Oesophagus Flashcards
What causes GORD?
incompetent LOS - more frequent relaxation causing reflux of gastric contents
What forms the UOS?
cricopharyngeus muscle
What are the risk factors for GORD?
age
obesity
fatty and spicy foods
alcohol, caffeine, smoking
What are the clinical features of GORD?
heartburn - burning, retrosternal sensation
worse after meals, lying down
cough
odynophagia
What are red flags for someone with suspected GORD?
dysphagia
weight loss
need to rule out malignancy
How is GORD diagnosed?
good history
resolution with PPI trial
OGD - rule out malignancy, complications of GORD
ambulatory pH monitoring (medical treatment failing)
manometry - ?motility disorders
What lifestyle modifications are made for GORD?
smoking cessation
weight loss
avoid coffee, alcohol, fatty and spicy food
What is the medical management of GORD?
antacids - symptomatic relief (no healing benefit) PPIs (potentially lifelong) H2 antagonists (ranitidine, cimetidine)
When is surgical management considered in GORD?
failure to respond to medical therapy
complications of GORD
patient wants to avoid lifelong medication
What is the surgical management of GORD?
360 degree Nissan fundoplication
gastric fundus is wrapped around GOJ
crura also tightened (crural repair)
What are the complications of a fundoplication?
dysphagia
delayed gastric emptying (damaged vagus nerve)
recurrence
abdominal bloat
What are the complications of GORD?
aspiration pneumonia
Barrett’s oesophagus
What is Barrett’s oesophagus?
metaplasia of oesophageal mucosa
stratified squamous to columnar
premalignant
What type of cancer usually occurs in the upper and middle 1/3rds of the oesophagus?
squamous cell carcinoma
associated with smoking and excessive alcohol
What type of cancer usually occurs in the lower 1/3rd of the oesophagus?
adenomacarcinoma
associated with Barretts
What are the clinical features of oesophageal cancer?
progressive dysphagia
weight loss (cancer and dysphagia related)
hoarseness
odynophagia
on examination:
evidence of weight loss
supraclavicular lymphadenopathy
metastatic signs - ascites, jaundice, hepatomegaly
How is suspected oesophageal cancer investigated?
urgent OGD with biopsy CT CAP (mets) endoscopic USS +/- FNA (for staging)
What is the surgical management of oesophageal cancer?
oesophagectomy - stomach made into conduit tube
complications
- post op nutrition is hard (may require feeding jejunostomy)
- anastomotic leak
What is the management of oesophageal cancer?
usually surgery
+/- chemo
+/- radiotherapy
How are oesophageal tumours staged?
TNM
T1 - within mucosa T2 - muscularis propria T3 - adventitia T4a - local tissue spread T4b - distant mets §
What is achalasia?
primary motility disorder of oesophagus
What are the clinical features of achalasia?
progressive dysphagia
retrosternal pain
regurgitation
weight loss
How is achalasia investigated?
OGD (to investigate dysphagia) - normal oesophageal manometry - absence of peristalsis - LOS failure to relax - high resting tone barium swallo (rarely done) - birds beak oesophagus
How is achalasia managed?
medical: CCBs or nitrates (temporary relief), botox injections (LOS)
endoscopic balloon dilatation (risk of perforation and need for further intervention)
surgery: laparoscopic Heller cardiomyotomy (need life long PPI)
What is diffuse oesophageal spasm? How does it present?
uncoordinated multifocal high amplitude contractions of oesophagus (seen on manometry)
presents with dysphagia and retrosternal chest pain
What are oesophageal tears?
rupture to any part of the oesophageal wall
What are the subtypes of oesophageal tears?
full thickness rupture
superficial mucosal tear (Mallory Weiss)
What can cause an oesophageal rupture?
iatrogenic - endoscopy
severe, forceful vomiting (Boerhaave’s syndrome)
What is Boerhaave’s syndrome?
oesophageal rupture caused by vomiting
What does oesophageal rupture lead to?
leakage of stomach contents into mediastinum and pleural cavity
severe inflammatory response
physiological collapse, multiorgan failure, death
What are the clinical features of an oesophageal rupture?
severe, sudden onset retrosternal pain
respiratory distress
subcutaneous emphysema
What investigations are done for an oesophageal rupture?
high clinical suspicion - endoscopy in theatre
routine bloods and group and save
urgent CT CAP with IV and oral contrast
(leakage of oral contrast, air or fluid in mediastinum or peural cavity)
How is an oesophageal rupture managed?
ABCDE - high flow oxygen, IV access, fluid resus, broad spectrum antibiotics
non surgical: resus, NG tube, chest drain - done if more stable (usually iatrogenic rupture)
surgical: on table endoscopy (site of perforation), emergency thoracotomy (control leak and wash out chest)
What is a Mallory Weiss tear?
laceration in oesophageal mucosa
generally small and self limiting
What usually causes a Mallory Weiss tear?
vomiting
How is dysphagia investigated?
OGD
oesophageal manometry
(barium swallow - rarely performed)
What are the emergency causes of haematemesis?
oesophageal varices
gastric ulceration
What are the non-emergent causes of haematemesis?
Mallory Weiss tear
oesophagitis
gastritis
How is haematemesis investigated?
routine bloods, Group and Save
OGD
erect CXR (perforated peptic ulcer - pneumoperitoneum)
CT abdo with IV contrast (triple phase)
