Oesophagus Flashcards
State some causes of dysphagia; split your answers into mechanical and neuromuscular causes
State some key questions you must ask in a dysphagia history
- Difficulty in initiating swallowing action?
- Do you cough after swallowing?
- Do you have to swallow a few times to get food to pass your throat?
- Regurgitation
- Weight loss
- Hoarse voice
- Refferred ear or neck pain
*Recent data has shown that asking about differenece between swallowing solids vs liquids is poor differentiatior between oesophageal and pharyngeal causes of dysphagia
You must determine if someone has dysphagia or odynophagia as odynophagia has different causes; what is odynophagia?
Pain when swallowing
What investigations are required when a pt has dysphagia?
- Endoscopy +/- biopsy: exclude malignancy
-
Bloods:
- FBC
- U&Es
- LFTs
- Manometry & 24hr pH studies: if motitlity disorder suspected
- Barium swallow studies:if pharyngeal pouch suspected
What is manometry?
What is 24hr pH study?
How do you do them?
Both assess function of oesophagus:
- Manometry: measures pressures of oesophagus at regular intervals and assess oesophageal sphincters
- 24hr pH study: measures pH of oesophagus
Often done together. First have manometry, spray local anaesthetic in nose then pass tube down into stomach. Asked to eat piece of bread with butter and pressures/movement measured then tube removed. A smaller/finer tube then inserted and left in place for 24hrs to measure pH. Few restrictions on what can eat, but must eat and drink and keep diary of what consumed, symptoms etc..
NICE reccommend an urgent upper GI endoscopy within 2 weeks to assess for oesophageal cancer in which people?
- Any pt with dysphagia
- Any pt aged =/>55yrs with weight loss plus any of:
- Upper abdominal pain
- Reflux
- Dyspepsia
*Non-urgent referral recommended with haematemesis or =/>55yrs with treatment resistant dyspepsia or uppper abdo pain
Which members of MDT should be involved in care of dysphagia pt?
- SALT
- Dietician
Discuss the pathophysiology of GORD
- Lower oesophageal sphincter episodicly relaxes (this is normal)
- In GORD, these relaxation episodes become more frequent
- Allows reflux of gastric contents into oesophagus
- The acid gastric contacts result in muscosal damange and pain in oesophagus
State some risk factors for GORD
- Age
- Male
- Obesity
- Alcohol
- Smoking
- Caffeinated drinks
- Fatty foods
- Spicy foods
Describe clinical features of GORD
- Chest pain
- Burning
- Retrosternal
- Worse after meals
- Worse lying down, bending over or straining
- Relieved, or eased, by antacids
- Excessive belching
- Odynophagia
- Chronic cough
- Nocturnal cough
What investigations are required if you suspect GORD?
Mostly a clinical diagnosis based on history and resolution of symptoms after a trial of PPI.
If medical treatment fails and urgery being considered you would do:
- 24hr pH monitoring *GOLD STANDARD
- Combined with oesophageal manometry
If thought malignancy then would do:
- Upper GI endoscopy (OGD)
What classification is used to grade reflux oesophagitis based on severity from endoscopic findings?
*Not majorly important to know
Los Angeles Classifcation
Discuss the management of GORD, include:
- Conservative
- Medical
- Surgical
Conservative
- Avoiding triggers e.g. alcohol, coffee, fatty foods, chocolate etc…
- Eat smaller meals
- Weight loss
- Smoking cessation
- Sleep with bed raised
Medical
- PPI
- Add in H2 antagonist
Surgical
- Fundoplication
- Stretta: radio-frequency energy delivered endscopically to cause thickening of LOS
- Linx: string of magnetic beads inserted around LOS laparscopically which tightens LOS
State some potential complications of GORD
- Barrett’s oeosphagus
- Oesophagitis
- Oesophageal strictures
- Oesophageal cancer
- Aspiration pneumonia
What is fundoplication?
What are main side effects of surgery?
Is surgery often succesful?
- Gastro-oesophageal junction and hiatus are dissected and fundas of stomach wrapped around GOJ creating a physiological LOS. Numerous different approachees. Image shows the Nissen’s (posterior 360 approach).
- Main side effects (usually settle after 6 weeks as post-operative swelling & inflammation subsides):
- Dysphagia
- Bloating
- Inability to vomit
- More effective than medical treatment but due to complications and side effects most pts don’t want it
What is Barrett’s oesophagus?
