Oesophagus Flashcards
what is GORD and what is the pathophysiology
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
risk factors for GORD
age, obesity, male gender, alcohol, smoking, caffeine intake and spicy foods
clinical features of GORD
chest pain - burning retrosternal, worse after meals and when laying down or straining
belching, chronic cough, nocturnal cough
red flags for suspected upper GI malignancy
patients with dysphagia
any patient >55yrs with weight loss, upper abdo pain, dyspepsia or reflux
management of GORD
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
what are the 2 main subtypes of oesophageal cancer
squamous cell carcinoma and adenocarcinoma
what are the differences in aetiology between adenocarcinoma and squamous cell carcinomas of the oesophagus
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
if a patient presents with dysphagia, what is it important to think about/rule out
oesophageal cancer
what are the common clinical features of oesophageal cancer
most common is progressive dysphagia (difficulty swallowing - starting with solids them transitioning to liquids aswell)
weight loss, odynophagia (painful swallowing), hoarseness
what are the red flag signs for oesophageal malignancy that require urgent upper GI endoscopy
any patient with dysphagia
any patient >55yrs with weight loss and upper abdo pain, dyspepsia, or reflux
initial investigations into suspected oesophageal malignancy
first line is an upper GI endoscopy (OGD - oesophagogastroduodenoscopy)
any malignancy then biopsied and sent for histology
what staging investigations is it important to do in a patient with oesophageal malignancy
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
management of oesophageal cancer
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
what subtype of oesophageal cancer is most common in developing countries
squamous cell carcinomas; smoking and alcohol association
what are the 2 main sub-categories of oesophageal tears
mallory-weiss tears; superficial mucosal tears
full thickness ruptures
what is oesophageal perforation and how does it lead to death
= 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
what are the most common causes of oesophageal rupture
iatrogenic - e.g. endoscopy
or after severe forceful vomiting
what are the classic clinical features of a ruptured oesophagus
severe sudden onset retrosternal chest pain
respiratory distress
subcutaneous emphysema (air becomes trapped under the skin)
investigations into suspected oesophageal tears
routine bloods + group and save
gold standard = urgent CT-chest-abdo-pelvis with IV and oral contrast
urgent endoscopy when in theatre
management of oesophageal perforation
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
what are mallory-weiss tears and how do they occur
lacerations in the oesophageal mucosa - usually at the gastro-oesophageal junction
they tend to occur after a period of profuse vomiting
how do mallory-weiss tears present and what is their management
present with a short period of haematemesis
they are usually small and self limiting
most cases managed conservatively
how long is the oesophagus
25cm
what type of muscle is present in each third of the oesophagus
upper third = skeletal muscle
middle third = transition zone of both skeletal and smooth muscle
lower third = smooth muscle
