Oesophagus

Question 1

Most frequent cause of inflammation of oesophagus?

Answer 1

Due to reflux of acidic gastric contents

Question 2

Dysphagia?

Answer 2

Difficulty swallowing

Question 3

Odynophagia?

Answer 3

Pain during act of swallowing

Question 4

Dyspepsia?

Answer 4

Indigestion

Question 5

What does dyspepsia/ indigestion mean?

Answer 5

Disordered digestion, pain in lower chest or upper abdomen after eating.
Sometimes accompanied by nausea, vomiting, feeling of unease/ fullness

Question 6

What is acid reflux usually a consequence of?

Answer 6

Incompetent lower oesophageal sphincter

Question 7

What conditions can cause acid reflux?

Answer 7

Systemic sclerosis
CNS depressants e.g. alcohol
Pregnancy (elevated intra-abdominal pressure)
Hyperthyroidism

Question 8

How does the oesophageal epithelium appear histologically in reflux?

Answer 8

Regenerative and hyperplastic meaning that it is having to replace itself frequently

Question 9

Reflux oesophagitis?

Answer 9

Inflammation of oesophagus due to refluxed low pH gastric content

Question 10

Causes of reflux oesophagitis?

Answer 10

Defective sphincter mechanism
Abnormal oesophageal motility
Inc intra-abdominal pressure (pregnancy)

Question 11

Microscopic appearance of reflux oesophagitis?

Answer 11

Basal zone epithelial expansion
Intraepithelial neutrophils, lymphocytes & eosinophils
Lengthened lamina propria papillae

Question 12

What is the clinical name for reflux oesophagitis?

Answer 12

Gastro-oesophageal reflux disease (GORD)

Question 13

What is GORD?

Answer 13

Chronic acid reflux

Question 14

Pathophysiology of GORD?

Answer 14

Incompetent LOS
Poor oesophageal clearance
Barrier function/ visceral sensitivity

Question 15

Lower oesophageal sphincter (LOS)?

Answer 15

Separates oesophagus & stomach

Question 16

Features of GORD pain?

Answer 16

Burning
Worse on bending
Seldom radiates to arm
Worse with hot drinks/ alcohol
Relieved by antacids

Question 17

Diagnosis of GORD?

Answer 17

Made without investigations unless alarm signs (dysphagia)

Question 18

Investigations for GORD?

Answer 18

Endoscopy (upper GI)
Intraluminal monitoring (oesophageal manometry & pH)
Barium swallow
Nuclear studies

Question 19

Complications of GORD?

Answer 19

Peptic stricture
BARRETT’S
Oesophageal carcinoma/ adenocarcinoma
Ulceration (bleeding)

Question 20

Management of GORD?

Answer 20

Symptom relief
Healing oesophagi’s
Prevent complications

Question 21

Lifestyle modifications for GORD?

Answer 21

Smoking cessation
Lose weight
Prop up bed head
Avoid provoking factors

Question 22

Drugs for GORD treatment?

Answer 22

Antacids
H2 receptor antagonists
PPI’s

Question 23

Antacids for GORD treatment?

Answer 23

Symptomatic relief
Alginate containing
Form gel raft with gastric contents to reduce reflux
10ml 3x daily

Question 24

H2 receptor antagonists in GORD treatment?

Answer 24

Frequently if antacids fail

Cimetidine & ranitidine

Question 25

PPI's in GORD treatment?

Answer 25

E.g. omeprazole | Reduce gastric acid secretion

Question 26

Drugs of choice in all but mild cases?

Answer 26

PPI's

Question 27

Non erosive reflux disease?

Answer 27

No response to PPI's Have continuing symptoms Normal endoscopy Usually female with functional problems

Question 28

Indications for surgery for GORD/ good result?

Answer 28

Typical reflux symptoms with documented acid reflux Symptoms Response to PPI

Question 29

Surgery should rarely be done if ?

Answer 29

Oesophageal dysmotility unrelated to acid reflux No response to PPIs Underlying functional bowel disease

Question 30

Surgery never performed for?

Answer 30

Hiatus hernia alone

Question 31

Which surgery for GORD?

Answer 31

Fundoplication | Laparoscopic

Question 32

What is the fundoplication procedure?

Answer 32

Upper part of stomach os wrapped around lower oesophagus Nissen (complete/ 360 degrees wrap) Toupe (partial/ 270) Laparososcopic

Question 33

Barrett's oesophagus?

Answer 33

Squamous epithelium lining the oesophagus is replaced by columnar epithelium of the type normally lining the intestine caused by chronic inflammation and damage from GORD

Question 34

Microscopic appearance of Barrett's oesophagus?

Answer 34

Columnar (glandular) type metaplasia

Question 35

Explain the events of Barrett's oesophagus?

Answer 35

Squamous epithelium does not cope well with acid from stomach Gastric acid is neutralised by mucin produced by columnar cells and glands So a metaplastic change occurs to cope with the new noxious stimulus (potentially tissue damaging) Epithelium now unstable

Question 36

Where should normal squamocolumnar junction be and where is it in Barrett's?

Answer 36

Should be at gastro-oesophageal junction | In Barrett's is more proximal

Question 37

Investigations for Barrett's?

Answer 37

Endoscopy (UGI) +/- biopsy

Question 38

Management of Barrett's?

Answer 38

Lifestyle advice PPI's (useful for GORD) Radiofrequency ablation Oesophagectomy

Question 39

GOLD standard for high grade dysplasia in Barrett's oesophagus?

Answer 39

Oesophagectomy

Question 40

Infectious oesophagi's?

Answer 40

Can be caused by infection from fungi, yeast, virus or bacteria

Question 41

Can candida be associated with oesophagitis?

Answer 41

Yes

Question 42

Are people with a normal immune system likely to get infectious oesophagitis?

Answer 42

No

Question 43

Eosinophilic oesophagitis?

Answer 43

Allergic inflammatory condition of oesophagus that involves eosinophils Eosinophils migrate to the esophagus in large numbers, then precipitate an allergic reaction when a trigger food is eaten.

Question 44

Common presentation of eosinophilic oesophagitis?

Answer 44

``` Difficulty swallowing Food impaction Stomach pains, Regurgitation or vomiting Decreased appetite Food bolus stuck in throat ```

Question 45

Endoscopic appearance of eosinophilic oesophagitis?

Answer 45

Corrugated oesophagus ( multiple rings) or trachealisation (fixed oesophageal rings) when concentric rings are seen around the lumen.

Question 46

In eosinophilic oesophagi's what is recommended if specific allergen identified?

Answer 46

Abstinence

Question 47

In cases which show generalised atopy, what may they respond to?

Answer 47

Oral sodium cromoglycate

Question 48

Histology appearance of eosinophilic oesophagitis?

Answer 48

Very spongiotic epithelium (lots of gaps appearing between the cells) with huge numbers of eosinophils.

Question 49

What may treatment of allergic oeosphagitis include?

Answer 49

Steroids Chromoglycate Montelukast

Question 50

Hiatus hernia?

Answer 50

Most common type of diaphragmatic hernia | Stomach passes partly or completely into chest cavity through the opening (hiatus) for the oesophagus