Oesophagus🥳 Flashcards
GORD pathophysiology?
episodes of LOS relaxation become more frequent allowing reflex of gastric contents into the oesophagus resulting in pain & mucosal damamge in the oesophagus
GORD risk factors?
- age
- obesity
- male
- alcohol
- smoking
- caffeine
- fatty/spicy food
- inc intra abdo pressure eg pregnancy
- HH
GORD clinical features?
- chest pain - classically burning retrosternal sensation (what makes it better x1 and worse x4?)
- additional symptoms may inc belching. odynophagia, chronic cough, nocturnal cough
- always check for red flag symptoms eg??
GORD on examination?
typically unremarkable. 10% of pts will have developed barretts oesophagus by time they seek med attention
GORD differential diagnosis?
- GI differentials - malignancy (oesophageal or gastric), PUD or oesophageal motility disorders
- coronary artery disease & biliary colic mimic GORD
GORD investigations?
in most pts a clinical diagnosis is reached from a good Hx & resolution of symptoms after a trial of a PPI
GORD NICE states the red flag symptoms for a suspected GI malignancy requiring urgent endoscopy are?
- pts w dysphagia
- any pt >55yrs w weight loss & upper abdo pain, dyspepsia or reflux
GORD imaging?
- OGD (only in those w red flag). used to exclude malignancy & complications of reflex (eg?? x3) BUT if symptoms are new onset or worsening despite PPI pt should be referred
- 24 hr pH monitoring is the gold standard. (who is required for & combined w?)
GORD conservative management?
- lifestyle management - eg??
- PPIs
GORD surgical management?
- 3 main indications for surgery - failure to respond to medical therapy, patient preference to avoid life long med. patients w complications of GORD (particularly??)
- fundoplication - what are the SEs? when do these settle? why?
- new techniques - stretta & linx (what are these?)
GORD complications?
- aspiration pneumonia
- barretts oesophagus
- oesophageal strictures
- oesophageal ca
OESOPHAGEAL TEARS what are they?
ruptures to any part of the oesophageal wall
main 2 are either superficial mucosal tears (mallory weiss) or full thickness
OESOPHAGEAL TEARS what is oesophageal perf?
- this is a FULL THICKNESS rupture of the oesophageal wall
- stomach contents leak into mediastinum & pleural cavity -> triggers severe inflammatory response
- surgical emergency !!
OESOPHAGEAL TEARS oesophageal perf aetiology?
- iatrogenic eg ?
- after severe forceful vomiting ie spontaneous - this is ? syndrome
- most common site of perf?
- rare
OESOPHAGEAL TEARS clinical feature?
classic picture: pt presents w severe onset retro sternal chest pain, resp distress & subcutaneous emphysema following severe vomiting or retching - MACKLERS TRIAD
**what one of the triad is often absent??
OESOPHAGEAL TEARS investigations?
- bloods inc G&S
- initial CXR - ca show evidence of pneumomediastinum or intra thoracic air fluid levels
- CT CAP w IV and PO contrast - what may this show?
!! high level of clincial suspicion? urgent endoscopy in theatre
OESOPHAGEAL TEARS initial management ?
pts often are septic & haemodynamically unstable so resus, high flow o2, broad spec abx
OESOPHAGEAL TEARS principles of definitive management ?
- control oesophageal leak
- eradicate mediastinal & pleural contamination
- decompress oesophagus (via what? x2)
- nutritional support
OESOPHAGEAL TEARS overall management?
surgical:
- on table endoscopy (to determine what?) then emergency thoracotomy
- leaking = common. feeding jej inserted during surgery. then CT w contrast @ 10-14 days before PO food
non surgical: who’s suitable? iatrogenic perf are more stable than spontaneous (why??), minimal contamination pts, contained perf pts, no sx of mediastinitis/no food in mediastinum or pleura pts, spontaneous perf pts who are too frail/++co-morbidities for surgery treatment involves: - ICU/HDU - abx & antifungals cover - NBM for 1-2 wks w endoscopic NG tube insertion on drainage - large bore chest drain insertion - TPN or feeding jej
OESOPHAGEAL TEARS what are mallory weiss tears?
lacerations in the oesophageal mucosa @ the gastro oesophageal junction
- occur after period of profuse vomiting and so causes a short period of haematemesis
- generally small & self limiting
OESOPHAGEAL TEARS mallory weiss tears investigations ?
