The Oesophagus

Question 1

Sliding hiatus hernia definition and consequences

Answer 1

90%
Gastrooesophageal junction is drawn up through the diaphragm hiatus
Lower oesophageal sphincter becomes defective
-> reflux -> endoscopy

Question 2

Para oesophageal hernia definition and consequences

Answer 2

10%
Bulge of stomach herniated directly
Gastrooesophageal remains bellow diaphragm
->no reflux
->pain due to strangulation-> requires repair

Question 3

GORD predisposing factors

Answer 3

Male
Increased intra abdo pressure
-pregnancy
-obesity
-big meals
Smoking
Alcohol
Antimuscarinics
Achalasia surgery
Hiatus hernia

Question 4

GORD symptoms

Answer 4

'Heart burn'
Dyspepsia
Regurgitation
Water brash
Burping and bloating
Cough 
Worse on bending and lying down
Worse with hot drinks and alcohol
Relieved by PPI

Question 5

GORD investigations

Answer 5

Clinical diagnosis unless red flag synptoms

• dysphagia
• 45 and new onset
• > endoscopy

Question 6

GORD management

Answer 6

Life style

• loose weight
• sleep with head raised
• stop smoking
• avoid spicy/fatty foods
• avoid large meals
• go to bed with empty stomach

Medication

• medication review
• antacids
  1) PPI ‘azole’
  2) H2 blocker ‘tidine’
• metocloperamide

Surgery
-fundoplication

Question 7

Differentials of dysphagia

Answer 7

Obstruction/Function/Compression 
Common:
-peptic oesophagitis
-stricture
-oesophageal carcinoma
-sub carina lymph node 

Uncommon:

• achlasia
• stroke
• candida oesophagitis

Rare:

• pharyngeal pouch
• oesophageal web

Question 8

Investigations of dysphagia

Answer 8

FBC and ESR
Endoscopy
MRI
Motility studies

Question 9

GORD complications

Answer 9

Stricture
Barretts
Cancer
Oesophagitis
Ulcer
Anaemia

Question 10

Barrett’s oesphagus definition

Answer 10

Replacement of normal squamous oesophagus with columnar cells
-> clearly visible on endoscopy
-> 1cm above the gastro oesophageal junction
-> confirm with biopsy
2% of pop
5% of GORD

Question 11

Barretts clinical features

Answer 11

A symptomatic
GORD
Dysphagia
Anaemia
Acute bleed

Question 12

Barretts management

Answer 12

Surveillance every 2-5 years
GORD treatment
High grade dysphasia becomes cancer in 30-40%-> WLE-> Oesophagectomy

Question 13

Oesophageal malignancy pathology

Answer 13

Adenocarcinoma 60-70% 
-bottom 1/3 
-GORD
Squamous carcinoma 30-40% 
-top 2/3
-smoking
-alcohol
-achlasia

Question 14

Oesophageal CA symptoms

Answer 14

Insidious dysphagia solids-> liquids
Odonophagia
Dyspepsia
Progressive wt loss
Iron deficiency anaemia
Chronic GI bleed 
Obstructive jaundice

Question 15

Oesophageal CA risk factors

Answer 15

>50 years
Alcohol
Smoking
Peptic oesophagitis and stricture
Achlasia
Oesophageal web/pharyngeal pouch

Question 16

Oesophageal CA investigations

Answer 16

Endoscopy and biopsy 
Staging:
-endoscopic USS
-CT
-PET 
Fitness for op

Question 17

Oesophageal CA management

Answer 17

Endoscopic:

• very early/palliative
• radiofrequency ablation
• extensive follow up

Surgical resection:

• operable disease/no mets
• +/- chemo/radio therapy
• lymph node clearance

Palliative:

• relieve dysphagia
• chemotherapy
• stent
• laser destruction

Question 18

Oesophageal CA prognosis

Answer 18

5 year survival
Mucosal 80-90%
Full thickness 5%

Question 19

Achalasia pathology

Answer 19

Dilation and musculodystrophy above lower sphincter
Loss of ganglion cells
Oesophagus becomes elongated and inflamed

Question 20

Achalasia presentation

Answer 20

‘Slowing down’ of digestion
Develops in to dysphagia
Regurgitation
Wt loss

Question 21

Achalasia management

Answer 21

-> Endoscopy
-> Contrast study
Ballon dilation -> 80% resolution
Hellers procedure
Botox