Oesophageal Disorders Flashcards
Plummer-Vinson Syndrome
Plummer-Vinson syndrome
Triad of:
dysphagia and odonyphagia (secondary to oesophageal webs)
glossitis
iron-deficiency anaemia (cheilosis/angular stomatitis)
Occurs in post menopausal women
Increased risk of squamous cell Ca of oesophagus and pharynx
Treatment includes iron supplementation and dilation of the webs
Mallory Weiss Syndrome
Mallory-Weiss syndrome
Severe vomiting → painful mucousal lacerations at the gastroesophageal junction resulting in haematemesis. Common in alcoholics
Boerhaave Syndrome
Boerhaave syndrome
Severe vomiting → oesophageal rupture
Plummer-Vinson Syndrome - Example Question
A 54 year old Caucasian female presents with a 3 month history of dysphagia to bread and solid meats, with no problems with swallowing oral liquids. She has lost about 2 stones in weight unintentionally during this period. She denies any night sweats or fevers, haematemasis, change in bowel habit or malaena. She reports no change in her voice or aspiration episodes. On examination, you note koilonychias and an enlarged tongue on examination with conjunctival pallor. Her blood tests are as follows:
Hb 7.6 g/dl MCV 62 fl Platelets 246 * 109/l WBC 7.2 * 109/l Ferritin 22 ng/ml Na+ 142 mmol/l K+ 4.2 mmol/l Urea 5.6 mmol/l Creatinine 55 µmol/l CRP 20 mg/l
Her GP refers her for an urgent upper oesophageal-gastric endoscopy (OGD) as part of the 2 week wait of suspected cancer. OGD reveals narrowed distal oesophageal lumen caused by webs that are ruptured as the scope is passed. What is the likely diagnosis?
> Plummer-Vinson syndrome Oesophageal squamous cell carcinoma Oesophageal adenocarcinoma Pharyngeal carcinoma Oesophageal rings
Oesophageal webs in association with iron deficiency anaemia (resulting in clinical glossitis and koilonychia) and dysphagia is Plummer-Vinson syndrome, particularly prevalent in middle aged White Caucasian females. The post cricoid oesophageal webs are premalignant for oesophagal squamous cell carcinoma (SCC) and pharyngeal SCC, which instead of webs on OGD, present as plaques, nodules or ulcerated masses instead. However, the agreed frequency of follow up OGD monitoring is debated in Plummer-Vinson syndrome. Frequently, the webs recede on iron replacement and break on the scope passing through, improving dysphagia. Infrequently, dilation may be required, as in oesophageal rings, caused by mucosal outfolds most frequently as a result of chronic oesophageal reflux and hence, treated in conjunction with proton pump inhibitors.
Pharyngeal Pouch
A pharyngeal pouch is a posteromedial diverticulum through Killian’s dehiscence. Killian’s dehiscence is a triangular area in the wall of the pharynx between the thyropharyngeus and cricopharyngeus muscles. It is more common in older patients and is 5 times more common in men
Features dysphagia regurgitation aspiration neck swelling which gurgles on palpation halitosis
Pharyngeal Pouch - Example Question
A 71-year-old man presents with dysphagia which has been getting progressively worse for the past few months. He is generally fit and well other than a history of chronic obstructive pulmonary disease. On occasions he has regurgitated some food after eating a large meal.
On examination of his abdomen no masses are noted. A barium swallow iwith fluoroscopy is arranged:
SEE PASSMED PHARNGEAL POUCH
‘ Still image taken from a barium swallow with fluoroscopy. During swallowing an outpouching of the posterior hypopharyngeal wall is visualised at the level C5-C6, right above the upper oesophageal sphincter’
What is the most likely diagnosis?
Cystic hygroma > Pharyngeal pouch Thyroglossal cyst Oesophageal cancer Achalasia
During swallowing an outpouching of the posterior hypopharyngeal wall is visualised at the level C5-C6, right above the upper oesophageal sphincter.
