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🕺🏽gen surg > Oesophagus🥳 > Flashcards

Oesophagus🥳 Flashcards

1
Q

GORD pathophysiology?

A

episodes of LOS relaxation become more frequent allowing reflex of gastric contents into the oesophagus resulting in pain & mucosal damamge in the oesophagus

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2
Q

GORD risk factors?

A
  • age
  • obesity
  • male
  • alcohol
  • smoking
  • caffeine
  • fatty/spicy food
  • inc intra abdo pressure eg pregnancy
  • HH
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3
Q

GORD clinical features?

A
  • 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??
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4
Q

GORD on examination?

A

typically unremarkable. 10% of pts will have developed barretts oesophagus by time they seek med attention

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5
Q

GORD differential diagnosis?

A
  • GI differentials - malignancy (oesophageal or gastric), PUD or oesophageal motility disorders
  • coronary artery disease & biliary colic mimic GORD
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6
Q

GORD investigations?

A

in most pts a clinical diagnosis is reached from a good Hx & resolution of symptoms after a trial of a PPI

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7
Q

GORD NICE states the red flag symptoms for a suspected GI malignancy requiring urgent endoscopy are?

A
  • pts w dysphagia

- any pt >55yrs w weight loss & upper abdo pain, dyspepsia or reflux

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8
Q

GORD imaging?

A
  • 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?)
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9
Q

GORD conservative management?

A
  • lifestyle management - eg??

- PPIs

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10
Q

GORD surgical management?

A
  • 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?)
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11
Q

GORD complications?

A
  • aspiration pneumonia
  • barretts oesophagus
  • oesophageal strictures
  • oesophageal ca
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12
Q

OESOPHAGEAL TEARS what are they?

A

ruptures to any part of the oesophageal wall

main 2 are either superficial mucosal tears (mallory weiss) or full thickness

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13
Q

OESOPHAGEAL TEARS what is oesophageal perf?

A
  • this is a FULL THICKNESS rupture of the oesophageal wall
  • stomach contents leak into mediastinum & pleural cavity -> triggers severe inflammatory response
  • surgical emergency !!
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14
Q

OESOPHAGEAL TEARS oesophageal perf aetiology?

A
  • iatrogenic eg ?
  • after severe forceful vomiting ie spontaneous - this is ? syndrome
  • most common site of perf?
  • rare
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15
Q

OESOPHAGEAL TEARS clinical feature?

A

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??

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16
Q

OESOPHAGEAL TEARS investigations?

A
  • 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
17
Q

OESOPHAGEAL TEARS initial management ?

A

pts often are septic & haemodynamically unstable so resus, high flow o2, broad spec abx

18
Q

OESOPHAGEAL TEARS principles of definitive management ?

A
  • control oesophageal leak
  • eradicate mediastinal & pleural contamination
  • decompress oesophagus (via what? x2)
  • nutritional support
19
Q

OESOPHAGEAL TEARS overall management?

A

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
20
Q

OESOPHAGEAL TEARS what are mallory weiss tears?

A

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
21
Q

OESOPHAGEAL TEARS mallory weiss tears investigations ?

A
  • 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
22
Q

OESOPHAGEAL TEARS mallory weiss tears management ?

A 
if unstable:
-ABCDE
- 2 large bore IV cannulas 
- start fluid resus if needed
- cross match 
can be managed conservatively !
23
Q

OESOPHAGEAL MOTILITY DISORDERS what are they?

A

a group of conditions characterised by abnormalities in oesophageal peristalsis

24
Q

OESOPHAGEAL MOTILITY DISORDERS differentials?

A
  • GORD
  • oesophageal CA
    due to their variable and atypical presentation pts are investigated for a number of pathologies before it is diagnosed
25
Q

ACHALASIA what is it?

A

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
26
Q

ACHALASIA pathophysiology ?

A

poorly understood

histology : progressive destruction of ganglion cels in the myenteric plexus

27
Q

ACHALASIA clinical features?

A
  • 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
28
Q

ACHALASIA OE?

A
  • rarely any obvious signs of note

- visible wt loss in longstanding cases secondary to reduced oral intake

29
Q

ACHALASIA investigation?

A
  • 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?
30
Q

ACHALASIA medical management ?

A
  • 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
31
Q

ACHALASIA surgical management?

A
  • 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
32
Q

DOS what is it?

A

diffuse oesophageal spasm is a disease characterised by multi focal high amplitude contractions of the oesophagus

33
Q

DOS pathophysiology ?

A

dysfunction of oesophageal inhibitory nerves

** can progress to??

34
Q

DOS clinical features?

A
  • 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
35
Q

DOS investigations?

A
  • 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?
36
Q

DOS management ?

A
  • CCBs to relax oesophageal SM - how do they work?

- pneumatic dilatation & heller myotomy can be trialled but have high rates of recurrence

37
Q

OESOPHAGEAL MOTILITY DISORDERS other causes?

A

autoimmune & connective tissue disorders eg systemic sclerosis, polymyositis & dermatomyositis
- treat underlying cause!! w nutritional modification & PPIs as required

🕺🏽gen surg (8 decks)

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