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ANKI GI > [7] Oesophageal Motility Disorders > Flashcards

[7] Oesophageal Motility Disorders Flashcards

1
Q

What are oesophageal motility disorders?

A

A group of conditions characterised by abnormalities in oesophageal peristalsis

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2
Q

How does the prevalence of oesophageal motility disorders compare to other oesophageal disorders?

A

They are less common than mechanical and inflammatory diseases of the oesophagus

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3
Q

How do oesophageal motility disorders typically manifest?

A

With difficulty swallowing solids and liquids

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4
Q

What are the major causes of oesophageal dysmotility?

A

Achalasia

Diffuse oesophageal spasm

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5
Q

How long is the oesophagus?

A

25cm

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6
Q

What is the upper third of the oesophagus composed of?

A

Skeletal muscle

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7
Q

What is the middle third of the oesophagus composed of?

A

It is a transition zone comprised of both skeletal and smooth muscle

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8
Q

What is the lower third of the oesophagus composed of?

A

Smooth muscle

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9
Q

What is the upper oesophageal sphincter comprised of?

A

Skeletal muscle

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10
Q

What is the purpose of the upper oesophageal sphincter?

A

It prevents air from entering the GI tract

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11
Q

What is the lower oesophageal sphincter composed of?

A

Smooth muscle

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12
Q

What is the purpose of the lower oesophageal sphincter?

A

It prevents reflux from the stomach

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13
Q

What propels ingested food down the oesophagus?

A

Peristaltic waves

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14
Q

What controls the peristaltic waves in the oesophagus?

A

Oesophageal myenteric neurones

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15
Q

What is the primary peristaltic wave of the oesophagus under the control of?

A

Swallowing centre

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16
Q

What is the secondary peristaltic wave of the oesophagus controlled by?

A

It is activated in response to distention

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17
Q

What happens as food descends the oesophagus?

A

The lower oesophageal sphincter relaxes, and remains so until food has passed

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18
Q

What is achalasia?

A

A primary motility disorder of the oesophagus, characterised by failure of smooth muscle relaxation

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19
Q

How common is achalasia?

A

Relatively rare (1 per 100,000)

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20
Q

What is the mean age of diagnosis of achalasia?

A

About 50 years

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21
Q

What is the pathophysiology of achlasia?

A

Unknown

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22
Q

What is a common histological feature of achlasia?

A

Progressive destruction of the ganglion cells in the myenteric plexus.

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23
Q

What does the failure of smooth muscle to relax in achalasia cause?

A

An inability of the oesophagus to relax, and a high resting tone and failure of relaxation of the lower oesophageal sphincter

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24
Q

What is the result of failure of the oesophagus to relax in achalasia?

A

Causes difficulty in passing food boluses down the oesophagus

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25
Q

What is the result of the high resting tone and failure of relaxation of the lower oesophageal sphincter in achalasia?

A

Means that the food bolus may get stuck, and fail to pass into the stomach

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26
Q

What is the result of the failure of food to pass into the stomach in achalasia?

A

Produces the symptoms of vomiting, discomfort, and developing poor nutritional status

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27
Q

Why is achlasia a progressive disease?

A

The current theory in its pathophysiology suggests that as the ganglionitis progresses, there is destruction of more and more neurones and subsequent worsening of severity of the condition

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28
Q

How will achalasia classically present?

A 
With progressive dysphagia when ingesting solids and liquids
Regurgitation of food
Coughing
Chest pain
Weight loss
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29
Q

How can achalasia cause coughing?

A

Due to overspill and aspiration, especially at night

30
Q

What may be found on examination with achalasia?

A

There are rarely any obvious signs of note, except for visible weight loss in longstanding or severe cases

31
Q

What are the main differential diagnoses for achalasia?

A

Other oesophageal motility disorders
GORD
Oesophageal malignancy
Angina

32
Q

What needs to be excluded in any patient presenting with dysphagia?

A

Oesophageal cancer

33
Q

What is the result of the need to exclude oesophageal cancer in patients with dysphagia?

A

Nearly all patients will require urgent endoscopy

34
Q

What may be found on endoscopy in achalasia?

