Oesophagus

Question 1

What are the anatomical and physiological factors which predispose to reflux disease?

Answer 1

A loose lower oesophageal sphincter (cardiac sphincter)

Inadequate oesophageal peristalsis

Question 2

What is a hiatus hernia?

Answer 2

A hiatus hernia is: herniation of part of the abdominal viscera through the oesophageal aperture of the diaphragm.

Question 3

How are hiatus hernia’s classified?

Answer 3

A sliding hernia is where the gastro-oesophageal junction herniates through the aperture (80% of cases).

A rolling hernia is where the gastro-oesophageal junction remains in place but part of the stomach herniates through a hole in the diaphragm (20% of cases)

Question 4

What are the causes of hiatus hernia’s?

Answer 4

Causes:

Increase intra-abdomnial pressure (fat, faeces, fluid)

Widening of the aperture

Shortening of the oesophagus (chronic oesophagitis)

Question 5

Define GORD.

Answer 5

Gastro-Oesophageal-Reflux-Disease: Abnormal gastric acid reflux into the oesophagus which may cause oesophagitis.

Question 6

What are the risk factors for developing GORD?

Answer 6

Lifestyle:

Spicy fatty food

Obesity

Smoking and Alcohol

Eating late at night + tight belts

Antaomical:

Weak lower oesophageal sphincter

Abnormal oesophageal peristalsis

Hiatus hernia

Question 7

What are the classical symptoms of GORD?

Answer 7

Heartburn: burning feeling, rising from the stomach or lower chest that is related to meals, lying down, stooping and straining.

Retrosternal discomfort.

Water Brash: Excess saliva

Odynophagia: If the GORD has caused oesophagitis or stricture.

Diagnosis is usually clinical may perform an endoscopy if not resolving despite treatment or red flags.

Question 8

What are the red flag upper GI symptoms which require further investigation?

Answer 8

Dysphagia

Haematemesis/melena

New onset reflux age greater than 55

Progressive weight loss

Iron deficiency anaemia

Epigastric mass

Investigation is endoscopy.

Question 9

Describe the how to manage GORD?

Answer 9

Lifestyle measures:

Smoking cessation

Reduce alcohol

Lose weight

Cut down on spicy/fatty food

Pharamcological:

PPI’s

Test for H.pylori

Surgery

Question 10

Describe the surgical measures of managing GORD?

Answer 10

Procedure called laproscopic fundoplication.

Essentially involves insertion of a ring of interlinked titanium beads with a weak magnetic force.

The magnetic force can be overcome when swallowing but should prevent reflux.

Question 11

What are the indications for surgery in GORD?

Answer 11

Although the literature suggests surgery is effective the evidence is limited in quality and therefore the prcedure should only be done in special cases.

In America indications include:

• failed medical management
• barrett’s oesophagus

Question 12

What are the long term complications of GORD?

Answer 12

Oesophagitis

Oesophageal ulcer

Oesophageal stricture

Barrett’s oesophagus

Question 13

What is barrett’s oesophagus?

Answer 13

Metaplasia from squamous cell to columnar cell epithelium in the oesophagus.

It is a pre malignant change.

Question 14

Describe the symptoms of Barrett’s oesophagus?

Answer 14

Often do not have any specific symptoms relating to there barrett’s may only have symptoms of GORD.

Question 15

How is barrett’s oesophague diagnosed?

Answer 15

It is diagnosed by endoscopy if it is seen samples ore taken for pathology.

Question 16

Describe how Barrett’s is managed based on its histological appearance?

Answer 16

Is there dysplasia?

No: rescope in 2-3 years

Yes: Is it high or low grade dysplasia?

Low: Rescope in 6 months with PPI treatment

High: 40% Ca risk

Options: surgical resection OR endoscopic ablation of barrett’s + excision of any nodes