Pathology of the Gastrointestinal Tract - Oesophagus Flashcards
What are the 7 pathologies of the oesophagus
Gastro-oesophageal reflux disease (GORD) oesophageal carcinoma Barrett's oesophagus hiatus hernia achalasia Zencker's diverticulum oesophageal varices
Describe GORD
describes any symptomatic condition or structural changes due to reflux of the stomach contents into the oesophagus
when does oesophagitis develop?
when the lower sphincter fails to act as an effective barrier to the entry of the gastric contents into the distal oesophagus
regardless of cause, what does acute oesophagitis cause?
what are the effects of oesophagitis? - 2 points
a burning pain in the chest that may stimulate the pain of heart disease
superficial ulcerations = most typical of reflux and the oesophagus is often dilated with loss of effective peristalsis
what exam is often carried out for GORD?
what would be seen? - 1 points
what exam is best?
what would be seen? - 4 points
often an endoscopy exam
ulcerated ‘streaks’ may be visualised on the flat mucosa of the distal oesophagus
double contrast barium study
hiatus hernia, a widened hiatus, strictures of the oesophagus and smooth strictures at the junction in the distal oesophagus
what is the treatment for GORD?
life style modifications to include weight loss, changes to diet and medication to reduce acidity = first lines of treatment
what symptom is likely to often result in a diagnosis of oesophageal cancer?
why is there a dismal prognosis?
progressive dysphagia in over 40s
the symptoms tend to appear late in the course of the disease
what are the two main histological types of oesophageal cancers?
what is the incidence?
squamous cell carcinoma (81-95%)
adenocarcinoma (4-19%)
higher in men than in women
what is there a direct link to in adenocarcinomas?
what is strong link with oesophageal cancers?
Barrett’s oesophagus
excessive alcohol intake and smoking
what are the earliest radiographic appearances on a barium swallow?
flat plaque-like lesions (sometimes with central ulceration) that involves one wall of the oesophagus
what modality has become integral for oesophageal carcinomas and why?
what other modality is used and why?
CT - for staging the disease
PET scans - help with evidence of tumour spread
what are used to manage symptoms? - 2 points
what else is offered? - 3 points
stenting or gastrostomy
endoscopic resection of the tissue layers, chemotherapy, radiotherapy
what is the prognosis for oesophageal cancers?
not good because the cancer is well established by the time the symptoms present
what is Barrett’s oesophagus?
related to severe reflux oesophagitis where the squamous cell lining of the oesophagus is damaged and replaced by columnar epithelium (similar to that in stomach) over time
what does Barrett’s oesophagus have an usually high tendency for ?
developing malignancy in the columnar cell-lined portion - these tumours are nearly always adenocarcinomas which otherwise very rare in the oesophagus
what are the symptoms for Barrett’s oesophagus? -3 points
what are pre-disposing factors?
long-term burning indigestion, dysphagia, reflux
overweight, smoking, alcohol (regular large amounts), spicy or fatty foods
however not all patients exhibit symptoms and Barrett’s may be an incidental finding
how many of those with Barrett’s will go on to develop oesophageal cancer?
1-5%
what is the radiographic appearance of Barrett’s oesophagus? - 2 points
the Barrett’s ulcer is usually separated from the hiatus hernia by a variable length of normal-appearing oesophagus
fibrotic healing of the ulcer often leads to a smooth, tapered stricture
What is the treatment for Barrett’s oesophagus? - 4 points
antacids/protein pump inhibitors avoiding alcohol & tobacco endoscopic treatment (resection of abnormal cells, radiofrequency ablation (surgical removal of body tissue), photodynamic therapy, cryotherapy) surgery (fundoplication - strengthens oesophageal sphincter, or resection of lower oesophagus)
what is the prognosis for Barrett’s oesophagus?
treatment should improve acid reflux symptoms and should keep Barrett’s oesophagus from getting worse but won’t reverse the changes that may lead to cancer
what is a Hiatus Hernia?
herniation of the stomach through the oesophageal hiatus (pause or break in continuity) of the diaphragm
what are the two types of hiatus hernia?
which is the most common?
sliding or rolling hiatus hernia
sliding hiatus hernia (95%)
describe a sliding hiatus hernia
where the gastro-oesophageal junction is displaced by more than 1cm above the hiatus and the hiatus is abnormally widened (3-4cm when the upper limit of normal is 15mm)
gastric fundus may also be above the diaphragm and present as a retro-cardiac mass on a CXR (presence of air-fluid level in mass)
when ?cause is uncertain what can happen with a hiatus hernia ….
found as an incidental finding on a barium meal exam
what is achalasia?
functional obstruction of the distal section of the oesophagus - causes a delay in the emptying of the oesophageal contents into stomach due to failure of the relaxation of the oesophago-gastric sphincter (caused by abnormality of the neurones that control the sphincter)
what may produce dilation of the distal end of the oesophagus?
lack of motility in the oesophagus further restricts the movement of food
what are the symptoms for achalasia?
regurgitation
dysphagia
heartburn
what is the radiographic appearance for achalasia?
barium study - tapered, smooth, conical, 1-3cm narrowing of the distal oesophagus (‘rat-tail’ or ‘bird-beak’ appearance)
on sequential images, with patient upright, small spurts of barium seen to pass through the narrowed segment to enter the stomach
what is the treatment for achalasia?
medication before meals to assist in relaxing the oesophageal sphincter can be tried but if symptoms not controlled, an endoscopic balloon dilation may be done
last resort is surgery - to open up the sphincter
what are oesophageal diverticula ?
outpouchings - common lesions that either contain all layers of the wall or are composed of only mucosa and submucosa herniating through the muscular layer
what can result from diverticulum filling with food or secretions
aspiration pneumonia
where do Zencker’s diverticula arise from?
who does it commonly affect?
the posterior wall of the upper oesophagus - can become so large that they almost occlude the oesophageal lumen
the elderly in their 70s and 80s
what are the symptoms for Zencker’s diverticulum? - 4 points
feeling of food/liquid getting ‘stuck’ in their gullet
dysphagia
halitosis (bad breath)
regurgitation
what exam is performed and why?
barium swallow - may demonstrate the diverticulum at the level of c5/c6 (best seen on lateral view)
what is the treatment for Zencker’s diverticulum?
none required unless they interfere with swallowing in which case the diverticulum is resected and repaired with endoscopic stapling or laser surgery
what are oesophageal varices?
dilated veins, within the walls of the oesophagus, most commonly the result of increased pressure in the portal venous system (portal hypertension) - hence, usually the result of cirrhosis in the liver
what occurs in patients with portal hypertension?
much of the portal blood cannot flow along its normal pathway through the liver to the IVC and onto the heart, so instead goes via a circuitous collateral route and the increased blood flow through these veins causes the development of oesophageal varices
which is one choice of examination but why is this difficult?
barium swallow is not a sensitive test and so must be performed carefully with close attention to the amount of Barium used and the degree of oesophageal distention
what would be seen on the radiographs?
what % of oesophageal varices are detected by barium swallows?
multiple, diffuse rounded and oval filling defects may be demonstrated
50%
what is the modality of choice for oesophageal varices?
CT - excellent for detecting moderate to large oesophageal varices and for evaluating the whole of the portal venous system (aid underlying cause of hypertension)
what is the treatment for oesophageal varices?
vasoconstrictors used to constrict dilated vessels, if varices = bleeding then the main aim is to stem blood loss - using balloon tamponade (balloon introduced endoscopically and inflated to stop bleeding) or variceal ligation/banding (application of bands to capture the varix (protrusion from vein) so it would then receive no blood supply = necrose = slough off