Discuss the pathophysiology
- Metaplasia of oesophageal epithelia where the normal stratified squamous epithelium is replaced by simple columnar epithelium
- Most cases caused by chronic GORD; epithelium damaged by reflux of acidic stomach contents. Metaplasia occurs so cells are better adapted to the acidic environment. Metaplasia increases risk of dysplastic and neoplastic changes. Distal oesophagus most afffected.
*Remember: metaplasia is transformation of one differentiated cell type to another
State some risk factors for Barrett’s oesophagus
-
Chronic GORD (and associated risk factors)
- Male
- Smoking
- Obesity
- Age >50yrs
- Hiatus hernia
- FH of Barrett’s oesophagus
- Previous oesophageal strictures or ulcers
Barrett’s oesophagus presents with a history of chronic GORD; true or false?
True- same presentation as GORD unless adenocarcinoma has developed in which may have symptoms of that
What investigations are required if you suspect Barrett’s oesophagus?
Histological diagnosis therefore OGD with biopsy required. Pts with chronic GORD, resistant GORD or suspected malignancy should have an OGD.
Describe the appearance of Barrett’s oesophagus on OGD
- Red & velvety
- Some preserved squamous islands
Discuss the management of Barrett’s oesophagus, include:
- Conservative
- Medical
- Surveillance/monitoring
- Surgical
Conservative
- Avoiding triggers e.g. alcohol, coffee, fatty foods, chocolate etc…
- Eat smaller meals
- Weight loss
- Smoking cessation
- Sleep with bed raised
Medical
- PPI (high dose, twice daily)
- Add in H2 antagonist
- Stop any exacerbating medications e.g. NSAIDs
Surveillance
- Regular endoscopy (PASSMED says endoscopy recommended every 3-5yrs for patients with metaplasia)
Surgical
- PASSMED says any dysplasia must be treated:
- Radiofrequency ablation if preferred first line treatment
- Endoscopic mucosal resection is another option
The major risk of Barrett’s oesophagus is progression to adenocarcinoma; hence, what must all pts have regularly?
Endscopy
Which gender is oesophageal cancer more common in?
Men
State the two main types of oespohageal cancer and for each state:
- Where in oesophagus most common
- Where in world most common (developed or developing)
- Risk factors associated with each
Squamous cell carcinoma
- Middle & upper 1/3’s
- Developing world
- Risk factors:
- Smoking
- Excessive alcohol consumption
- Chronic achalasia
- Low vit A levels
Adenocarcinoma
- Lower 1/3 (as a consequence of metaplastic epithelium- dysplasia- malignant)
- Developed world
- Risk factors:
- Chronic GORD
- Obesity
- High fat intake
Discuss the clinical features of oesophageal cancer
Symptoms often vague & majority of pts present later:
- Dysphagia (progressive- classically starts with solids then liquids)
- Weight loss (dysphagia & cancer-related anorexia)
- Odynophagia
- Hoarsenss of voice
- Cachexia
- Supraclavicular lymphadenopathy
- Signs of metastatic disease
Any pt with dysphagia should be assumed to have oesophageal cancer until proven otherwise; true or false?
TRUE
NICE reccommend an urgent upper GI endoscopy within 2 weeks to assess for oesophageal cancer in which people?
- Any pt with dysphagia
- Any pt aged =/>55yrs with weight loss plus any of:
- Upper abdominal pain
- Reflux
- Dyspepsia
*Non-urgent referral recommended with haematemesis or =/>55yrs with treatment resistant dyspepsia or uppper abdo pain
What investigation is required if you suspect oesophageal cancer?
What further investigations are required if you find oesophageal cancer on the above investigation?
-
Urgent OGD (within 2 weeks)
- Any malignancy should be sent for biopsy
If malignancy found, pts have more investigations to allow staging and guid treatment. Main ones:
- CT chest-abdomen-pelvis (?mets)
- PET scan (?mets)
- Endoscopic ultrasound (measure penetration into oesophageal wall “T stage”)
- Staging laparoscopy (if have junctional tumour with intra-abdominal component- used to look for intra-peritoneal metastases)
- Fine needle aspiration of palpable cervical lymph nodes
- Bronchoscopy if have hoarseness of voice or haemoptysis
Majority of pts with oesophageal cancer present with early disease that can be cured; true or false?
