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Stage 3 > Gastroenterology: Oesophagus > Flashcards

Gastroenterology: Oesophagus Flashcards

1
Q

What is achalasia?

A

Condition of unknown aetiology which causes failure of the lower oesophageal sphincter to relax

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2
Q

What causes achalasia?

A

Failure of the lower oesophageal sphincter to relax due to degeneration of myenteric plexus

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3
Q

What is the epidemiology of achalasia?

A

1) Equally affects men and women
2) Small % associated with underlying oesophageal cancer

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4
Q

How does achalasia present?

A

1) Gradual onset (months-years) dysphagia
2) Regurgitation of undigested food
3) Aspiration
4) Retrosternal chest pain/heartburn/substernal chest cramps - often does not respond to PPI
5) Mild weight loss

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5
Q

What investigations do you do for achalasia?

A

1) Endoscopy (also rules out other more sinister pathologies)
2) Oesophageal manometry
3) Barium swallow

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6
Q

What do you see on endoscopy in achalasia?

A

Dilated oesophagus containing residual material (also rules out other more sinister pathologies)

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7
Q

What do you see on oesophageal manometry in achalasia?

A

High pressure and incomplete lower oesophageal sphincter relaxation

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8
Q

What does a barium swallow show in achalasia?

A

Classic bird’s beak appearance in advanced disease (dilated tapering oesophagus)

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9
Q

What condition shows birds beak appearance on barium swallow?

A

Achalasia (advanced)

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10
Q

What are medical treatments for achalasia?

A

1) Botox injections
2) CCBs or nitrates - can try in patients who fail botox therapy or are not suitable surgical candidates

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11
Q

What are surgical treatments for achalasia?

A

1) Oesophageal dilatation
2) Heller’s myotomy - surgical cleavage of the muscle
Then PPIs

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12
Q

What does the oesophagus act as a passage between?

A

Pharynx + stomach

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13
Q

At what level does the oesophagus enter the abdomen through the oesophageal hiatus in the diaphragm?

A

T10

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14
Q

What causes Barrett’s oesophagus?

A

1) Prolonged exposure of normal oesophageal squamous epithelium to the reflux in GORD
2) This causes mucosal inflammation and erosion, leading to the replacement of the mucosa with metaplastic columnar epithelium

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15
Q

Which condition results in Barrett’s oesophagus?

A

GORD

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16
Q

What is the normal mucosa in the oesophagus?

A

Squamous epithelium

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17
Q

What type of mucosa replaces the squamous epithelium in Barrett’s oesophagus?

A

Metaplastic columnar epithelium

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18
Q

What is the change in the oesophageal mucosa in Barrett’s oesophagus?

A

Squamous epithelium to metaplastic columnar epithelium

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19
Q

What might you see on endoscopy of Barrett’s oesophagus?

A

The length affected may be a few cm or the whole oesophagus and can be continuous or patchy

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20
Q

What % of people with GORD develop Barrett’s oesophagus?

A

3-5%

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21
Q

What is the most significant complication of Barrett’s oesophagus?

A

Oesophageal adenocarcinoma (risk of progression is low ~ 1% in low grade dysplasia)

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22
Q

What type of oesophageal cancer can result from Barrett’s oesophagus?

A

Adenocarcinoma

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23
Q

How do you diagnose Barrett’s oesophagus?

A

Endoscopy + biopsy of endoscopically visible columnarisation allows histological corroboration

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24
Q

Which histological criteria are used to diagnose Barrett’s oesophagus after endoscopy + biopsy?

A

Prague criteria

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25
Q

How do you manage Barrett’s oesophagus that is pre-malignant/high grade dysplasia?

A

1) Oesophageal resection OR eradicative mucosectomy - if young and fit
2) Endoscopic targeted mucosectomy or mucosal ablation by epithelial laser, radiofrequency (HALO) or photodynamic ablation (PD) - in others

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26
Q

How do you manage Barrett’s oesophagus with low-grade dysplasia?

A

Annual endoscopic surveillance

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27
Q

How do you manage Barrett’s oesophagus with no pre-malignant changes?

A

1) Surveillance endoscopy + biopsy every 1-3 years
2) High dose long term PPI

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28
Q

Which patients should have a one-off screening endoscopy for Barrett’s oesophagus?

A

Longstanding GORD e.g. > 5 years esp. > 50 years old

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29
Q

What is dysphagia?

A

Difficulty in swallowing and is an alarming symptom that requires urgent investigation with endoscopy

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30
Q

What are neurological causes of dysphagia?

A

1) Cerebrovascular disease
2) Parkinson’s disease
3) Motor neurone disease
4) Bulbar palsy

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31
Q

What motility disorders can cause dysphagia?

A

1) Achalasia
2) Diffuse oesophageal spasm
3) Systemic sclerosis

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32
Q

What are mechanical/obstructive causes of dysphagia?

