Week 3 - B - Oeseophagus - Oesophagitis (candida, herpes, allergic, reflux), G.O.R.D/ Barret's, Oeseophageal carcinoma

Question 1

What is the Z-line of the oesophagus?

Answer 1

The demarcation line, the squamocolumnar junction or the Z line - represents the normal oeseophagogastric junction where the squamos mucosa of the oeseophagus meets the columnar mucosa of the stomach.

Question 2

Oesophagitis is an inflammation of the lining of the gullet (oesophagus). It can be classified as acute oseophagitis and chronic oeseophagitis Which is more common and what causes both?

Answer 2

Acute oeseophagitis is rare. Causes include - Corrosive following chemical ingestion - Infection in immunocompromised patients eg candidiasis, herpes, CMV Chronic oesophagitis is common - Usually due to reflux disease - reflux oesophagitis Rare causes include Crohn’s

Question 3

What is allergic oesophagitis also known as? What is thought to cause it? Who does it tend to affect?

Answer 3

Allergic oesophagitis is also known as eosinophilic oeseophagitis - typically due to large numbers of eosinophils in the oesophagus This can be the result of an allergic reaction to food or the environment. Tends to affect young patients with a personal/family history of allergy

Question 4

Eosinophilic oesophagitis has increased eosinophils in the blood also How does eosinophilic oeseophagitis typically present?

Answer 4

EoE often presents with difficulty swallowing, food impaction, stomach pains, regurgitation or vomiting, and decreased appetite.

Question 5

How is eosinophilic oesophagitis diagnosed and treated?

Answer 5

Eosinophilic diagnosed with Upper GI endoscopy and biopsy - Endoscopy shows multiple concentric rings biopsy reveals eosinophilic infiltrates of oesophagus Treatment may include steroids, chromoglycate (mast cell destabiliser), monteleukast

Question 6

The most common cause of esophagitis is the reverse flow of acid from the stomach into the lower esophagus: gastroesophageal reflux disease (GERD) The inflammation of the oeseophagus is due to the refluxed low pH gastric content What may causes reflux of the gastric contents?

Answer 6

May be due to * a defective lower oeseophgeal sphincter mechanism * abnormal oeseophgeal motility * increased intra-abdominal pressure (eg pregnancy, obesity )

Question 7

What are the complications of reflux oeseophagitis?

Answer 7

Complications include * Oeseophagitis * Oesophageal ulceration * Benign oesophageal stricture * Haematemesis causing anaemia * Barret’s oeseophagus

Question 8

What are the symptoms of gastroesophgeal reflux disease? (GORD)

Answer 8

* Heartburn * Acid brash * Waterbrash * Acid b(aka acid brash)Belching * Odynophagia * Weight loss * Hoarsejess * Coughing

Question 9

What is Heartburn? Acid brash? Waterbrash? Odynophagia? What is dyspepsia?

Answer 9

Heartburn - burning, retrosternal discomfort after meals, lying, stooping or straining - relieved by antacids Acid brash - acid or bile regurgitatio Water brash - excessive amount of salivation in response to acid/bile regurgitation Odynophagia - painful swallowing eg from oesophagitis or ulceration Dyspepsia, also known as indigestion, is a term that describes discomfort or pain in the upper abdomen.

Question 10

Gastrooeseophegeal reflux disease is often treated as per symptoms There are some indications for endoscopy however What would indicate the need for an endoscopy?

Answer 10

Upper GI endoscopy if any of the following * Dysphagia * Patient >/= 55 years old with ALARM Symptoms * Treatment refractory dyspepsia

Question 11

What are the ALARM Symptoms and what are they a sign of? If the endoscopy is negative, what should be carried out?

Answer 11

ALARM Symptoms * Anaemia (iron deficiency) * Loss of weight * Anorexia * Recenet onset/progressive symptoms * Malaena/haematemesis * Swallowing difficulty ALARM Symptoms may possibly be a sign of gastric cancer

Question 12

If the endoscopy is negative, what should be carried out?

Answer 12

If the endoscopy is negative, carry out 24hr oeseopgeal pH monitoring +/- monometry to help diagnose GORD Manometry measures the strength of the lower oeseopheal sphincter- Esophageal manometry measures the rhythmic muscle contractions that occur in your esophagus when you swallow. The test also measures the force and coordination of esophageal muscles as they move food to your stomach.

Question 13

Treatment of GORD What are the lifestyle modifications that should be used to help treat GORD?

Answer 13

Stop smoking Lose weight if obese Prop up head on the bed Avoiding eating near bed time (3 hours) Avoid provoking factors

Question 14

Pharmacological treatment of GORD is aimed at both symptoms relief and healing the oesophagitis What can be given for symptoms relief? What is prescribed as 1st line and 2nd line treatment for the oeseophagitis?

