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Y4 Gastrointestinal > Oral & oesophageal pathology > Flashcards

Oral & oesophageal pathology Flashcards

1
Q

Define what GORD is

A

This is symptoms of oesophagitis secondary to refluxed gastric contents (≥ 2 heartburn episodes per week &/or complications)

Note - think of it as chronic oesophagitis

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2
Q

What are the 3 pathophysiological causes of GORD?

A
  1. Due to either an incompetent lower oesophageal sphincter (LOS) +/- a hiatus hernia
  2. Abnormal oesophageal motility
  3. Increased intra-abdo pressure e.g. obesity, pregnancy
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3
Q

What are the complications of GORD ?

A
  1. Oesophagitis - may present as upper GI bleeding
  2. Benign oesophageal stricture formation
  3. Barretts oesophagus
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4
Q

What is barretts oesophagus ?

A

It is where the distal oesophagus undergoes metaplasia from squamous to columnar epithelium

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5
Q

What is dysplasia ?

A

This is the development of abnormal cells within any tissue type

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6
Q

Define what metaplasia is

A

This is the replacement of one differentiated cell type with another mature differentiated cell type

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7
Q

What is the classical macroscopic appearance of barretts oesophagus ?

A

Red velvety mucosa in distal (lower) oesophagus

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8
Q

What does barretts oesophagus increase the risk of ?

A

Oesophageal cancer - adenocarcinoma

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9
Q

If someone is diagnosed with barretts oesophagus what is the management of this ?

A
  • 1st line = Endoscopic survellience (every 3-5 years) + biopsies & high dose PPI
  • 2nd line = If dysphagia develops either endoscopic muscoal ressection or radiofrequency ablation done
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10
Q

What are the symptoms of GORD?

A
  • Heartburn (dyspepsia)
  • Acid reflux
  • Waterbrash
  • Dysphagia
  • Odonophagia - painful swallowing
  • Weight loss
  • Chest pain
  • Hoarsness
  • Coughing
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11
Q

How is GORD diagnosed ?

A

1st line = upper GI endoscopy if they have symptoms for > 4 weeks &:

  • Persistent vomiting
  • GI bleeding/iron def. anaemia
  • Palpable mass
  • Age > 55
  • Dysphagia
  • Symptoms despite treatment or relapsing
  • Weight loss

2nd line = 24hrs oesophageal pH monitoring +/- manometry if endoscopy is normal

Note - also would offer H.pylori testing and a barium swallow may be useful if suspecting a hiatus hernia

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12
Q

What causes acute oesophagitis ?

A

Corrosives:

  • NSAID’s
  • Infections in immunocompromised patients - candidiasis, herpes, CMV
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13
Q

What is the treatment of endoscopically proven oesophagitis/GORD ?

A
  • 1st line = Full dose PPI for 1-2 months + if response then low dose treatment as required
  • 2nd line = if no response then double-dose PPI for 1 month
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14
Q

What is the treatment of endoscopically negative oeosphagitis/GORD?

A
  • 1st line = full dose PPI for 1 month + if response then offer low dose treatment
  • 2nd line = if no response then H2RA or prokinetic for one month
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15
Q

What is the 3rd line options for treating GORD/oesophagitis and who is it used for?

A
  • Laproscopic fundoplication (this heals the oesophagitis)
  • Used for young patients, severe/unresponsive or those who do not wish or cannot tolerate PPI therapy
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16
Q

What is allergic ‘eosinophilic’ oesophagitis and its key features ?

A
  • This has a similar presentation to GORD but patients typically have a personal/fam history of allergy, asthma, or atopy
  • pH probe is negative for reflux & increased eosinophils are seen in the blood
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17
Q

How is allergic oesophagitis diagnosed ?

A

Oesophageal biopsy demonstrating a large number of intraepithelial eosinophils

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18
Q

What is the treatment of allergic oesophagitis ?

A

1st line = steroids (fluticasone inhaler)

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19
Q

What is a hiatus hernia and what are the 2 types ?

A

Herniation of part of the stomach above the diaphragm. There are 2 types:

  1. Sliding - the gastroesophageal junction moves above the diaphragm
  2. Rolling (paraoesophageal): the gastroesophageal junctions remains below the diaphragm but a separate part of the stomach herniates through the oesophageal hiatus
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20
Q

What are the clinical features suggestive of a hiatus hernia ?

A
  • Symptoms of GORD
  • Patient classically obese & female
  • Shouldnt usually be associated with dysphagia or haematemesis
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21
Q

How is a hiatus hernia diagnosed ?

A

Barium swallow

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22
Q

What is the treatment of a hiatus hernia ?

A
  • 1st line = loose weight & treat reflux (GORD treatment)
  • Surgical repair if rolling hiatus hernia or persistent symptoms despite aggressive treatment
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23
Q

What is gastroparesis ?

A

It is an autoimmune neuropathy resulting in delayed gastric emptying

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24
Q

What are the sign/symptoms of gastroparesis ?