FALSE- most pts present with advanced disease hence 70% treated palliatively
Discuss the management of oesophageal malignancy for non-palliative:
- SSC
- Adenocarcinoma
As mentioned, 70% pts prsent with advanced disease so management is palliative however if not advanced management options include:
SSCs
- Chemo-radiotherapy
- Surgical management difficult
Adenocarcinoma
-
Neoadjuvant chemotherapy or chemo-radiothearpy with oesophageal resection
- All surgical approaches involve removal of tumour, top of stomach and surrounding lymph nodes. Stomach made into tube and brought into chest to replace oesophagus. Big operation- involves opening abdominal and chest cavity
Discuss post operative nutrition following oesphageal resection for malignancy
Post-operative nutrition is a major problem for these patients as they lose the reservoir function of the stomach. Many centres will routinely insert a feeding tube into the small bowel (a “feeding jejunostomy”) to aid nutrition. However, most patients will need to eat 5-6 small meals per day to meet their nutritional requirements.
State some potential complications of surgery for oesophageal cancer
- Anastomotic leak (8%)
- Re-operation
- Pneumonia (30%)
- Death (4%)#
*any deterioration is post-oesophagectomy pt should be considred anastomotic leak until proven otherwise
Discuss what palliative managment of oesophageal cancer involves
- Oesophageal stent
- Radiotherapy and/or chemotherapy to reduce size, bleeding and temporarily relieve some symptoms
- Nutritional support
- Thickened fluids
- Supplements
- RIG tube
There is a broad spectrum of oesophageal tears; what are the two main subcategories?
- Superficial musocal tear (Mallory-Weiss tears)
- Full thickness ruptures (perforations)
What are the two most common causes of oesphageal full thickness rupture/perforaton?
What is Boerhaave’s syndrome?
- Iatrogenic e.g. endoscopy
- Severe forceful vomitting
*These are most common causes but oesophageal ruputures are rare; although when happen they are surigical emergency.
Boerhaave’s syndrome= spontaneous oesophageal rupture
Where is the most common site for a full thickness oesophageal rupture/perforation?
Just above diaphragmn in left postero-lateral position
Why is an oesophageal ruputure a surgical emergency?
- Perforation will result in leakage of stomach contents into mediastinum & pleural cavity
- Triggers severe inflammatory response
- Rapidly overwhelming
- Lead to physiological collapse, multi-organ failure and even death
Pts deteriorate rapidly hence early identification and management is essential.
Describe clinical features of oesophageal rupture
Hint: think about triad
- Severe sudden onset chest pain
- Retrosternal
- Respitatory distress
- Subcutaneous emphysema
- History of severe vomitting or retching
*Mackler’s triad (vomitting, chest pain & subcutaneous emphysema) only present in 15% pts
What investigations are required for an oesophageal rupture?
-
Routine bloods
- FBC
- U&E
- LFT
- CRP
- Coagulation
- Group & save
- CXR
- CT chest abdomen pelvis with IV & oral contrast ** INVESTIGATION OF CHOICE
- Urgent endoscopy (if high level of clinical suspcion)
What might you see on CXR in pt with oesophageal rupture?
What might you see on CT chest-abdomen-pelvis in pt with oesophaeal rupture?
CXR
- Pneumomediastinum
- Intra-thoracic air fluid levels
CT chest-abdomen-pelvis with IV and oral contrast
- Pneumomediastinum
- Fluid in mediastinum
- Pneumothorax
- Pleural effusion
*Leakage of oral contrast from oesophagus into mediastinum is pathonogmonic
Discuss the principles of definitive management of an oesophageal rupture (for both operative and non-operative)
- Control oesophageal leak
- Eradication of mediastinal & pleural contamination
- Decompress the oesophagus (trans gastric drain or endoscopically placed NG tube)
- Nutritional support
Pts with iatrogen perforations are often more stable than those with spontaenous perforation and hence may be suitable for non-operative management. Discuss non-operative management
- Transfer to ICU/HDU
- Abx
- NBM for 1-2 weeks with endoscopic NG tube insertion
- Large bore chest drain
- TPN or feeding jejunostomy insertion
Why are pts with iatrogenic oesophageal perforations often more stable?
Pt wil have usually been NBM prior to procedure so doesn’t have associated contamination
Pts with spontaneous oesophageal perforations are often unstable and require operative management; discuss the operative management of oesophageal perforations
- Immediate suitable resuscitation
- On table endoscopy to identify site of leak and guide surgery
- Immediate surgery to control leak and wash out chest
- Feeding jejunostomy
- CT scan with contrast 10-14 days before starting oral intake
For Mallory-Weis tears, discuss:
- What they are
- When they tend to occur
- Investigations
- Prognoiss
- Management
- Tear in oesophageal mucosa (often near gastro-oesophageal junction)
- Typically occurs after profuse vomitting and results in short period of haematemesis
- Investigations similar to those for haematemesis, if haematemesis stopped and likely MW tear may not investigate.
- Generally self limting
- Management: reasurrance and monitoring
What do we mean by motility disorders of oesphagus?
