Oesophagus

Question 1

What is GORD?

Answer 1

Gastro-oesophageal reflux disease

Gastric acid from the stomach leaks up into the oesophagus

Question 2

Risk factors of GORD

Answer 2

Age
Obesity
Male gender
Smoking
Caffeinated drinks
Fatty or spicy foods

Question 3

Clinical features of GORD

Answer 3

Chest pain - burning retrosternal sensation, worse after meals, lying down or straining
Relieved by antacids
Chronic cough

Question 4

Red flag symptoms associated with GORD

Answer 4

Dysphagia
Weight loss
Early satiety
Malaise
Loss of appetite

Question 5

Differential diagnosis of GORD

Answer 5

Malignancy - oesophageal or gastric
Peptic ulceration
Oesophageal motility disorders
Oesophagitis

Question 6

GORD investigations

Answer 6

Upper GI endoscopy to exclude malignancy and complications
- if new in onset or worsening despite PPIs
24hr pH monitoring
- failure of medical treatment so surgical options considered

Question 7

Conservative management of GORD

Answer 7

Avoiding known precipitants
Weight loss
Smoking cessation

Question 8

Medical management of GORD

Answer 8

Proton pump inhibitors - lifelong

Question 9

Surgical management of GORD

Answer 9

Fundoplication

- gastro-oesophageal junction and hiatus are dissected and fundus wrapped around GOJ

Question 10

Indications for surgical management of GORD

Answer 10

Failure to respond to medical treatment
Patient preference
Patients with complications of GORD

Question 11

Complications of GORD

Answer 11

Aspiration pneumonia
Barrett's oesophagus
Oesophagitis
Oesophageal strictures
Oesophageal cancer

Question 12

Define Barrett’s oesophagus

Answer 12

Metaplasia of the oesophageal epithelial lining

- normal stratified squamous epithelium is replaced by simple columnar epithelium

Question 13

Risk factors for Barrett’s oesophagus

Answer 13

Caucasian
Male
>50 yrs
Smoking
Obesity
Presence of hiatus hernia
Family history

Question 14

Clinical features of Barrett’s oesophagus

Answer 14

History of chronic GORD

Examination unremarkable

Question 15

Investigations for Barrett’s oesophagus

Answer 15

Histological diagnosis - OGD biopsy

Oesophagus appears red and velvety with preserved pale squamous islands

Question 16

Management of Barrett’s oesophagus

Answer 16

PPI
Lifestyle advice
Regular endoscopy - progression to adenocarcinoma

Question 17

Main types of oesophageal cancer

Answer 17

Squamous cell carcinoma

Adenocarcinoma - more common in developed world

Question 18

Risk factors for squamous cell carcinoma of oesophagus

Answer 18

Smoking
Excessive alcohol consumption
Chronic achalasia
Low vitamin A levels
Iron deficiency

Question 19

Risk factors for adenocarcinoma of oesophagus

Answer 19

Long standing GORD
Obestiy
High dietary fat intake

Question 20

Clinical features of oesophageal cancer

Answer 20

Dysphagia

Significant weight loss

Question 21

Investigations for oesophageal cancer

Answer 21

Upper gastrointestinal endoscopy
- biopsy and send for histology
CT Chest-Abdomen-Pelvis and PET-CT
- check for distant metastases
Endoscopic ultrasound 
- measure penetration of oesophageal wall
Staging laparoscopy

Question 22

Curative management of oesophageal cancer

Answer 22

Surgery - oesophageal resection
Neoadjuvant chemotherapy
Chemo-radiotherapy

Question 23

Pallative management of oesophageal cancer

Answer 23

Oesophageal stent
Radio/chemotherapy
Photodynamic therapy
Nutritional support
Gastromy tube

Question 24

Define an oesophageal tear

Answer 24

Ruptures to any part of the oesophageal wall

Question 25

Define oesophageal perforation

Answer 25

Full thickness rupture of the oesophgeal wall - leakage of stomach contents into mediatinum - overwhelming inflammatory response Surgical emergencye

Question 26

Causes of oesophageal perforation

Answer 26

Iatrogenic | Severe forceful vomiting

Question 27

Clinical features of oesophageal perforation

Answer 27

Retrosternal chest pain Respioratory distress Subcutaneous emphysema

Question 28

Investigations for oesophageal perforation

Answer 28

Routine bloods - G&S | CT chest-abdo-pelvis with IV or oral contrast

Question 29

Management of oesophageal perforation

Answer 29

Urgent and aggressive resuscitation - high flow oxygen, IV access, fluid resuscitation and broad spectrum antibiotics Control oesophageal leak Eradication of mediastinal and pleural contamination Decompress oesophagus Nutritional support

Question 30

Define a Mallory-Weiss tear

Answer 30

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

Question 31

Define achalasia

Answer 31

Primary motility disorder of the oesophagus | Characterised by failure of relaxation of LOS

Question 32

Clinical features of achalasia

Answer 32

``` Progressive dysphagia Regurgiation of food Coughing Chest pain Weight loss ```

Question 33

Investigations for achalasia

Answer 33

``` OGD Oesophageal manometry - absence of oesophageal peristalsis - failure of relaxation of LOS - high resting LOS tone ```

Question 34

Management of achalasia

Answer 34

``` Conservative - sleeping with many pillows - eating slowly - plenty of fluid with meals Medical - calcium channel blockers - botox injections Surgical - endoscopic balloon dilaiton - laparoscopic Heller myotomy ```

Question 35

Define diffuse oesophageal spasm (DOS)

Answer 35

Multi-focal high amplitude contractions of oesophagus