Week 3 - C - Hiatus Hernia (sliding/rolling), Dysmotility (Gastroparesis, Achalasia) Mallory Weiss Tear, Boerhaave's syndrome

Question 1

What is a hiatus hernia? What are the different types?

Answer 1

Hiatus hernia is the term used to describe a condition where part of the stomach pushes up into the lower chest through a weakness in the diaphragm. The two types of hiatus hernia are Sliding hiatus hernia Paraoesophageal hernia (rolling hiatus hernia)

Question 2

Which type of hiatus hernia is GORD more common in? Why is this?

Answer 2

GORD is more common in a sliding hiatus hernia This is because the gastro-oesophageal junction slides up into the chest - therefore the lower oesophageal sphincter becomes less competent In high paraoesophageal hiatus hernia, the gastrooesoephageal sphincter remains in the abdomen but a bulge of stomach herniates up into the chest alongside the oesophagus

Question 3

What patients are hiatus hernias more common? What is the typical presentation of both types?

Answer 3

Hiatus hernias are more common in obese patients Sliding hiatus hernia often presents with symptoms of GORD due to incompetent LOS Rolling hiatus hernia is generally asymptomatic, however patients with large hernias may develop GORD

Question 4

What is the treatment of a hiatus hernia?

Answer 4

Lose weight Treat GORD - antacids + PPI first line (add H2RA if PPIs do not control symptoms alone) Surgery may be indicated if intractable symptoms - keyhole surgery to reduce the hernia

Question 5

What is gastroparesis? What is thought to be caused by?

Answer 5

Gastroparesis is a disease in which the stomach cannot empty itself of food in a normal fashion - delayed gastric emptying There is no physical obstruction It’s thought to be the result of a problem with the nerves and muscles that control how the stomach empties. If these nerves are damaged, the muscles of your stomach may not work properly and the movement of food can slow down.

Question 6

What are the symptoms of gastroparesis?

Answer 6

Feeling of fullness Nausea Vomiting Weight loss Upper abdominal pain Sometimes GORD

Question 7

In many cases of gastroparesis, there’s no obvious cause. This is known as idiopathic gastroparesis. Known causes of gastroparesis include what?

Answer 7

Known causes of gastroparesis include * Poorly controlled diabetes mellitus - causing autonomic neuropathy * Cannabis * Medciations - eg opiates and anticholinergics * Systemic diseases such as systemic sclerosis

Question 8

How is gastroparesis diagnosed?

Answer 8

Usually involves ruling out other causes eg by CXR and endoscopy Gastric emptying scan - considered the definitive test * – you eat a food (often eggs) containing a very small amount of a radioactive substance that can be seen on the scan. * Gastroparesis is diagnosed if more than 10% of the food is still in your stomach 4 hours after eating

Question 9

How is gastroparesis treated?

Answer 9

* Removal precipitating drugs * Control diabetes * Eat little and often Prescribe prokinetic drugs * Domperidone or metoclopramide (D2 receptor antagonists) (domperidone does not cross the BBB so avoids side effects associated with metoclopramide) * Erythromycin is aslo an option as it stimulates stomach muscle contraction

Question 10

What is achalasia?

Answer 10

Achalsia is where there is failure of co-ordinated oesophageal peristalsis and the lower oesophageal sphincter fails to relax It is thought to be caused by loss (degeneration) of the myenteric plexus (Auerbach’s) in the oesophagus and LOS area

Question 11

What are the clinical features of achalasia?

Answer 11

Dysphagia of both liquids and solids Regurgitation of food - may lead to cough or aspiration pneumonia Decreased weight Heartburn

Question 12

What investigations are used in the diagnosis of achalasia?

Answer 12

Upper GI endoscopy is usually first line - not good for diagnosing achalasia but rules out malignancy Characteristic findings are usually seen on manometry or barium swallow May also see changes on CXR

Question 13

Manometry is considered the most important diagnostic test in patients with achalasia What is seen on manometry in these patient

Answer 13

* oesophageal manometry - considered the most important diagnostic test - shows excessive LOS tone which doesn’t relax on swallowing

Question 14

What is seen on barium swallow and on CXR in patients with achalasia?

Answer 14

barium swallow shows grossly expanded oesophagus, fluid level, ‘bird’s beak’ appearance CXR: wide oesophagus in mediastinum, fluid level

Question 15

Drug treatment is an option in the treatment whilst waiting for definite intervention What are the options here?

