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Gastroenterolgy & Nutrition (Y3) > The Oesophagus > Flashcards

The Oesophagus Flashcards

1
Q

What are the main 3 oesophageal symptoms?

A
  • dysphagia
  • heartburn
  • painful swallowing (odynophagia)
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2
Q

How is dysphagia usually investigated?

A

it is investigated with a barium swallow, followed by gastroscopy where appropriate

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3
Q

What are the commonest causes of dysphagia?

What are the differences between the onset of dysphagia in these situations?

A
  • peptic or malignant strictures
  • bulbar palsies

mechanical narrowing of the oesophagus produces progressive dysphagia, initially for solids and eventually for liquids

motor disorders produce dysphagia for both solids and liquids together

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4
Q

What is heartburn and what produces it?

What can it be confused with?

A

a retrosternal or epigastric burning sensation produced by the reflux of gastric acid into the oesophagus

the pain may radiate up to the throat and be confused with chest pain of cardiac origin

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5
Q

What usually makes heartburn worse?

A

bending or lying down

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6
Q

When does painful swallowing tend to occur?

A
  • with infections of the oesophagus - herpes simplex, Candida
  • in gastro-oesophageal reflux disease - particularly with alcohol and hot liquids
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7
Q

What is involved in the pathophysiology of gastro-oesophageal reflux disease?

A
  • tone of the lower oesophageal sphincter (LOS) is reduced and there are frequent transient LOS relaxations
  • there is increased mucosal sensitivity to gastric acid and reduced oesophageal clearance of acid
  • delayed gastric emptying and prolonged postprandial and nocturnal reflux also contribute
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8
Q

What are the predisposing factors for gastro-oesophageal reflux disease?

A
  • hiatus hernia
  • obesity
  • pregnancy
  • systemic sclerosis
  • certain drugs - such as nitrates and tricyclics
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9
Q

What are the clinical features of GORD?

A
  • heartburn is the major symptom
  • burning is aggrevated by bending, stooping and lying down and may be relieved by antacids
  • may be pain on drinking hot drinks
  • cough and nocturnal asthma can occur from aspiratrion of gastric contents into the lungs
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10
Q

How is GORD diagnosed?

A

the diagnosis is clinical and investigation is not usually required in patients without “alarm symptoms”

(these are weight loss, dysphagia and anaemia)

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11
Q

What is the investigation of choice in GORD?

What will be seen?

A

gastroscopy

it may show oesophagitis (mucosal erythema, erosions and ulceration)

the mucosa can be normal in patients with symptoms of reflux

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12
Q

What may barium swallow show in a patient with GORD?

A

an ulcerated lower oesophagus

it will demonstrate a hiatus hernia if this is present

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13
Q

When is 24-hour intraluminal pH monitoring used in GORD?

A

it is usually reserved for the confirmation of GORD prior to surgery and in difficult diagnostic cases

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14
Q

What conservative measures are involved in the management of GORD?

A
  • weight loss
  • reduction in alcohol intake
  • cessation of smoking
  • simple antacids

these actions are often sufficient for mild symptoms

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15
Q

What is the first line medication treatment for GORD?

A

alginate-containing antacids

these prevent reflux by forming a ‘foam raft’ on gastric contents

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16
Q

Why are H2-receptor antagonists and prokinetic agents used in GORD?

What are examples of these?

A

H2 receptor antagonists:

  • e.g. ranitidine
  • improves the symptoms of heartburn

Prokinetic agents:

  • e.g. metoclopramide and domperidone
  • enhances GI motility by increasing frequency or strength of contractions, without disrupting their rhythm
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17
Q

What are examples of proton-pump inhibitors (PPIs) and how do they work?

A
  • omeprazole
  • esomeprazole
  • lansoprazole
  • pantoprazole

they inhibit gastric hydrogen/potassium ATPase and block luminal secretion of gastric acid

they are potent acid blockers and the drug of choice for all but mild cases of GORD

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18
Q

How are PPIs prescribed in cases of GORD?

How long should they be used for?

A

maintenance acid-suppressive therapy is often necessary due to the likelihood of reflux symptoms to relapse

the aim is to reduce to the minimum dose necessary to control symptoms (“step-down approach”)

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19
Q

What are the 3 endoscopic procedures that can be used in management of GORD?

