2: GORD, Barrats Oesophagus, Oesophageal Carcinoma, Achalasia, Plummer-Vinson Flashcards by Grace Poole

Define gastroesophageal reflux

reflux of gastric acid from the stomach into the oesophagus

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Define GORD

when reflux of gastric acid into the oesophagus causes symptoms

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How does the incidence of GORD change with age

increases with age

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In which gender is GORD more common

males (2:1)

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What are the four mechanisms contributing to GORD

Reduced LOS tone
Gastric acid hypersecretion
Dysmotility
Delayed gastric emptying

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What factors increasing intra-abdominal pressure may contribute to GORD

Obesity

Pregnancy

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What factors lowering oesophageal sphincter tone may contribute to GORD

Alcohol
Caffeine
Smoking
Medications: TCA, anticholinergics

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What are two other factors that are thought to contribute to GORD

Stress

- Hiatus hernia

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Give 5 symptoms of GORD

Retrosternal chest pain worse following meals and on lying down
Water-brashing
Odynophagia
Belching
Nocturnal cough
Asthma

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In investigating for GORD: if an individual is over 55 or has ALARM symptoms what should be done

Upper GI endoscopy

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What are the ALARMS symptoms

Anaemia 
Loss of weight 
Anorexia 
Recent change in Sx
Melena/haematemesis 
Swallowing difficultly

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Over what age with GORD are patients offered an upper GI endoscopy immediately

55 years

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If patients are not over 55 and have no ALARMS symptoms how should they be immediately managed

Lifestyle Changes
Medication review
OTC Antacids
Review in 4W

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What antacids are offered

Magnesium Tricillate

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If individuals improve on: medication review, lifestyle changes, OTC antacid what is the next step

No further intervention

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If individuals do not improve on: medication review, lifestyle changes, OTC antacid what is the next step

Test for H.Pylori

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If H.pylori test is negative what is offered

Trial or H2 antagonist (ranitidine) or PPIs for 4W

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If individuals do not improve on ranitidine or H2 blocker what is done

Continue on low-dose treatment and offer upper GI endoscopy

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If individuals test positive for H.pylori what should be done

H.pylori treatment and review in 4W

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After 4W of H.pylori treatment what is performed to check it is eradicated

Urea breath test

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What is the gold-standard investigation for GORD

24h pH monitoring

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When is 24h pH monitoring for GORD indicated

considering surgical intervention

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What is 24h pH monitoring often performed with and why

oesophageal manometry to exclude oesophageal dysmotility

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What are 5 pieces of lifestyle advice for someone with GORD

Weight Loss
Smoking Cessation
Small regular meals
Reduce alcohol
Reduce hot drinks
Reduce citrus, tomatoes, fizzy drinks, spicy food, caffeine
Avoid over-eating 3h before bed

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What is first-line medical therapy for someone with GORD

Antacids - magnesium trisillicate. Alginates - gaviscon

What are there 3 indications for surgical management of GORD

1. Poor response to medical therapy 2. Complication of GORD 3. Patient request - does not want to take long-term meds

What is the main surgical method for managing GORD

Fundoplication

What is Nissen's fundoplication

The fundus of the stomach is wrapped around the LOS posteriorly 360'

If GORD is prolonged what 4 complications may it lead to

1. Oesophagitis 2. Barret's oesophagus 3. Oesophageal stricture 4. Anaemia

What is the most serious risk associated with GORD

Metaplasia-dysplasia sequence

Explain metaplasia-dysplasia sequence of GORD

- Chronic inflammation of the oesophagus can cause metaplasia of oesophageal squamous epithelium to columnar epithelium. This is called Barret's oesophagus - 0.1-0.4% of Barrett's oesophagus transforms to oesophageal carcinoma

What is Barret's oesophagus

Metaplasia of squamous epithelium in the oesophagus to simple columnar epithelium

What causes barrett's oesophagus

Chronic GORD

Which gender is Barrett's oesophagus more common

Male (7:1)

Which ethnicity is Barrett's more common

Caucascian

Which age group is Barrett's seen in

>50's

What are 4 risk factors for Barrett's oesophagus

Smoking FH Obesity Hiatus Hernia

Explain association between alcohol GORD, Barret's and oesophageal carcinoma

Alcohol is a risk factor for both GORD and Oeseophageal carcinoma. It is not a risk factor for Barrett's