Answer 15

Calcium channel blockers and Nitrates They relax the smooth muscle of the oesophagus

Question 16

What is given for the definite treatment of achalasia?

Answer 16

1st line definitive treatments Endoscopic ballon dilatation (pneumatic dilatation) or Heller cardiomyotomy - a surgical procedure in which the muscles of the cardia (lower esophageal sphincter or LES) are cut, allowing food and liquids to pass to the stomach.

Question 17

What is given after both pneumatic dilataton and heller cardiomyotomy due to a potential complication of the operation? What can be performed during the Heller cardiomyotomy due to this complication?

Answer 17

Due to the complication of GORD, a PPI is usuallly given after both penumatic dilatation or heller cardiomyotomy During heller cardiomyotomy, a prophylactic partial fundoplication can be carried out - fundus of stomach wrapped around oeseophagus to prevent GORD

Question 18

In patient who are not good surgical candidates, what treatment can be given for achalasia?

Answer 18

Can give pharmacological treatment with CCBs or nitrates Can also try endoscopic intra-sphincteric injection of botulimin toxin (paralyses the muscle) - repeat every few months - usually given in frail older people

Question 19

What is a Mallory Weiss tear and what causes it?

Answer 19

A mallory weiss tear is an oesophageal mucosal - usually a longitudinal tear at the gastroesophageal junction It is due to persistent vomiting/retching which causes haematemesis

Question 20

What type of patients are mallory weiss tears more common in? How is definitive diagnosis made? What is the treatment?

Answer 20

Mallory Weiss tears are more common in alcoholics Definitive diagnosis is made from an Upper GI endoscopy (oesophagogastroduodenoscopy) Treatment is that is usually resolves spontaneously

Question 21

If the bleed in a Mallory Weiss tear continues and does not resolve spontaneously, what is often used to treat the bleed?

Answer 21

Whilst receiving the diagnostic oesophageal endoscopy patient may receive one of or a combination of adrenaline injection/heater probe thermo-coagulation/clips * An adrenaline injection in or around the bleeding point to vasoconstrict the arteries * Thermocoagulation - cauterize the arteries * Endoscopic clipping of the bleeding Follow up by giving an intravenous PPI

Question 22

What is the difference between an oeseophageal rupture and Boerhaave’s syndrome? What is the cause?

Answer 22

Esophageal rupture is a rupture of the esophageal wall. Iatrogenic causes eg endoscopy, dilatation account for the majority of cases of esophageal perforations In contrast, the term Boerhaave syndrome is reserved for the 10% of esophageal perforations which occur due to vomiting

Question 23

What is Boerhaave’s syndrome also known as? Describe the typical cause of a patient with Boerhaave’s syndrome?

Answer 23

Boerhaave’s syndrome is also known as spontaneous oeseophageal rupture aka effort rupture of the oesophagus The classic history of esophageal rupture is one of severe retching and vomiting followed by excruciating retrosternal chest and upper abdominal pain.

Question 24

What is the presentation of Boehaave’s syndrome?

Answer 24

Mackler’s triad includes chest pain, vomiting, and subcutaneous emphysema, and while it is a classical presentation, it is only present in 14% of people. Odynophagia, tachypnoea, dyspnoea, fever and shock develop soon after

Question 25

What is subcutaneous emphysema that is often seen as part of the Mackler’s triad in Boerhaave’s syndrome?

Answer 25

Subcutaneous emphysema (SCE, SE) occurs when gas or air travels under the skin. Subcutaneous refers to the tissue beneath the skin, and emphysema refers to trapped air. - crackling sensation felt on palpating the skin over the chest or neck caused by air tracking from the lungs

Question 26

How is Boerhaave’s syndrome diagnosed? Why is endoscopy not carried out?

Answer 26

The diagnosis of Boerhaave’s syndrome is suggested on the plain chest radiography and confirmed by chest CT scan Endoscopy has no role in the diagnosis of spontaneous esophageal perforation. Both the endoscope and insufflation of air can extend the perforation and introduce air into the mediastinum

Question 27

How is Boerhaave’s syndrome treated? Image on left shows what is inserted should surgery be delayed

Answer 27

VERY HIGH MORTALITY RATE * Its treatment includes immediate antibiotic therapy to prevent mediastinitis and sepsis * Surgical repair of the perforation - thoracotomy * and if there is significant fluid loss it should be replaced with IV fluid therapy since oral rehydration is not possible If surgery is delayed, T-tube may be needed for drainage of the oesophagus - oesophago-cutaneous fistula created