Group of conditions characterised by abnormalities in oesophageal peristalsis
Remind yourself of the anatomy of the oesphagus
- 25cm tube divided into thirds:
- Upper: skeletal muscle
- Middle: transition zone of skeletal and smooth muscle
- Lower: smooth muscle
- Upper oesophageal sphincter= skeletal muscle. Prevents air entering GI tract
- Lower oesophgeal sphincter= smooth muscle. Prevents reflux from stomach
For achalasia discuss:
- What it is
- Pathophysiology
- Why does it cause a problem
- Mean age of diagnosis
- Failure of relaxation of LOS and progressive failure of contraction of oesophageal smooth muscle
- Poorly understood but common histological feature is progressive destruction of ganglion cells in myenteric plexus
- High resting tone & failure of relaxation of LOS means food bolus gets stuck in oesophagus; this can cause dysfunction in proximal oeophagus as it is squeezing against fixed outflow/obstruction
- Mean age diagnosis ~50yrs
Discuss clinical features of achalasia
- Progressive dysphagia (both solids & liquids)
- Vomitting
- Chest discomfort
- Regurgitation of food
- Coughing (due to overfill & aspiration- worse at night)
- Weight loss
What investigations are required for suspected achalasia?
- OGD (urgent 2 week referral- as with any dysphagia)
- Oesophageal manometry *GOLD STANDARD
- Barium swallow (rarely done)
What may you find on OGD of someone with achalasia?
Usually normal
May find tight LOS which may suddently give way
Manometry is the gold standard investigation for achalasia; what are the three key features of achalasia on manometry?
- Absence of oesophageal peristalsis
- Failure of relaxation of LOS
- High resting LOS tone
What might you see on barium swallow in achalaisa?
Birds beak appearance
Discuss the management of achalasia, include:
- Conservative
- Medical
- Surgical
Conservative
- Sleep with few pillows to minimise regurgitation
- Chew food thoroughly
- Eat slowly
- Drink plenty with meals
Pharmacological
- CCBs
- Nitrates
- Botox injections into LOS by endoscopy
*Can be partly effective for temporary relief
Surgical
- Endoscopic balloon dilation: insert balloon into LOS which is dilated to stretch muscle fibres
- Laparscopic Heller myotomy: division of specific fibres of LOS which fail to relax
Which surgical management for achalasia has higher sucess rate and lower side effect profile- endoscopic balloon dilation or laparascopic Heller myotomy?
Laparascopic Heller Myotomy has 85% improvement (EBD has 75%) and has lower side effect profile
What is a potential complication of achalasia?
- Increased risk oesphageal cancer (x8-16)
For diffuse oesophageal spams state:
- What it is
- Pathophysiology
- What it can progress to
- Characterised by multi-focal high amplitude contractions of oesophagus
- Dysfunction of oesophageal inhibitory nerves
- In some individuals can progress to achalasia
Discuss clinical features of diffuse oesophageal spasm
- Severe dysphagia (both liquids & solids)
- Chest pain
- Central
- Exacerbated by food
- Can respond to nitrates hence may be mistaken for anginal chest pain
What investigations are required for suspected diffuse oesphageal spasm?
- OGD (all pts with dysphagia- urgent OGD- 2 week)
- Manometry= GOLD STANDARD/DEFINITIVE DIAGNOSIS
- Barium swallow (rarely done now)
What would you find on manometry of a pt with diffuse oesphageal spasm?
Repetitive, simultaneous and ineffective contractions of oesophagus
What would you find on barium swallow of someone with diffuse oesophageal spasm?
corkscrew appearance
Discuss the management of diffuse oesophageal spasms
-
Nitrates or CCBs to relax oesophageal smooth muscle
- symptomatic improvement
- long term efficacy uncertain
- Pneumatic dilation/endoscopic balloon dilation (if LOS dysfunctional)
- Myotomy (in severe cases)
Other than achalasia & diffuse oesophageal spasm, state some other causes of oesophageal dysmotility
- Autoimmune & connective tissue
- Systemic sclerosis
- Polymyositis
- Dermatomyositis
*Treat underlying cause and give nutritional modificationoand PPI as required
What is a pharyngeal pouch?
What are features?
What investigation is required?
What is the management?
- Posteromedial diverticulum of oesophagus through Kilian’s dehiscence (triangular area between cricopharyngeal and thyropharyngeal muscles).
- Features:
- Dysphagia
- Regurgitation
- Halitosis
- Aspiration
- Neck swelling which gurgles on palpation
- Barium swallow combined with dynamic fluoroscopy
- Surgery