A

Endoscopic gastroplasty:

  • sutures are placed endoscopically in the lower oesophagus

Stretta procedure:

  • radiofrequency energy is delivered to the LOS to induce fibrosis

Endoscopic injection of submucosal polymers:

  • this will bolster the LOS
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20
Q

Which groups of patients may have surgery to manage their GORD?

A
  • those who continue to have symptoms in spite of full medical therapy
  • in young people whose symptoms return rapidly on stopping treatment
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21
Q

What is the surgical procedure that tends to be used in patients with GORD?

A

Nissen fundoplication

the fundus of the stomach is sutured around the lower oesophagus to produce an antireflux valve

this is performed laparoscopically

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22
Q

What is the major complication of GORD?

How does it present and how is it treated?

A

oesophageal stricture formation

this presents with intermittent dysphagia and is treated with endoscopic dilatation

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23
Q

What condition may result from long-standing acid reflux?

A

it may cause metaplasia from squamous to columnar epithelium in the lower oesophagus

this is known as Barrett’s oesophagus

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24
Q

How is a diagnosis of Barrett’s oesophagus made?

A

through endoscopy

the pale glossy squamous epithelium is replaced by red-coloured columnar epithelium

25
Q

How are patients with Barrett’s oesophagus managed?

A

it is the premalignant condition for oesophageal adenocarcinoma

patients should undergo regular endoscopies with multiple biopsies to look for dysplasia or carcinoma

26
Q

What is achalasia?

A

a disease of unknown aetiology, characterised by aperistalsis and non-propulsive tertiary contractions in the body of the oesophagus

there is failure of the LOS to relax on initiation of swallowing

27
Q

How do patients with achalasia tend to present?

What ages are usually affected?

A
  • can present at any age but is rare in childhood
  • usually a long history of dysphagia for both liquids and solids, which may be associated with regurgitation
  • severe retrosternal chest pain may occur, particularly in younger patients
28
Q

What are the 4 different investigations that may be carried out in achalasia?

A

Barium swallow:

  • shows dilatation of the oesophagus
  • lack of peristalsis
  • gradually tapering lower end of the oesophagus (beak deformity)
  • asynchronous contractions of the oesophagus

Gastroscopy:

  • excludes oesophageal carcinoma which presents similarly on X-ray and symptoms

Oesophageal manometry:

  • demonstrates aperistalsis and failure of LOS relaxation

Chest X-ray:

  • shows dilated oesophagus with a fluid level behind the heart
  • the fundal gas shadow is not present
29
Q

What is the main aim of management for achalasia?

A

there is no cure for achalasia and the goal of treatment is relief of patient symptoms and improved oesophageal emptying

30
Q

What are the two most effective treatment options for achalasia?

A
  • endoscopic graded pneumatic balloon dilatation of the LOS
  • surgical division of the sphincter
31
Q

What are alternative treatments for achalasia in patients who are too high risk for surgery?

A
  • endoscopic injection of the LOS with botulinum toxin (botox)
  • pharmacological treatment with calcium-channel blockers

these will both relax the LOS

32
Q

How does injection of the LOS with botulinum toxin work (botox)?

A

botox inhibits the release of acetylcholine from cholinergic nerve terminals in the myenteric plexus

this reduces smooth muscle contraction and LOS tone

33
Q

What are the complications associated with achalasia?

A
  • GORD is a complication of all treatments, particularly surgery
  • there is a slight increase in the incidence of squamous carcinoma of the oesophagus but this risk is not reduced by endoscopic or surgical treatment
34
Q

How is the oesophagus involved in systemic sclerosis?

A

the smooth muscle layer of the LOS is replaced by fibrous tissue

the LOS pressure is reduced, thereby permitting reflux

35
Q

How do patients with systemic sclerosis present with oesophageal symptoms?

What is the treatment?

A

patients may be asymptomatic or complain of reflux and dysphagia

dysphagia is caused by stricture formation complicating reflux

treatment is as for reflux and stricture formation

36
Q

What is diffuse oesophageal spasm?

How does it present?

A

a severe form of abnormal oesophageal motility which most commonly presents in middle age

it can produce chest pain and dysphagia

37
Q

How does diffuse oesophageal spasm appear on barium swallow?

A

a “corkscrew” appearance may be seen on barium swallow

38
Q

What is “nutcracker oesophagus”?

A

a variant of diffuse oesophageal spasm characterised by high-amplitude peristaltic waves in the oesophagus

39
Q

What is the treatment for diffuse oesophageal spasm?