Diffuse Oesophageal Spasm
Diffuse oesophageal spasm
Features
dysphagia
chest pain
Diagnosis
barium swallow demonstrates a ‘corkscrew appearance’
Diffuse Oesophageal Spasm - Example Question
A 53 year old presents with recurrent episodes of dysphagia to solids and fluids, resolving completely after 2 weeks. This is his third episode in 4 months. He reports weight loss of over two stones since the problem started and is fearful of further oral intake in case he vomits up any food he tries to ingest. He denies haematemasis or malaena. His past medical history includes angina, for which he currently takes minimal doses of GTN. He stopped taking isosorbide mononitrate prescribed to him by his cardiologist as it caused unbearable headaches. His mother died of pancreatic cancer and his uncle recently had an anterior resection for sigmoid colonic carcinoma. His GP initially improved his swallowing symptoms with nifedipine but they now have no effect. An OGD was unable to pass an obstruction at the proximal oesophagus. A barium swallow demonstrated a ‘corkscrew appearance’. What is the next management?
Change ISMN to diltiazem Oral imipramine Percutaneous endoscopic gastrotomy (PEG) tube insertion Sildenafil > Widespread pneumatic dilation
The patient presents mainly with symptomatic dysphagia with barium swallow appearance suggestive of diffuse oesophageal spasm (DES). He appears intolerant of long-acting nitrates. The management of DES is controversial beyond this point but it is generally accepted that calcium channel blockers are optimal for those presenting primarily with chest pain, dysphagia resistant to pharmacological therapies require more invasive or surgical treatments. Endoscopic botox is beneficial but may require multi-level injections and repeat treatments. Widespread pneumatic dilation, though appearing drastic, is the most appropriate management for this patient, who reports significant weight loss due to severe dysphagic symptoms.
Achalasia Diagnosis and Mx: Example Question
An 81 year-old woman presents with a 2 year history of dysphagia for both solids and liquids. She now has to chew her food a lot before swallowing and often has to drink water with every bite. Frequently she coughs after eating and has experienced pain on several occasions behind her sternum when swallowing.
Barium swallow reveals narrowing at the gastro-esophageal junction, producing a ‘bird’s beak’ appearance.
What is the most appropriate medical management for this condition?
Ramipril > Nifedipine Losartan Stenting Bisoprolol
The diagnosis in this case is achalasia, which characterized by difficulty in swallowing, regurgitation of food and liquids and episodes of chest pain. Diagnosis is achieved via oesophageal manometry and barium swallow radiographic studies. The most common form of achalasia is primary achalasia, which has no known cause. Medical treatment includes drugs that help reduce the lower oesophageal pressure, such as calcium channel blockers (e.g. nifedipine) or nitrates (isosorbide dinitrate and nitroglycerin).
Achalasia
Achalasia
Failure of oesophageal peristalsis and of relaxation of lower oesophageal sphincter (LOS) due to degenerative loss of ganglia from Auerbach’s plexus i.e. LOS contracted, oesophagus above dilated. Achalasia typically presents in middle-age and is equally common in men and women.
Clinical features
dysphagia of BOTH liquids and solids
typically variation in severity of symptoms
heartburn
regurgitation of food - may lead to cough, aspiration pneumonia etc
malignant change in small number of patients
Investigations
manometry: excessive LOS tone which doesn’t relax on swallowing - considered most important diagnostic test
barium swallow shows grossly expanded oesophagus, fluid level, ‘bird’s beak’ appearance
CXR: wide mediastinum, fluid level
Treatment
intra-sphincteric injection of botulinum toxin
Heller cardiomyotomy
balloon dilation
drug therapy has a role but is limited by side-effects
Plummer Vinson Syndrome
Oesophageal webs in association with iron deficiency anaemia (resulting in clinical glossitis and koilonychia) and dysphagia is Plummer-Vinson syndrome, particularly prevalent in middle aged White Caucasian females.
The post cricoid oesophageal webs are premalignant for oesophagal squamous cell carcinoma (SCC) and pharyngeal SCC, which instead of webs on OGD, present as plaques, nodules or ulcerated masses instead.
However, the agreed frequency of follow up OGD monitoring is debated in Plummer-Vinson syndrome.
Frequently, the webs recede on iron replacement and break on the scope passing through, improving dysphagia. Infrequently, dilation may be required, as in oesophageal rings, caused by mucosal outfolds most frequently as a result of chronic oesophageal reflux and hence, treated in conjunction with proton pump inhibitors.
