Oesophagus Flashcards
Define oesophageal webs
Thin mucosal membrane that grows across lumen of upper! Oesophagus and may cause dysphasia.
Name 2 risk factors oesophageal webs
• Severe, chronic iron deficiency anemia (resolve with treatment)
• female
Symptoms oesophageal webs?
Dysphagia for solids.
Often signs of anaemia (underlying cause)
Diagnosis oesophageal webs
Barium swallow:webs upper oesophagus
Treatment oesophageal webs?
• Treat iron deficiency anaemia
• easily ruptured during œsophagoscopy
Name 5 causes proximal or mid esophageal strictures
• Caustic ingestion acid or alkali
• malignancy, radiation therapy, extrinsic compression, scc
• infections esophagitis: Candida, CMV, HSV, HIV
• medication induced esophagitis: NSAIDs, phenytoin, kCL, tetracycline, ascorbic acid, alendronate
• idiopathic eosinophilic esophagitis
• disease skin: pemphigus vulgaris, benign mucous membrane (cicatricial) pemphigoid
• AIDS and immunosuppression post transplant , graft vS host disease
• trauma, foreign body/ post-op structure, congenital esophageal stenosis
Name 5 causes distal esophageal strictures
• Peptic stricture: GORD, zollinger Ellison syndrome
• Adenocarcinoma
• collagen vascular disease: scleroderma, SLE, rheumatoid arthritis
• chrohn disease
• sclerotherapy, prolonged ngt
• extrinsic compression, alkaline reflux following gastric resection
Symptoms peptic stricture? (5)
• Heartburn, odynophagia, food impaction, weight loss, chest pain
• progressive dysphasia for solids = most commonly !
• atypical presentation = chronic cough, asthma secondary to aspiration
• obstruction perceived at a point either above or at level of lesion
Differential for dysphagia solids and liquids simultaneously?
Achalasia
Collagen Vascular disorders
Type of dysphagia due to schatzki ring?
Intermittent and nonprognessive
Treatment esophageal stricture? (4)
• Treat underlying cause eg Candida
• Long term PPI,
• endoscopic dilation or
• intralesional steroid injection or
• endoscopic stricturoplasty, stent etc
Name 6 types esophageal cancer
• squamous cell carcinoma
• Adenocarcinoma
Rare:
• neuroendocrine
• lymphoma
• gist
• melanoma
Name 9 risk factors esophageal squamous cell carcinoma
Non-modifiable
•male
Lifestyle
• smoking and alcohol
• caustic injury
• recurrent thermal injury due to ingestion of high temperature beverages
• diet: low fruits and veg, high in nitrogenous compounds eg beans, nuts, meat, poultry, fish
• lower socioeconomic status
Medical conditions
• longstanding achalasia
• tylosis (rare autosomal dominant disease with hyperkeratosis palm and sole)
• hpv
Name 4 risk factors esophageal Adenocarcinoma
Non-modifiable
• male
Comorbidities
• GERD and Barret’s esophagus
Lifestyle
• obesity
• smoking
Symptoms oesophageal cancer? (7)
Typical
• progressive dysphagia
• involuntary progressive weight loss and anorexia
• fatigue due to anaemia in presence of chronic, occult bleeding or chee to anaemia of chronic illness
• may vomit blood or pass melena
Symptoms of local invasion
• coughing, choking and recurrent pneumonias due to tracheo-esophageal fistula
• hoarseness due to vocal cord palsy from recurrent laryngeal nerve invasion
• aspiration pneumonia
Grading of dysphagia?
0: no dysphagia
1: can swallow some solids
2:can only swallow semi solids
3: liquids only
4: can’t swallow anything
Clinical examination findings esophageal cancer? (6)
• severely wasted, dehydrated pale, lethargic
Signs metastasis:
• tinge of jaundice (liver)
• hepatomegaly
• supraclavicular cervical lymph nodes
• chest pneumonia or pleural effusion
Other signs mets to bones, adrenal glands, brain, peritoneum
Common sites metastasis esophageal cancer? (7)
• Lymph
• lung
• liver
• bones
• brain
• adrenal glands
• peritoneal surfaces
Diagnostic investigations for esophageal cancer?
• Barium swallow: can be done initially to evaluate anatomy before invasive procedures. Features= irregular apple core stricture, shouldering, prox dilatation esophagus, axis deviation or angulation, TOF if present
• endoscopy and biopsy mainstay. Nb to document: exact site relative to GE J, extension into stomach and distance from teeth, length lesion, circumferential involvement, obstruction, adjacent pre-malignant lesions ie squamous dysplasia or be. Need 6 biopsies.