A

treatment is difficult, but calcium-channel blockers (e.g. oral nifedipine) may be helpful

40
Q

What is a hiatus hernia?

What are the 2 main forms?

A

herniation of a part of the stomach through the oesophageal hiatus of the diaphragm

the two main forms are sliding and para-oesophageal

41
Q

What is a sliding hiatus hernia?

How common is it and what symptoms does it produce?

A

the gastro-oesophageal junction slides through the hiatus and lies above the diaphragm

this accounts for 95% of all cases

on its own, a sliding hiatus hernia is not responsible for symptoms unless there is associated reflux

42
Q

What happens in a para-oesophageal hiatus hernia?

A

the gastric fundus rolls up through the hiatus alongside the oesophagus

the gastro-oesophageal junction remains BELOW the diaphragm

43
Q

What are the complications associated with para-oesophageal hiatus hernia?

How are they treated?

A

they never regress and pose a serious risk of complications including:

  • gastric volvulus (rotation & strangulation of the stomach)
  • bleeding
  • respiratory complications

this is treated surgically

44
Q

What are the 2 different types of oesophageal malignancies?

What parts of the oesophagus are affected?

A

squamous cell carcinoma:

  • usually affects the middle third of the oesophagus

adenocarcinoma:

  • usually affects the lower third of the oesophagus
45
Q

What is the epidemiology of squamous cell carcinoma of the oesophagus?

What are predisposing conditions / risk factors?

A
  • incidence of 5-10 per 100,000 in the UK
  • most common in the 60-70 year age group
  • associated with heavy alcohol intake, heavy smoking, high intake of salted fish / pickled vegetables
  • predisposing factors include achalasia and coeliac disease
46
Q

What does adenocarcinoma result from?

A

it arises from the columnar-lined epithelium of the lower oesophagus (Barrett’s oesophagus) which results from long-standing reflux

47
Q

What are the clinical features associated with malignant oesophageal tumours?

A
  • progressive dysphagia (initially for solids and then for liquids)
  • weight loss
  • chest pain (which may be due to bolus food impaction or local infiltration)
  • physical signs are usually absent
48
Q

What is the initial investigation for malignant oesophageal tumours?

A

gastroscopy and biopsy of the tumour

a barium swallow will show the strictured area, but biopsies cannot be taken

49
Q

What types of investigation are invovled in staging malignant oesophageal tumours?

A
  • CT scan of chest and abdomen
  • MRI
  • endoscopic ultrasonography

these are helpful in staging the lesion to decide the most appropriate treatment

50
Q

What is involved in the management of malignant oesophageal tumours?

A

in many patients, only symptomatic treatment to relieve their dysphagia is possible

this is usually performed endoscopically and may be:

  • insertion of an expanding metal stent to keep the oesophagus open
  • laser to photocoagulate the tumour
  • alcohol injections into the tumour to cause local necrosis
51
Q

When is surgical resection appropriate in patients with oesophageal malignancies?

A

when staging has shown that the tumour has not infiltrated outside of the oesophageal wall

a combination of chemotherapy and radiotherapy prior to surgery (neo-adjuvant chemotherapy) may increase survival

52
Q

What is the prognosis like for oesophageal malignancies?

A

prognosis is poor (9% 5-year survival) as most patients can only be treated palliatively

53
Q

What are the most common causes of oesophageal perforation?

A

the most common cause is iatrogenic and occurs after endoscopic dilatation of oesophageal strictures (usually malignant) or achalasia

it may occur after forceful vomiting (Boerhaave’s syndrome), when there is also usually severe chest pain and collapse

54
Q

What is Boerhaave’s syndrome?

A

a rare and potentially fatal condition characterised by a transmural tear of the distal oesophagus induced by a sudden increase in pressure

the classic triad consists of abdominal/chest pain, vomiting and subcutaneous emphysema

55
Q

How may oesophageal perforation present?

A

there may be fever, hypotension and surgical emphysema on examination

56
Q

How is oesophageal perforation diagnosed?

A

diagnosis is made by chest X-ray

this may be normal or show air in the mediastinum and neck, and a pleural effusion

a gastrografin swallow (not barium) will confirm the diagnosis

57
Q

What is the treatment for oesophageal perforation?

A

intravenous antibiotics, nil by mouth and intravenous fluids

surgical repair is needed for patients with large tears or who fail to settle with conservative management

58
Q
A

Gastroenterolgy & Nutrition (Y3) (4 decks)

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