. Pain is made worse by lying down
What is regurgitation? What conditions does it occur in?
Reflux of oesophageal contents into the mouth/pharynx Occurs in reflux disease + oesophageal strictures
What is odynophagia? What condition does it indicate?
Painful swallow
Oesphagitis caused by GORD/infection
- candida in HIV patients
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
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.
How is the diagnosis of GORD made?
The history
risk factors for GORD
male
age
obesity
smoking
alcohol
When is an endoscopy (OGD) indicated?
New onset GORD > 55 years old or worsening despite PPI
patients with ALARM Symptoms
What are the ALARM Symptoms?
Anaemia
Loss of weight
Anorexia
Recent onset of progressive symptoms
Malena or haematemesis
Swallowing difficulty
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
What non-pharmacological management is indicated in GORD?
Weight loss
Smoking cessation
Avoidance of aggravating foods (e.g. coffee, fatty foods) + excess alcohol
What is the first line treatment for mild GORD?
Antacids, e.g. gavascon
What is the first line treatment for severe GORD or patients with complications?
PPIs e.g. omeprazole
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
What do H2 receptor antagonists do?
Relieve the symptoms of GORD. e.g. ranitidine
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
