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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
What are the risk factors for gastroparesis development ?
* Idiopathic * Diabetes mellitus * Cannabis * Medication e.g. opiates, anticholinergics * Systemic diseases e.g. systemic sclerosis
26
How is gastroparesis diagnosed?
Gastric scintigraphy with a 99Technetium-labelled meal
27
How is gastroparesis treated?
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
28
What is achalasia ?
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.
29
What are the clinical features of achalasia ?
* 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
30
What are the results of the 2 main investigations for achalasia ?
* 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)
31
What is the treatment of achalasia ?
* 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
What are the 2 main types of oesophageal carcinoma ?
Adenocarcinoma & squamous cell carcinoma
33
What are the key risk factors for squamous cell carcinoma development (of the oesopgagus)?
* 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
What are the key risk factors for adenocarcinoma of the oesophagus development ?
* GORD or barretts oesophagus * Obesity * Caucasian & Europe/USA
35
What are the general risk factors for oesophageal carcinoma development ?
* Obesity * Fam history * Achalasia * Plummer vinson syndrome
36
What is plummer vinson syndrome ?
Rare disease characterised by: 1. Painless dysphagia secondary to oesophageal webs 2. Glossitis 3. Iron-def. anaemia
37
What is the treatment of plummer vinson syndrome ?
Iron supplements & dilatation of oesophageal webs
38
What is a peptic stricture ?
A narrowing or tightening of the oesophagus reuslting in swallowing difficulties (also called a benign oesophageal stricture)
39
What are the causes of peptic strictures?
* **GORD** * Corrosives * Surgery * Radiotherapy
40
What are the clinical features of peptic strictures ?
* Long history of dysphagia - which is non-progressive & lack of systemic features seen in malignancy * Symptoms of GORD
41
How are peptic strictures diagnosed ?
* 1st line = endoscopy * 2nd line = pH & manometry + fluroscopic studies if endoscopy fails to detect it
42
What is the treatment of peptic strictures ?
Endoscopic balloon dilatation
43
What is diffuse oesophageal spasm?
These are painful contractions within the oesophagus
44
What are the clinical features of diffuse oesophageal spasm ?
Intermittent dysphagia + chest pain/ retrosternal discomfort & Dyspepsia
45
How is diffuse oeosphageal spasm diagnosed ?
pH & manometry + barium studies (nutcracker/corck-screw appearance)
46
What is a pharyngeal pouch
It is a posteromedial diverticulum through Killians dehiscence )a triangular area in the wall of the pharynx between the thyropharyngeus & cricopharyngeus muscles)
47
Who are pharyngeal pouches most common in ?
Older men
48
What are the typical features of a pharyngeal pouch?
* Dysphagia * Reguritation * Aspiration * Chronic cough * Halitosis - from food decaying in the pouch * Midline neck swelling that gurgles on palpation
49
How is a pharyngeal pouch diagnosed ?
Barium swallow/studies with fluroscopy
50
What is the treatment of pharyngeal pouches ?
Surgery
51
What subtype of systemic sclerosis results in dysphagia ?
CREST syndrome
52
What are the clinical features of CREST syndrome systemic sclerosis ?
* **C**alcinosis * **R**aynaulds phenomenon * o**E**sophageal dysmotility * **S**clerodactyly - thickness & thighness of skin of fingers & toes * **T**elangectasia
53
What autoimmune neuromuscular disorder can result in dysphagia ?
Myasthenia gravis
54
What are the clinical features of myasthenia gravis ?
* 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
What is boerhaave syndrome ?
Severe vomiting resulting in oesophageal rupture
56
What is oesophageal rupture ?
This is the disruption of the oesophageal wall in absence of pre-exisiting pathology
57
What are the clinical features of oesophageal rupture ?
* 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
What are the causes of oesophageal rupture ?
* Iatrogenic e.g. endoscopy (biopsy/dilatation) * Trauma e.g. penetrating injury/ingestion of foreign body * Boerhaave syndrome * Carcinoma
59
How is oesophageal rupture diagnosed ?
* **CT & contrast studies** * Endsoscopy & CXR may be useful
60
What is the treatment of oesophageal rupture ?
Surgery
61
What do all patients with new-onset dysphagia require ?
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
What causes of dysphagia may not be diagnosed on initial endoscopy & therefore require what ?
* Motility disorders (achalasia, oesophageal spasm, systemic sclerosis, MG) * ==\> Fluroscopic studies (barium swallow), pH & manometry studies done
63
What is oesophageal candidiasis ?
It is an opportunisitc infection of the oesophagus caused by candida albicans. Resulting in oeosphagitis
64
What are the signs/symptoms suggestive of oesophageal candidiasis ?
* Dyshagia +/- retrosternal discomfort (heartburn) * Odynophagia - but no consitutional symptoms & systemically well * Something in there history of being immunocompromised
65
Who is most commonly affected by oesophageal candidiasis ?
People in immunocompromised states e.g. post-chemo, HIV patients, steroid inhalder use etc
66
What CD4+ count puts HIV patients at risk of oeosphageal candidiasis ?
CD4+ \< 100
67
What is the treatment of oesophageal candidiasis ?
1st line = fluconazole or itraxonazole
68
Where in the oesophagus do adenocarcinomas & squamous cell carcinomas arise & from what cell type??
* Adenocarcinoma ==\> lower 1/3rd from gland cells * SSC ==\> middle 1/3rd from epithelial cells
69
What are the signs/symptoms of oesophageal carcinomas ?
* Dysphagia - often progressive * Hoarsness * Cough * Retrosternal chest pain * Consitutional symptoms - WL, fatigue, anaemia
70
How are oesophageal carcinomas diagnosed ?
1st line = upper GI endoscopy +/- endoscopic U/S
71
If an oesophageal malignancy is detected how is it staged ?
Using CT/MRI - mainly CT of chest, abdo & pelvis
72
What is the treatment of oesophageal carcinomas ?
* 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
What is the main type of oral cancers ?
SSC
74
What are the risk factors for oral cancers?
* HPV esp 16 * Candida infections * Nutritional deficiences - A, iron * Post-transplant * History of oral SSC personally or in the fam
75
What are the at risk sites for oral cancer development ?
* Floor of the mouth * Ventral tounge (underside) & lateral boarder of tongue * Soft palate * Retromolar pads/ tonsillar pillars
76
What are the main presenting features of oral cancers?
* 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
What is the treatment of oral cancers ?
Surgery +/- adjuvant therapy

Y4 Gastrointestinal (28 decks)

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