Oesophagitis and Barrett's oesophagus Flashcards
What types of oesophagitis are there?
Acute (rare)
Chronic (common)
What are the two possible causes of acute oesophagitis?
- The spread of bacterial infection from the nasopharynx to involve the oesophagus:
Herpes simplex type 1, Cytomegalovirus, Candida albicans
Particularly seen in immunocomprimised patients after chemotherapy, immunosuppressed patients after transplant, or patients with AIDS.
Candidiasis is also seen in patients with diabetes or on antibiotic therapy. - Ingestion of corrosive substances
What are the two types of chronic oesophagitis?
Specific or non-specific
What is non-specific chronic oesophagitis?
It is very common
It usually results from reflux oesophagitis
What causes specific chronic oesophagitis?
TB and Crohn’s disease.
Although it is very rare.
What is reflux oesophagitis?
Inflammation of the oesophagus due to refluxed low pH gastric content.
List some potential causes of reflux oesophagitis?
Defective sphincter mechanism Hiatus hernia Increased gastric fluid volume Inefficient luminal clearance Abnormal oesophageal motility Increased intra-abdominal pressure (in pregnancy)
What percentage of the Western population is affected by GORD?
35%
When is GORD diagnosed?
It is diagnosed when there are clinical symptoms, endoscopic lesions or histopathological alterations attributable to gastro-oesophogeal reflux
Is there a correlation between symptoms and oesophagitis?
There is a poor correlation.
E.g, some patients have severe symptoms but little or no damage to their oesophageal lining
while some patients are asymptomatic but have obvious inflammation on endoscopy
What is a hiatus hernia?
When part of the stomach herniates in to the chest cavity.
There are two types: sliding and rolling
Sliding: gastro-oesophageal junction slides up into the chest, and in many cases the lower oesophageal sphincter becomes incompetent.
Rolling: The gastro-oesophageal junction remains inthe abdomen, but a bulge of stomach herniates up into the chest alongside the oesophagus.
What lifestyle factors are potential risk factors for GORD?
Smoking Alcohol Obesity Hot beverages Caffeine Patient age and gender
What happens to the cells lining the oesophagus in GORD?
Exposure of the squamous mucosa to refluxed acids leads to cell injury, accelerated desquamation (shedding of the epithelial layer), erosion and inflammation.
What is the result of the increased cell loss?
There is hyperplasia of the squamous epithelium with elongated subepithelial connective tissue papillae, thickened basal cell layer and less mature cells occupying most of the epithelial thickness.
What sort of response accompanies the epithelial injury?
An inflammatory cell response. This varies from small numbers of polymorphs including eosinophils and neutrophils, as well as lymphocytes, to the formation of granulation tissue with many acute inflammatory cells and fibrinous exudate if ulceration occurs.
This heals by epithelial regeneration and underlying fibrosis.
What can be a consequence of this ulceration formation and healing?
There is subsequent shrinking which can produce segmental narrowing (a benign oesophageal stricture) in the area of healed ulceration.
What is granulation tissue?
Newly formed connective tissue often found at the edge or the base of ulcers and wounds, comprising capillaries, fibroblasts, myofibroblasts and inflammatory cells embedded in mucin-rich ground substance.
How is the epithelial continuity restored?
Usually this is achieved by proliferation of squamous cells.
In some patients, the lost squamous epithelium is replaced by columnar, intestinal -like epithelium. This is Barrett’s oesophagus.
What are the complications of gastro-oesophageal reflux?
Ulceration (bleeding)
Stricture
Barrett’s oesophagus
What is conservative management of GORD?
Lose weight Stop smoking Avoid large meals late at night Avoid alcohol Avoid fatty foods, chocolate, peppermint Elevate head of bed
Describe how GORD is investigated
Often no investigation is needed
Endoscopy
Barium swallow
Oesophageal manometry and pH studies
Describe pharmacological management of GORD?
Gaviscon, Maalox
Proton pump inhibitors
H2 receptor antagonist
Fundoplication
What is the treatment for a benign oesophageal stricture?
Dilatation at endoscopy (risk of severe bleeding/perforation 1:100)
High dose PPI
What is Barrett’s oesophagus?
It is a long term consequence of reflux of acid or bile
metaplasia from squamous to columnar epithelium
a) What is there increased risk of in Barrett’s oesophagus?
b) What is recommended?
a) oesophageal adenocarcinoma
Epithelial dysplasia precedes malignancy
b) Regular surveillance is recommended
What does Barrett’s oesophagus look like on endoscopy?
Proximal extension of salmon-coloured tongues, replacing the usual pearly white squamous epithelium
this can expand to a complete cylinder of columnar epithelium or be patchy.
What does histology of Barrett’s oesophagus look like?
Intestinal metaplasia
Columnar epithelium with goblet cells and tall intervening mucous-producing cells- these both secrete intestinal type mucous
How is Barrett’s oesophagus managed?
This depends on the biopsy.
If there is pre-malignant or high grade dyspepsia:
oesophageal resection or eradicative mucosectomy, if patient is young and fit.
If not, endoscopic targeted musectomy, or mucosal ablation
No pre-malignant change found:
Regular endoscopy and biopsy
Anti-reflux measures (high dose long term PPIs)
What is allergic oesophagitis?
Eosinophilic oesophagitis.
There is usually a personal or family history of allergy, the patient is usually young and may have asthma.
The pH probe is negative for reflux
Is allergic oesophagitis more common in males or females?
males
What is increased in the blood in allergic oesophagitis?
Eosinophils
How does the oesophagus appear on endoscopy in allergic oesophagitis?
Corrugated or spotty
What is the treatment for allergic oesophagitis?
Steroids or chromoglycate or montelukast