Answer 14

Antacids can be provided for symptoms relief eg gaviscon * 1st line - PPI (proton pump inhibitor - inhibits H+/K+ ATPase pump at basolateral membrane of gastric mucosa) eg lansoprazole or omeprazole * 2nd line - if symptoms continue (refractory), * add an H2RA (H2 receptor antagonist) eg ranitidine or cimetidine * or try twice daily PPI

Question 15

In severe cases of GORD - confirmed by oesophgeal pH monitoring / manometry that are not responding to pharmacological therapy, what is the surgical option that can be tried?

Answer 15

Laproscopic Nissen fundopication - minimally invasive procedure which is done to restore the function of the lower esophageal sphincter by wrapping the fundus of the stomach around the oesophagus. - young patients with severe confirmed / unresponsive disease

Question 16

What is the pathogenesis of adenocarcinoma?

Answer 16

Chronic acid reflux –> Intestinal metaplasia - metaplastic change of the oeseophagus (stratified squamous epithelium changes to columnar epithelium) –> Which leads to dysplasia (low grade then high grade) –> Which leads to neoplasia -adenocardinoma

Question 17

What is barret’s oeseophagus?

Answer 17

Barret’s oeseophagus is the intestinal metaplasia of the normal stratified squamous epithelium of the distal 1/3rd of the oesophagus to a columnar epithelium as a result of chronic GOD It is a pre-malignant condition

Question 18

How is Barret’s oeseophagus diagnosed?

Answer 18

There are no screening programs for Barrett’s - it’s typically identified when patients have an endoscopy for evaluation of upper gastrointestinal symptoms such as dyspepsia. Biopsy of endoscopically visible columnarization allows histological collaboration

Question 19

What are the risk factors for malignant transformation in Barret’s oeseophagus?

Answer 19

Long segment of oeseophagus involved >3cm Any evidence of dysplasia Smoking and obesity are also risk factors

Question 20

What is the management for Barret’s oesophagus? * What changes in treatment if from metaplastic Barret’s to dysplastic?

Answer 20

Management for Barret’s For patients with metaplasia * Involves endoscopic assessment with biopsies every 3-5 years * and HIgh dose PPI For patients with dysplasia Endoscopic mucusal resection (EMR) OR Radiofrequency ablation (RFA) of mucosa

Question 21

What are the two types of oeseophageal cancer? Which is more common and where?

Answer 21

Two types of oesophgeal cancer are squamous cell carcinoma of the oesophagus and adenocarcinoma of the oesophagus SCC is mainly in the east and developing countries AC is mainly in the west and incidence is increasing Both more common in males

Question 22

What are the different risk factors for oeseophageal carcinoma? (SCC and AC)

Answer 22

Squamous cell carcinoma of oeseophagus * Alcohol * Tobacco * HPV * Low fruit and veg diet Adenocarcinoma of the oesophagus * Tobacco * GORD * Obesity * Low fruits and vegetables

Question 23

What is the presentation of oesophageal cancer? Where in the oesophagus to adenocarcinomas and squamous cell carcinomas tend to affect?

Answer 23

Presentation Dysphagia - most common symptom Anorexia and weight loss Retrosternal chest pain Hoarseness Cough The majority of adenocarcinomas are located in the lower third near the gastroesophageal junction whereas squamous cell tumours are most commonly found in the middle third of the oesophagus.

Question 24

How is oeseophageal cancer diagnosed? What signs would require an endoscopy?

Answer 24

Diagnosis of oesophageal cancer is made from upper GI endoscopy + biopsies (at least 6) Endoscopy is required if * Dysphagia * Age >/= 55 with alarm symptoms * Treatment refractory dyspepsia

Question 25

Once oesophageal carcinoma is diagnosed, patient must be staged How is the patient staged?

Answer 25

CT chest, abdomen and pelvis to look for metastasis PET-CT is more sensitive for distal nodal disease If CT does not show mets, then Endoscopic ultrasound is more sensitive for regional (local) nodal disease

Question 26

What are the mechanisms of metastases of oesophageal cancer?

Answer 26

Direct invasion by submucosal infiltration Local lymphatic invasion Vascular invasion - usually later

Question 27

TNM staging is used to classify the stage of oeseophageal carcinoma Describe the TNM staging?

Answer 27

Tis - arcinoma in situ T1 - invaded submucosa T2 - invaded muscularis externa (aka propria) T3 - invaded adventitia T4 - invasion of adjacent structures N0 - no node spread N1-3 - regional node mets M0 - no distant spread M1 - distant metastasis

Question 28

Survival rates poor with or without treatment What is the treatment of local oesophageal cancer? What is the treatment if not

Answer 28

For localised oesophageal cancer (stage 1-3) - endoscopic resection or oesophagectomy may be tried with neoadjuvant chemotherapy If not a surgical candidate or stage IV (distant mets) - then radical chemoradiotherapy (usually the choice in SCC)