Oesophagus Flashcards

1
Q

what is GORD and what is the pathophysiology

A

condition whereby gastric acid leaks up into the oesophagus

dysfunction of the lower oesophageal sphincter - it relaxes too much and allows the reflux of gastric contents into the oesophagus

this results in pain and mucosal damage in the oesophagus

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2
Q

risk factors for GORD

A

age, obesity, male gender, alcohol, smoking, caffeine intake and spicy foods

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3
Q

clinical features of GORD

A

chest pain - burning retrosternal, worse after meals and when laying down or straining

belching, chronic cough, nocturnal cough

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4
Q

red flags for suspected upper GI malignancy

A

patients with dysphagia

any patient >55yrs with weight loss, upper abdo pain, dyspepsia or reflux

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5
Q

management of GORD

A

conservative; avoid caffeine, alcohol, spicy foods, weight loss, smoking cessation, PPIs - lifelong

surgical; fundoplication - wrap fundus around oesophagus to recreate LOS lower down - side effects include dysphagia, bloating and inability to vomit

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6
Q

what are the 2 main subtypes of oesophageal cancer

A

squamous cell carcinoma and adenocarcinoma

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7
Q

what are the differences in aetiology between adenocarcinoma and squamous cell carcinomas of the oesophagus

A

squamous cell = developing countries, upper/middle third of the oesophagus, associated with smoking and excessive alcohol consumption

adenocarcinoma = developed world, lower third of oesophagus, arises as a consequence of Barrett’s oesophagus, associated with GORD, obesity and high fat intake

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8
Q

if a patient presents with dysphagia, what is it important to think about/rule out

A

oesophageal cancer

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9
Q

what are the common clinical features of oesophageal cancer

A

most common is progressive dysphagia (difficulty swallowing - starting with solids them transitioning to liquids aswell)

weight loss, odynophagia (painful swallowing), hoarseness

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10
Q

what are the red flag signs for oesophageal malignancy that require urgent upper GI endoscopy

A

any patient with dysphagia

any patient >55yrs with weight loss and upper abdo pain, dyspepsia, or reflux

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11
Q

initial investigations into suspected oesophageal malignancy

A

first line is an upper GI endoscopy (OGD - oesophagogastroduodenoscopy)

any malignancy then biopsied and sent for histology

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12
Q

what staging investigations is it important to do in a patient with oesophageal malignancy

A

CT chest-abdo-pelvis and PET-CT scan ; both used to assess for distant metastases

endoscopic ultrasound ; measures penetration into the oesophageal wall

staging laparoscopy ; look for intra-peritoneal mets

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13
Q

management of oesophageal cancer

A

only a small proportion of oesophageal cancers are suitable for surgical intervention

the survival rate is poor due to presentation with already advanced disease - therefore approx 70% are treated palliatively

chemo and radiotherapy are the main options with surgical resection possible in very few patients with early disease

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14
Q

what subtype of oesophageal cancer is most common in developing countries

A

squamous cell carcinomas; smoking and alcohol association

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15
Q

what are the 2 main sub-categories of oesophageal tears

A

mallory-weiss tears; superficial mucosal tears

full thickness ruptures

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16
Q

what is oesophageal perforation and how does it lead to death

A

= full thickness rupture of the oesophageal wall

results in leakage of stomach contents into the mediastinum and pleural cavity, which triggers a severe inflammatory response which will rapidly become overwhelming, leading to physiological collapse, multi organ failure and death

17
Q

what are the most common causes of oesophageal rupture

A

iatrogenic - e.g. endoscopy

or after severe forceful vomiting

18
Q

what are the classic clinical features of a ruptured oesophagus

A

severe sudden onset retrosternal chest pain

respiratory distress

subcutaneous emphysema (air becomes trapped under the skin)

19
Q

investigations into suspected oesophageal tears

A

routine bloods + group and save

gold standard = urgent CT-chest-abdo-pelvis with IV and oral contrast

urgent endoscopy when in theatre

20
Q

management of oesophageal perforation

A

urgent and aggressive resus required; high flow oxygen, fluid resus, broad spectrum abx - all given immediately

principles of definitive management;

  • control the leak
  • wash out and remove the mediastinal and pleural contamination
  • decompress oesophagus
  • nutritional support

those with spontaneous perforations require surgery to control the leak and wash out the chest - this is done via thoracotomy

those with iatrogenic perforations can be managed non-operatively

21
Q

what are mallory-weiss tears and how do they occur

A

lacerations in the oesophageal mucosa - usually at the gastro-oesophageal junction

they tend to occur after a period of profuse vomiting

22
Q

how do mallory-weiss tears present and what is their management

A

present with a short period of haematemesis

they are usually small and self limiting

most cases managed conservatively

23
Q

how long is the oesophagus

A

25cm

24
Q

what type of muscle is present in each third of the oesophagus

A

upper third = skeletal muscle

middle third = transition zone of both skeletal and smooth muscle

lower third = smooth muscle

25
Q

what is the function of both the upper and lower oesophageal sphincters and what type of muscle is each comprised of

A

UOS = skeletal muscle; prevents air entering the GI tract

LOS = smooth muscle; prevents reflux from the stomach

26
Q

what controls the peristaltic waves of the oesophagus

A

oesophageal myenteric neurones

27
Q

what controls the primary and secondary waves of peristalsis in the oesophagus

A

primary wave = under control of the swallowing centre

secondary wave = activated in response to distension

28
Q

what is Achalasia

A

primary motility disorder of the oesophagus

failure of relaxation of the LOS and the absence of peristalsis along the oesophageal body

29
Q

what is the believed pathophysiology of achalasia

A

progressive destruction of the ganglion cells in the myenteric plexus (controls peristalsis)

30
Q

clinical features of Achalasia

A

progressive dysphagia + regurgitation of food

nocturnal cough, aspiration, chest pain, dyspepsia, weight loss

symptoms are vague and therefore results in a delay in diagnosis

31
Q

investigations into achalasia

A

upper GI endoscopy first to exclude cancer

gold standard = oesophageal manometry; measures pressure of LOS sphincter and surrounding muscle

32
Q

management of Achalasia

A

sleep with multiple pillows to reduce regurgitation, eat slowly, plenty of fluids with meals

pharmacological options; use of CCBs to inhibit LOS contraction, Botox injections into LOS via endoscopy - both only provide short lived respite

surgery; provide long term improvements, however come with some side effects

33
Q

what is diffuse oesophageal spasm and what causes it

A

disease characterised by multi-focal high amplitude contractions of the oesophagus

thought to be caused by dysfunction of the oesophageal inhibitory nerves

34
Q

clinical features of diffuse oesophageal spasm

A

severe dysphagia to both solids and liquids

central chest pain

35
Q

diffuse oesophageal spasm vs angina

A

both respond to nitrates - making it difficult to distinguish between the two

however DOS is not exertional like angina

36
Q

investigations into diffuse oesophageal spasm and management

A

oesophageal manometry - shows pattern of repetitive, simultaneous and ineffective contractions of the oesophagus

management; CCBs limit strongest contractions

37
Q

what condition is characterised by a ‘bird peak’ appearance on barium swallow

A

achalasia

38
Q

what type of epithelium lines the lumen of the oesophagus

A

stratified squamous non-keratinized