A

1) Benign strictures
2) Malignancy
3) Pharyngeal pouch
4) Extrinsic pressure from lung cancer
5) Mediastinal lymph nodes
6) Retrosternal goitre

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33
Q

What are other causes of dysphagia?

A

1) Oesophagitis
2) Globus (psychological)

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34
Q

What type of cause does swallowing of liquids and solids being equally affected from the start suggest?

A

Motility disorders e.g. achalasia

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35
Q

What does progressive dysphagia of solids and then liquids suggest?

A

Benign or malignant stricture

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36
Q

What does difficulty in making the swallowing suggest?

A

Neurological cause

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37
Q

What does painful dysphagia (odynophagia) suggest?

A

1) Candida infection
2) Malignancy
3) Ulcer or spasm

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38
Q

What does a bulging neck on swallowing, gurgling or halitosis suggest?

A

Pharyngeal pouch

39
Q

What diagnosis does dysphagia + iron deficiency anaemia suggest?

A

Plummer-Vinson syndrome (also known as Paterson–Brown–Kelly syndrome)

40
Q

What is Plummer-Vinson syndrome (also known as Paterson–Brown–Kelly syndrome)?

A

Rare disease - upper oesophageal web, post cricoid dysphagia + iron deficiency anaemia (signs of which include glossitis, angular stomatitis and pallor) - associated with squamous cell carcinoma of the oesophagus

41
Q

What type of oesophageal cancer is Plummer-Vinson syndrome associated with?

A

Squamous cell carcinoma

42
Q

What are the two types of oesophageal cancer?

A

1) Adenocarcinoma
2) Squamous cell carcinoma

43
Q

Which type of oesophageal cancer is the leading cause in the Western world?

A

Adenocarcinoma - due to increasing rates of metabolic syndrome

44
Q

Which type of oesophageal cancer is the most common worldwide?

A

Squamous cell carcinoma

45
Q

In which part of the oesophagus does squamous cell carcinoma usually present?

A

Top ⅔ of oesophagus

46
Q

In which part of the oesophagus does adenocarcinoma usually present?

A

Lower 1/3

47
Q

What is oesophageal adenocarcinoma associated with?

A

Obesity + GORD

48
Q

How does GORD lead to oesophageal adenocarcinoma?

A

1) Recurrent reflux leads to metaplastic formations of mucin-producing glandular tissue known as Barrett’s oesophagus
2) Ongoing reflux will lead to the development of neoplasia
3) Barrett’s oesophagus has an annual rate of conversion to oesophageal adenocarcinoma at a rate of around 0.5% per year

49
Q

What is a direct cause of ongoing reflux and therefore obesity?

A

Metaplastic change from squamous cell to glandular cells

50
Q

What is the most important risk factor for oesophageal cancer (both types)?

A

Smoking

51
Q

What are other risk factors for oesophageal cancer as well as smoking?

A

1) High alcohol intake
2) Achalasia
3) Zenker diverticulum (pharyngeal pouch)
4) Oesophageal web
5) High intake of hot beverages
6) Dietary intake of increase dietary nitrosamines, areca or betel nuts

52
Q

How does oesophageal cancer present?

A

1) Progressive dysphagia from solids to liquids ± pain on swallowing (odynophagia)
2) Weight loss
3) Hoarseness

53
Q

What is different in the presentation of oesophageal cancer vs motility disorders e.g. oesophageal spasm and achalasia?

A

Cancer - progressive dysphagia from solids to liquids
Motility - dysphagia to solids and liquids from the start

54
Q

How do you manage any patient presenting with dysphagia?

A

Immediately refer for an upper GI endoscopy to rule out oesophageal cancer

55
Q

When do patients with oesophageal often present and why?

A

Late - bc dysphagia only really occurs when there is obstruction of > ⅔ of the lumen

56
Q

What causes hoarseness in oesophageal cancer?

A

Local invasion of the recurrent laryngeal nerve

57
Q

What is always the initial investigation for oesophageal cancer?

A

Upper GI endoscopy (unless contraindicated) - allows visualisation of the tumour and grading via biopsy

58
Q

What needs to be done after oesophageal cancer is diagnosed with endoscopy?

A

Tumour must be staged to asses whether it is resectable

59
Q

When is an oesophageal tumour not resectable?

A

If there is extensive local spread or any distant metastases

60
Q

What investigations can be done in oesophageal cancer to stage the tumours?

A

1) CT chest, abdo + pelvis
2) MRI
3) Endoscopic ultrasound
4) FDG-PET scan
5) Laparoscopy

61
Q

What is the first line investigation in oesophageal cancer after endoscopy?

A

CT chest, abdo, pelvis

62
Q

What is another name for a pharyngeal pouch?