Name 4 signs of advanced esophageal cancer on imaging
• Endoscopic: long circumferential lesion > 8cm length
• ba swallow:tracheo-oesoph fistula, axis deviation and angulation
• cxr: pleural effusions or cannonball lesions
• Ultrasound abdomen: liver mets, Ascites
Staging esophageal cancer?
Ajcc TNM
Tumour (CT chest abdomen pelvis, endoscopic ultrasound more sensitive, bronchoscope t4a )
• Tis: high grade dysplasia
• t1
- a: invade lamina propria or muscularis mucosae
-B: submucosa
• t2: muscularis propria
• t3: adventitia
• t4
- a: adjacent structures eg pleura, pericardium, azygous vein, diaphragm, peritoneum
-B: major adjacent structures eg aorta, vertebral body, trachea
Regional lymph nodes (CT chest abdomen pelvis, endoscopic ultrasound more sensitive)
• n1: 1-2 nodes
• n2: 3-6
• n3: ≥7
Metastasis (CT chest abdomen pelvis, endoscopic ultrasound, pet CT, staging laparoscopy with ≥ t3 or node involvement )
M1
Management Tis and T1a esophageal cancer (confined to mucosa)? (2)
• Locally ablative techniques: radiofrequency ablation
• or endoscopic resection
Very low risk metastasis
Management T 1 and T 2 NoMo esophageal cancer (confined to esophagus )?
Surgical resection esophagectomy with Adjacent lymph nodes (t1b submucosal involvement has 20% risk lymph metastasis )
Management T1-3 N1-3 and T4a Mo esophageal cancer? (2)
• Still resectable. Surgery
• adjuvant chemo or chemoradiotherapy
Management m1 and T4b Mo esophageal cancer? (3)
Aka disseminated and locally advanced irresectable
Palliation:
•oesophageal dilatation with self expanding metal stent for high grade dysphagia
• radiation (brachytherapy or external beam): early dysphagia
• Og junction tumours radiation is better. Stent will encourage GERD
• morphine syrup analgesia
Management cervical esophageal cancer?
• can’t be safely resected with adequate clear margins.
• definitive chemoradiotherapy with curative intent
Name 4 types esophagectomy for esophageal cancer
• Trans-hiatal: ideal for low tumour or early tumour with probable minimal lymph node involvement. Open abdo cavity only
• two stage ivor-lewis: distal third tumours. Open abdominal and thoracic cavity.
• three stage mckeon: open thorax abdomen and neck for the anastomosis
• also resent part or all of stomach in og junction tumours
What type of injury do alkali ingestion cause?
Liquefactive necrosis
What type of injury do acid ingestion cause?
Coagulative necrosis
What kind of dysphagia will be present in diffuse oesophageal spasm?
Total, grade 4 dysphagia
Name and describe the 2 types of esophageal spasms
• Diffuse: contractions of normal amplitude but uncoordinated, simultaneous or rapidly propagated
• hypertensive peristalsis: aka nutcracker esophagus. Contractions coordinated but excessive amplitude
Diagnosis esophageal spasm?
High resolution manometer
Treatment esophageal spasm? (8)
• CCB
• Botox
• nitrates
• tricyclic antidepressants
• sildenafil
• dilatation
• myotomy
• esophagectomy
Define and describe pathopysiolgy esophageal achalasia (3)
• Absence esophageal peristalsis and Lower esophageal sphincter fails to relax in response to swallowing
• due to progressive destruction ganglion cells in myenteric plexus
• bolus can get stuck → further dysfunction due to continuous squeezing against fixed outflow
Symptoms achalasia? (5)
• Progressive dysphagia to solids and liquids
• chest pain
• regurgitation
• weight loss
• aspiration (cough), vomiting, heartburn
Diagnosis esophageal achalasia? (3)
• Barium swallow - bird’s beak appearance, esophageal dilatation, stasis of barium in esophagus
• esophageal manometer gold Standard: absent peristalsis, incomplete Les relaxation in response to swallowing, high resting Les tone.
• symptoms similar to cancer so do esophagogastroscopy to rule out
Treatment esophageal achalasia? (4)
Medical
• ccb or nitrates for temporary relief
• endoscopic Botox injections relieve for a few months
Surgery
• laparoscopic heller myotomy preferably with partial funduplication
• peroral endoscopic myotomy (poem)
Endoscopic balloon dilatation
Esophagectomy last resort