How will Barrett's oesophagus present clinically

Prolonged symptoms of GORD

What histological change occurs in Barrett's oesophagus

Squamous epithelium to simple columnar epithelium

What is first-line investigation for Barrett's oesophagus

OGD and biopsy

How will Barrett's oesophagus present on OGD

The distal oesophagus opposed to appearing white, will appear red

What is required to make a diagnosis of Barrett's oesophagus

Biopsy

What classification system is used to determine length of Barrett's

Prague's classification

What medication should all patients with Barret's oesophagus be started on

PPI

What is the mainstay management of Barret's oeseophagus and why

Frequent surveillance OGDs due to risk of oesophageal carcinoma

If individual on biopsy has no dysplasia, how often should they receive an OGD for Barrett's oesophagus

2-5 years

If individual on biopsy has low-grade dysplasia, how often should they receive an OGD for Barrett's oesophagus

every 6 months

If low-grade dysplastic barret's oesophagus is flat how is it managed

endoscopic radio frequency ablation (ERA)

If low-grade dysplastic barret's oesophagus is nodular how is it managed

endoscopic mucosal resection (EMR)

how frequent should high-grade dysplastic barret' s oeseophagus receive OGD

every 3 months

if high-grade barret's oesophagus is flat how is it managed

endoscopic radio frequency ablation (ERA)

if high-grade barret's oesophagus is nodular how is it managed

endoscopic mucosal resection (EMR)

what is the definitive treatment for high-grade barrett's

oeseophagectomy

what is the main risk with barret's oesophagus

0.1-0.4% transform to oesophageal adenocarcinoma

what are the two types of oeseophageal carcinoma

Squamous cell carcinoma

which anatomical part of the oesophagus does oesophageal SCC occur

Upper 1/3

which anatomical part of the oesophagus does oesophageal adenocarcinoma occur

Lower 1/3

in which country is SCC more common

Developing

in which country are adenocarcinomas more common

Developed countries

how do majority of oesophageal adenocarcinomas form

Dysplasia-Metaplasia sequence

what are 5 risk factors for oesophageal squamous cell carcinoma

- Achalasia - Vitamin A deficiency - Smoking - Alcohol - IDA

What are 6 risk factors for oeseophageal adenocarcinoma

- Smoking - Alcohol - GORD/Barret's - Achalasia - Plummer-Vinson - Obesity

What is plummer-vinson syndrome

Individual forms webs in the oeseophagus which causes dysphagia

What is the most common symptom of oesophageal carcinoma

Dysphagia - usually solids then liquids.

what are 3 other symptoms of oesophageal cancer

Weight Loss Vomiting Melena Anorexia

what is first-line investigation for individuals with suspected oesophageal cancer

OGD

if oesophageal cancer what is used to look for metastses

CT-CAP

if no metastses are found on CT-CAP investigation is used and why

Endoscopic US - able to look for local metastses and assess tumour depth (T)

What investigation may also be offered for junctional oesophageal carcinomas

Laparoscopy to look for metastses

if no metastses found on laparoscopy what investigation is used for oesophageal cancer

PET-CT

outline investigations for oesophageal cancer

1. OGD in 2W 2. CT CAP: to stage 3. Endoscopic US: assess tumour depth and local metastses 4. Laproscopy for junctional tumours 5. PET-CT if laparoscopy negative

how are 70% of patients with oesophageal cancer managed and why

Palliative due to patient's presenting at advanced stages

how are oesophageal SCC managed

Chemoradiotherapy

how are oesophageal adenocarcinomas managed

Oeseophagectomy with Neo-adjuvant CRT

how are oesophageal carcinoma patients palliatid

- Oesophageal stenting - Chemoradio to reduce size - Gastrotomy to bypass obstruction - Nutritional support- thickened fluids

why is overall prognosis of oesophageal adenocarcinoma poor

Due to patients presenting late

what is overall survival rate of oesophageal adenocarcinoma

5-10%

Define achalasia

Disrupted oesophageal peristalsis and failure of LOS to relax due to absence of ganglia in auerbachs plexus

Which age-group is achalasia more common

Middle-age

Which gender is achalasia more common

Male and Females

How will achalasia present clinically

- Dysphagia of both solids and liquids | - Regurgitation of food could lead to cough and aspiration pneumonia

What is first line investigation of achalasia

Manometry

What will be seen on mamometry in achalasia

Increase LOS tone

what will be seen on barium swallow in achalasia

Dilation of the oesophagus with a fluid-level giving a 'birds-beak appearance'

what will be seen on CXR in achalasia

Widened mediastinum with fluid-level

how may achalasia be managed

- intersphenteric botox injections - heller cardiomyopathy - pneumatic balloon dilation

what is Plummer Vinson syndrome

Rare disease characterised by formation of oesophageal webs that lead to dysphagia

What is the triad of symptoms in Plummer Vinson syndrome

1. Dysphagia 2. IDA 3. Glossitis

2: GORD, Barrats Oesophagus, Oesophageal Carcinoma, Achalasia, Plummer-Vinson Flashcards

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