A

Zenker’s diverticulum

63
Q

What is a pharyngeal pouch?

A

A herniation of the pharyngeal mucosa through a point of weakness between the thyropharyngeus and cricopharynxgeus muscle in the inferior constrictor of the pharynx

64
Q

How does pharyngeal pouch present?

A

1) Dysphagia
2) Chronic cough
3) Halitosis
4) Regurgitation of undigested food
5) Weight loss
6) Aspiration
7) Bulging neck on swallowing
8) Gurgling

65
Q

What investigation do you avoid in suspected pharyngeal pouch?

A

Endoscopy - due to risk of perforating the lesion

66
Q

What is the first line investigation in pharyngeal pouch?

A

Barium swallow

67
Q

What would you see on barium swallow in pharyngeal pouch?

A

Residual pool of contrast within the pouch

68
Q

How do you manage pharyngeal pouch/Zenker’s diverticulum?

A

1) Small and asymptomatic - no treatment necessary
2) Surgical approaches - resection of the diverticulum/pouch or incision of cricopharynxgeus muscle

69
Q

What kind of pain does oesophageal spasm cause?

A

Constricting chest pain

70
Q

What are triggers for oesophageal spasm?

A

1) Food
2) Hot drinks
3) Alcohol
4) Lying flat

71
Q

How can you differentiate between angina and oesophageal spasm with GTN?

A

GTN relieves angina pain within minutes, GTN relieves oesophageal spasm more slowly

72
Q

What is the dysphagia like in oesophageal spasm?

A

Intermittent

73
Q

How does diffuse oesophageal spasm present?

A

1) Intermittent dysphagia
2) ± constricting chest pain

74
Q

How do you diagnose oesophageal spasm?

A

Barium swallow

75
Q

What would you see on barium swallow in oesophageal spasm?

A

Abnormal contractions e.g. corkscrew oesophagus

76
Q

What are causes of a benign oesophageal stricture?

A

1) GORD
2) Corrosives
3) Surgery
4) radiotherapy

77
Q

How do you treat benign oesophageal structure?

A

Endoscopic balloon dilatation

78
Q

What causes a malignant stricture?

A

Oesophageal, gastric or pharyngeal cancer

79
Q

What does an apple core effect on barium swallow suggest?

A

Malignant oesophageal structure - cancer

80
Q

What does a malignant oesophageal stricture look like on barium swallow?

A

1) Shouldered edges lead to an apple core effect with an irregular mucosal pattern
2) On video fluoroscopy there would be no peristalsis visible in this segment
3) Normal gastro-oesophageal junction

81
Q

How do benign oesophageal strictures look like on barium swallow?

A

More funnelled appearance with a normal mucosal pattern

82
Q

What are two examples of benign oesophageal strictures?

A

1) Oesophageal web or ring (Plummer-Vinson syndrome)
2) Peptic stricture

83
Q

How does the dysphagia present in an oesophageal stricture (benign or malignant)?

A

Progressive dysphagia - solids then liquids

84
Q

What are causes of oesophageal ulceration?

A

1) Steroid use
2) HSV, CMV, Candida (in HIV infection)

85
Q

How do you treat oesophagitis?

A

PPI e.g. lansoprazole

86
Q

What is a complication of oesophagitis?

A

Upper GI bleed

87
Q

What are the two types of hiatus hernia?

A

1) Sliding (80%) - when the gastro-oesophageal junction slides up into the chest
2) Rolling (20%) - when GOJ reminds in abdomen but a bulge of stomach herniates up into the chest alongside the oesophagus

88
Q

In which type of hiatus hernia is acid reflux most common?

A

Sliding - bc the lower oesophageal sphincter becomes less competent (less common in rolling bc GOJ remains intact)

89
Q

What is the epidemiology of hiatus hernia?

A

1) Common - 30% of patients > 50 years
2) Especially obese women
3) 50% have symptomatic GOR

90
Q

How do you diagnose hiatus hernia?

A

Barium swallow (upper GI endoscopy visualises mucosa ?oesophagitis but cannot reliably exclude hiatus hernia)

91
Q

How is oesophagitis diagnosed?

A

Upper GI endoscopy

92
Q

How do you treat hiatus hernia?

A

1) Lose weight
2) Treat reflux symptoms
3) Surgery

93
Q

What are indications for surgery in hiatus hernia?

A

1) Intractable symptoms despite aggressive medical therapy
2) Complications of GORD
3) Repair rolling hiatus hernia prophylactically (even if asymptomatic) as it may strangulate, which needs prompt surgical repair (and has high mortality and morbidity rate)

94
Q

How do you treat rolling hiatus hernia?

A

Surgically repair prophylactically even if asymptomatic - bc it may strangulate, which needs prompt surgical repair and has high mortality and morbidity rate

Stage 3 (61 decks)

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