Oesophagus

Question 1

Eisinophilic oesophagitis - Pathophys & Rx

Answer 1

Dysphagia common sx (consider in young ppl w/ reflux, impaction)

Cytokine Th2 (IL-4, IL-5, IL-13) due to food allergens: 
inflammatory response leads to remodelling of oesophageal mucosa 
potentially subepithelial fibrosis

Rx: PPI –> topical steroid (Fluticasone puffer, 1mg orodisp Budesonide) + diet

Question 2

6 allergies in Eisinophilic oesophagitis

Answer 2

SO WHAT, EGGS MAY NEED SAUCE (4ED top 4), need bx after exclusions

1. Soy
2. Wheat
3. Eggs
4. Milk
5. Nuts
6. Shellfish

Question 3

Oesophagus problems

Answer 3

Benign (longer course, liquids + solids, intermittent, young, no LOW early)

1. Eisinophilic oesophagitis
2. Reflux
3. Achalasia
4. Distal Oesophageal Spasm

Malignant (older, shorter course, solids > liquids): AdenoCa (barretts), SqCC (Ach)

Question 4

Achalasia - Moa & Dx

Answer 4

Incomplete LOS relaxation

• Endoscopy: Done to exclude stricturing lesions/Ca (?tight sp, dilated oes)
• CXR: no gastric air bubble, Retrocardiac fluid level
• Ba Swallow: Rats tail/Birds beak, Holdup in dilated oesophagus
• Manometry: Most sensitive test

Question 5

Mamometry

Answer 5

Type 1 Achalasia - Classic

No peristalsis + incomplete LES relaxation w/ elevated Pb >10 mm Hg.
minimal contractility in the esophageal body

Question 6

Ba swallow

Answer 6

Birds peak / rats tail

(Type 2 achalsia - Compression)

Question 7

Mamometry

Answer 7

Type 2 Achalsia - Compression

No peristalsis + incomplete LES relaxation w/ elevated Pb >10 mm Hg.
intermittent periods of panesophageal pressurization

Best outcomes (most likely have weight loss assoc)

Question 8

Mamometry

Answer 8

Type 3 (Spastic Achalsia)

No peristalsis + incomplete LES relaxation w/ elevated Pb >10 mm Hg.
premature or spastic distal esophageal contractions

Question 9

Mamometry

Answer 9

Type 1 Achalasia - Classic
No peristalsis + incomplete LES relaxation w/ elevated Pb >10 mm Hg.
minimal contractility in the esophageal body

Question 10

Mamometry

Answer 10

EGJ outflow obstruction

Question 11

Mamometry

Answer 11

Jackhammer oesophagus

Question 12

Rx - Achalsia

Answer 12

• Meds not effective (GTN, CCB)
• Balloon Dilation: (un)Controlled LOS rupture, inc balloon size (30mm → 40mm), 5% perf, & ?rpt, similar efficacy to myotomy (best for OLD)
• Botox: to LOS, 70% ‘success’ but need repeats after 3-6m
• Myotomy: Lap surg division of LOS, fundoplication added (Dor patch), v effective, low morbidity (best for YOUNG)
• POEM: Per Oral Endoscopic Myotomy, reflux after as no fundoplication

Question 13

DOS - MoA & Sx

Answer 13

• Synchronous, uncoordinated oesophageal contractions
• occurs earlier after a swallow than achalasia
• Probably loss of inhibitory innervation
• Dysphagia: cold liquids, large boluses, ?impaction
• Chest pain & Regurgitation (contraction squirts back up)

Question 14

Mamometry

Answer 14

DOS

simultaneous high amplitude contractions w/ no peristalsis in oesophageal body

Question 15

DOS - Rx

Answer 15

• Diet mod: Soft foods, Eat slowly, Wash down with water
• Drugs: acid suppression (Ca blockers), GTN spray for sx
• Botox – into oesophageal body
• Dilatation
• Myotomy (POEM) - occasionally

Question 16

Ba swallow

Answer 16

Normal

Question 17

Ba swallow

Answer 17

Achalasia

(below photo normal)

Question 18

Mamometry

Answer 18

Normal

Question 19

Mamometry

Answer 19

Achalasia - Type 1 likely .

No pressure wave

LOS never opens

Question 20

Ba swallow

Answer 20

Achalasia - birds beak

(below photo normal)

Question 21

Mamometry

Answer 21

Type 1 Achalasia - Classic
No peristalsis + incomplete LES relaxation w/ elevated Pb >10 mm Hg.
minimal contractility in the esophageal body

Question 22

Mamometry

Answer 22

Type 2 Achalsia - Compression

No peristalsis + incomplete LES relaxation w/ elevated Pb >10 mm Hg.
intermittent periods of panesophageal pressurization

Best outcomes (most likely have weight loss assoc)

Question 23

Mamometry

Answer 23

Type 3 (Spastic Achalsia)

No peristalsis + incomplete LES relaxation w/ elevated Pb >10 mm Hg.
premature or spastic distal esophageal contractions

Question 24

Ba swallow

Answer 24

Type 3 (Spastic Achalsia)

No peristalsis + incomplete LES relaxation w/ elevated Pb >10 mm Hg.
premature or spastic distal esophageal contractions

(photo of normal)

Question 25

Ba swallow

Answer 25

Type 2 Achalsia - Compression

No peristalsis + incomplete LES relaxation w/ elevated Pb >10 mm Hg.
intermittent periods of panesophageal pressurization

Best outcomes (most likely have weight loss assoc)

(photo of normal)

Question 26

Ba swallow

Answer 26

Type 1 Achalasia - Classic
No peristalsis + incomplete LES relaxation w/ elevated Pb >10 mm Hg.
minimal contractility in the esophageal body

(photo of normal)

Question 27

GORD criteria pH and amt of time

Answer 27

pH <4 >4% of time
Normal is post prandial & upright only (supine reflux not normal)

Question 28

Pathophysiology of Barretts & key cell types

Answer 28

• Squamous oesophagus metaphases due to acid, to mucosa of another type (cardia, gastric, intestinal)
• Intestinal most important for dysplasia to adenoCa
• Columnar mucosa - goblet cells
• Length at dx remains (doesn’t change)

Question 29

Barretts surveillance

Answer 29

No dysplasia 3-5yrs (PPI)

Low grade: 6 months (then ablation if found twice) + PPI

High grade: endoscopic resection + ablation + PPI + annual gastroscopy for 5yrs

Question 30

Eisinophilic oesophagitis - on bx

Answer 30

Histo: Eosinophils >15 /hpf on bx

Visual Ax: trachealization rings, linear furrowing, exudates, tears on dilation