A
  • Diabetic
  • Feeling of fullness/ early saiety
  • Nausea & vomiting
  • Weight loss
  • Upper abdo pain
  • Dyspepsia (indegestion/heartburn)
  • Bloating after eating
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25
Q

What are the risk factors for gastroparesis development ?

A
  • Idiopathic
  • Diabetes mellitus
  • Cannabis
  • Medication e.g. opiates, anticholinergics
  • Systemic diseases e.g. systemic sclerosis
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26
Q

How is gastroparesis diagnosed?

A

Gastric scintigraphy with a 99Technetium-labelled meal

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27
Q

How is gastroparesis treated?

A

Promotility agents:

  • either anti-emetics (metoclopramide, doperidone)
  • or Erythrpmycin

Remove precipitating factors e.g. drugs & eat little/ often with a liquid/sloppy diet

Gastric pacemaker may be required

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28
Q

What is achalasia ?

A

Failure of oesophageal peristalsis and of relaxation of lower oesophageal sphincter (LOS) due to degenerative loss of ganglia from Auerbach’s plexus i.e. LOS contracted, oesophagus above dilated.

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29
Q

What are the clinical features of achalasia ?

A
  • Dysphagia of BOTH liquids and solids
  • Typically variation in severity of symptoms
  • heartburn
  • Regurgitation of food - may lead to cough, aspiration pneumonia etc
  • Weight loss
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30
Q

What are the results of the 2 main investigations for achalasia ?

A
  • CXR shows wide mediastinum due to dilated oesophagus & fluid level in oesophagus
  • Barium swallow shows dilated tapering oesophagus ‘bird-beak’ appearance & fluid level in oesophagus
  • Manometry is the gold standard investigation - it shows excessive LOS tone which doesnt relax on swallowing (done after CXR & barium swallow)
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31
Q

What is the treatment of achalasia ?

A
  • 1st line = Heller’s cardiomyotomy if fit/well patient. If older/ unfit patient then do Endoscopic balloon dilatation
  • 2nd line = intra-sphincteric injection of botulinum toxin for those who cannot tolerate dilatation or surgery
32
Q

What are the 2 main types of oesophageal carcinoma ?

A

Adenocarcinoma & squamous cell carcinoma

33
Q

What are the key risk factors for squamous cell carcinoma development (of the oesopgagus)?

A
  • Smoking & alcohol
  • HPV 16 infection
  • Diet rich in nitrosamines e.g. smoked fish
  • Vit A or zinc def.
  • Tannic acid/ strong tea
  • Being from Iran, africa, brazil & china
34
Q

What are the key risk factors for adenocarcinoma of the oesophagus development ?

A
  • GORD or barretts oesophagus
  • Obesity
  • Caucasian & Europe/USA
35
Q

What are the general risk factors for oesophageal carcinoma development ?

A
  • Obesity
  • Fam history
  • Achalasia
  • Plummer vinson syndrome
36
Q

What is plummer vinson syndrome ?

A

Rare disease characterised by:

  1. Painless dysphagia secondary to oesophageal webs
  2. Glossitis
  3. Iron-def. anaemia
37
Q

What is the treatment of plummer vinson syndrome ?

A

Iron supplements & dilatation of oesophageal webs

38
Q

What is a peptic stricture ?

A

A narrowing or tightening of the oesophagus reuslting in swallowing difficulties (also called a benign oesophageal stricture)

39
Q

What are the causes of peptic strictures?

A
  • GORD
  • Corrosives
  • Surgery
  • Radiotherapy
40
Q

What are the clinical features of peptic strictures ?

A
  • Long history of dysphagia - which is non-progressive & lack of systemic features seen in malignancy
  • Symptoms of GORD
41
Q

How are peptic strictures diagnosed ?

A
  • 1st line = endoscopy
  • 2nd line = pH & manometry + fluroscopic studies if endoscopy fails to detect it
42
Q

What is the treatment of peptic strictures ?

A

Endoscopic balloon dilatation

43
Q

What is diffuse oesophageal spasm?

A

These are painful contractions within the oesophagus

44
Q

What are the clinical features of diffuse oesophageal spasm ?

A

Intermittent dysphagia + chest pain/ retrosternal discomfort & Dyspepsia

45
Q

How is diffuse oeosphageal spasm diagnosed ?

A

pH & manometry + barium studies (nutcracker/corck-screw appearance)

46
Q

What is a pharyngeal pouch

A

It is a posteromedial diverticulum through Killians dehiscence )a triangular area in the wall of the pharynx between the thyropharyngeus & cricopharyngeus muscles)

47
Q

Who are pharyngeal pouches most common in ?

A

Older men

48
Q

What are the typical features of a pharyngeal pouch?

A
  • Dysphagia
  • Reguritation
  • Aspiration
  • Chronic cough
  • Halitosis - from food decaying in the pouch
  • Midline neck swelling that gurgles on palpation
49
Q

How is a pharyngeal pouch diagnosed ?

A

Barium swallow/studies with fluroscopy

50
Q

What is the treatment of pharyngeal pouches ?

A

Surgery

51
Q

What subtype of systemic sclerosis results in dysphagia ?

A

CREST syndrome

52
Q

What are the clinical features of CREST syndrome systemic sclerosis ?