- bloods - eg? x4 + VBG
- OGD within 12 hrs of acute haematemsis or asap is pt unstable
- active bleeding or OGD unremarkable? Ct abdo w contrast
OESOPHAGEAL TEARS mallory weiss tears management ?
if unstable: -ABCDE - 2 large bore IV cannulas - start fluid resus if needed - cross match can be managed conservatively !
OESOPHAGEAL MOTILITY DISORDERS what are they?
a group of conditions characterised by abnormalities in oesophageal peristalsis
OESOPHAGEAL MOTILITY DISORDERS differentials?
- GORD
- oesophageal CA
due to their variable and atypical presentation pts are investigated for a number of pathologies before it is diagnosed
ACHALASIA what is it?
primary motility disorder of the oesophagus characterised by failure of LOS relaxation & the absence of peristalsis
- rare
- typically diagnosed at 50 yrs
- inc risk of CA w this condition
ACHALASIA pathophysiology ?
poorly understood
histology : progressive destruction of ganglion cels in the myenteric plexus
ACHALASIA clinical features?
- pts present w: progressive dysphagia & regurg. sx severity varies day to day
- other sx: resp comps (eg? x2), chest pain, dyspepsia, wt loss -> non specific sx!! so delay to diagnosis
ACHALASIA OE?
- rarely any obvious signs of note
- visible wt loss in longstanding cases secondary to reduced oral intake
ACHALASIA investigation?
- OGD (to exclude CA) - in severe disease can show a dilated oesophagus w retained food & inc resistance @ GOJ
- gold standard : oesophageal manometry (what is this?). 3 key features seen: absence of oesophageal peristalsis, failure of LOS relaxation & high resting LOS tone
- ** barium swallow isnt rlly used anymore but what characteristic appearance does it show?
ACHALASIA medical management ?
- inform & advise : sleep w multiple pillows to minimise regurg, eat slow, chew food thoroughly, drink plenty of fluids w meals
- pharmacological: CCBs (sublingual nifedipine) to inhibit LOS muscle contraction but their benefit is short lived. botox to LOS via endoscopy - only lasts a few months
ACHALASIA surgical management?
- laparoscopic heller myotomy - what is this? https://www.uhcw.nhs.uk/download/clientfiles/files/Patient%20Information%20Leaflets/Surgical%20Services/Upper%20G%20I/117572Laparoscopic_Heller_Myotomy(1863)_[April_2018].pdf
- per oral endoscopic myotomy (POEM) - what is this ? https://www.kch.nhs.uk/Doc/pl%20-%20853.1%20-%20peroral%20endoscopic%20myotomy%20(poem).pdf
- endoscopic balloon dilatation
- end stage refractory achalasia? oesophagectomy
DOS what is it?
diffuse oesophageal spasm is a disease characterised by multi focal high amplitude contractions of the oesophagus
DOS pathophysiology ?
dysfunction of oesophageal inhibitory nerves
** can progress to??
DOS clinical features?
- pt presents w severe dysphagia to solids & liquids
- central chest pain exacerbated by food
- responds to GTn so hard to distinguish from angina - but this pain is rarely exertional !!
- OE : normal
DOS investigations?
- manometry - shows a pattern of repetitive, simultaneous, and ineffective contractions of the oesophagus as well as potential concurrent dysfunction of the LOS
- endoscopy is usually normal
- not done anymore but what characteristic appearance is seen on a barium swallow?
DOS management ?
- CCBs to relax oesophageal SM - how do they work?
- pneumatic dilatation & heller myotomy can be trialled but have high rates of recurrence
OESOPHAGEAL MOTILITY DISORDERS other causes?
autoimmune & connective tissue disorders eg systemic sclerosis, polymyositis & dermatomyositis
- treat underlying cause!! w nutritional modification & PPIs as required