A
  • Calcinosis
  • Raynaulds phenomenon
  • oEsophageal dysmotility
  • Sclerodactyly - thickness & thighness of skin of fingers & toes
  • Telangectasia
53
Q

What autoimmune neuromuscular disorder can result in dysphagia ?

A

Myasthenia gravis

54
Q

What are the clinical features of myasthenia gravis ?

A
  • Muscle fatigability - get weaker during periods of activity & slowly improves after periods of rest
  • Extraocular muscle weakness - diplopia
  • Proximal muscle weakness - face, neck, limb & girdle
  • Ptosis
  • Dysphagia
55
Q

What is boerhaave syndrome ?

A

Severe vomiting resulting in oesophageal rupture

56
Q

What is oesophageal rupture ?

A

This is the disruption of the oesophageal wall in absence of pre-exisiting pathology

57
Q

What are the clinical features of oesophageal rupture ?

A
  • Odynophagia
  • Tachycardia, fever, shock
  • Dysponea
  • Suspect in patinets with severe chest pain without any cardiac pathology & signs suggestive of pnuemonia where there is a history of vomiting

Macklers triad - vomiting, chest pain, and S/C emphysema

58
Q

What are the causes of oesophageal rupture ?

A
  • Iatrogenic e.g. endoscopy (biopsy/dilatation)
  • Trauma e.g. penetrating injury/ingestion of foreign body
  • Boerhaave syndrome
  • Carcinoma
59
Q

How is oesophageal rupture diagnosed ?

A
  • CT & contrast studies
  • Endsoscopy & CXR may be useful
60
Q

What is the treatment of oesophageal rupture ?

A

Surgery

61
Q

What do all patients with new-onset dysphagia require ?

A

Urgent upper GI endoscopy - this usually diagnoses the cause (if I have not stated a different test then dysphagia cause is diagnosed via this)

62
Q

What causes of dysphagia may not be diagnosed on initial endoscopy & therefore require what ?

A
  • Motility disorders (achalasia, oesophageal spasm, systemic sclerosis, MG)
  • ==> Fluroscopic studies (barium swallow), pH & manometry studies done
63
Q

What is oesophageal candidiasis ?

A

It is an opportunisitc infection of the oesophagus caused by candida albicans. Resulting in oeosphagitis

64
Q

What are the signs/symptoms suggestive of oesophageal candidiasis ?

A
  • Dyshagia +/- retrosternal discomfort (heartburn)
  • Odynophagia - but no consitutional symptoms & systemically well
  • Something in there history of being immunocompromised
65
Q

Who is most commonly affected by oesophageal candidiasis ?

A

People in immunocompromised states e.g. post-chemo, HIV patients, steroid inhalder use etc

66
Q

What CD4+ count puts HIV patients at risk of oeosphageal candidiasis ?

A

CD4+ < 100

67
Q

What is the treatment of oesophageal candidiasis ?

A

1st line = fluconazole or itraxonazole

68
Q

Where in the oesophagus do adenocarcinomas & squamous cell carcinomas arise & from what cell type??

A
  • Adenocarcinoma ==> lower 1/3rd from gland cells
  • SSC ==> middle 1/3rd from epithelial cells
69
Q

What are the signs/symptoms of oesophageal carcinomas ?

A
  • Dysphagia - often progressive
  • Hoarsness
  • Cough
  • Retrosternal chest pain
  • Consitutional symptoms - WL, fatigue, anaemia
70
Q

How are oesophageal carcinomas diagnosed ?

A

1st line = upper GI endoscopy +/- endoscopic U/S

71
Q

If an oesophageal malignancy is detected how is it staged ?

A

Using CT/MRI - mainly CT of chest, abdo & pelvis

72
Q

What is the treatment of oesophageal carcinomas ?

A
  • If operable then lewis type oesophagectomy (radical oesophagectomy) +/- adjuvant chemo (cisplatin + 5-FU)
  • If non-operable then chemoradiotherapy +/- stenting & laser use to restore swallow for pallation
73
Q

What is the main type of oral cancers ?

A

SSC

74
Q

What are the risk factors for oral cancers?

A
  • HPV esp 16
  • Candida infections
  • Nutritional deficiences - A, iron
  • Post-transplant
  • History of oral SSC personally or in the fam
75
Q

What are the at risk sites for oral cancer development ?

A
  • Floor of the mouth
  • Ventral tounge (underside) & lateral boarder of tongue
  • Soft palate
  • Retromolar pads/ tonsillar pillars
76
Q

What are the main presenting features of oral cancers?

A
  • Red lesion (erythroplakia)
  • Red & white lesion (erythroleukoplakia)
  • Unexplained ulcer lasting > 3 weeks - having excluded trauma, systemic or drugs causes
  • Numb feeling of lip or face
  • Unexplained pain in the mouth or neck
  • Persistent unexaplined neck lump
  • Lump in the lip or oral cavity
77
Q

What is the treatment of oral cancers ?

A

Surgery +/- adjuvant therapy

Y4 Gastrointestinal (28 decks)

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