A

May be normal

Rarely, there is a tight lower oesophageal sphincter (which may suddenly give way)

35
Q

What is the gold standard for diagnosis of achalasia?

A

Oesophageal manometry

36
Q

What happens in oesophageal manometry?

A

A pressure sensitive probe is inserted into the oesophagus (tip placed 5cm above lower oesophageal sphincter). Then, the pressure of the sphincter and the surrounding muscle is measured

37
Q

What are the key features of oesophageal manometry in achalasia?

A

Absence of oesophageal peristalsis
Failure of relaxation of the lower oesophageal sphincter
High resting lower oesophageal sphincter tone

38
Q

What may barium swallows show in achalasia?

A

May show proximal dilation of the oesophagus, with a characteristic ‘birds beak’ appearance distally

39
Q

What is involved in the conservative management of achalasia?

A

Sleep with many pillows
Eating slowly and chewing foods thoroughly
Taking plenty of fluids with meals

40
Q

What medications can be used in the conservative management of achalasia?

A

Calcium channel blockers or nitrates

Botox injections

41
Q

How useful are calcium channel blockers/nitrates in achalasia?

A

They can be partly effective for temporary relief, but their action is typically short live

42
Q

How are botox injections given in achalasia?

A

They are injected into the lower oesophageal sphincter by endoscopy

43
Q

How long are botox injections effective for in achalasia?

A

A few months at most

44
Q

What are the surgical techniques that can be used in achalasia?

A

Endoscopic balloon dilation

Laparoscopic Heller myotomy

45
Q

What happens in endoscopic balloon dilation for achalasia?

A

A balloon is inserted into the lower oesophageal sphincter, which is dilated to stretch the muscle fibres

46
Q

What % of patients have a good response to endoscopic balloon dilation?

A

75%

47
Q

What are the risks with endoscopic balloon dilation?

A

Perforation

Need for further intervention

48
Q

What is the risk of perforation with endoscopic balloon dilation?

A

5%

49
Q

What happens in a laparoscopic Heller myotomy?

A

There is division of the specific fibres of the lower oesophageal sphincter which fail to relax

50
Q

What % of patients with achalasia have a long-term improvement in swallowing with a laparoscopic Heller myotomy?

A

85%

51
Q

What is the advantage of a laparoscopic Heller myotomy over endoscopic balloon dilation?

A

It has a lower side effect profile

52
Q

By how much does having long-standing achalasia increase the risk of oesophageal cancer?

A

8-16x, although the absolute risk remains small

53
Q

What is diffuse oesophageal spasm (DOS)?

A

A disease characterised by multi-focal, high amplitude contractions of the oesophagus

54
Q

What is diffuse oesophageal spasm thought to be caused by?

A

Dysfunction of the oesophageal inhibitory nerves

55
Q

What can DOS progress too in some patients?

A

Achalasia

56
Q

How will patients with DOS typically present?

A

Severe dysphagia to both solids and liquids

Central chest pain, usually exacerbated by food

57
Q

What may the pain from DOS respond well to?

A

Nitrates

58
Q

What is the problem with the pain from DOS responding well to nitrates?

A

it can make it difficult to distinguish from angina

59
Q

What feature might differentiate NOS pain from angina?

A

NOS pain is rarely exertional

60
Q

What is found on examination in NOS?

A

Examination is usually normal

61
Q

How is DOS investigated?

A

In the same manner as other motility disorders, with the definitive diagnosis being made via manometry

62
Q

What is found on endoscopy in DOS?

A

Usually normal

63
Q

What does manometry characteristically show in DOS?

A

A pattern of repetitive, simultaneous, and ineffective contractions of the oesophagus
May also be dysfunction of the lower oesophageal sphincter

64
Q

What may a barium swallow show in DOS?

A

‘Corkscrew’ appearance

65
Q

What is the initial management of DOS?

A

Agents that act to relax the oesophageal smooth muscle, typically nitrates or calcium channel blockers as first line

66
Q

How effective are nitrates or calcium channel blockers at managing DOS?

A

They limit the strongest contractions, so provide symptomatic improvement, although their long-term efficacy is unceratin

67
Q

Which patients with DOS might benefit from pneumatic dilation?

A

Patients with DOS and documented hypertension of the lower oesophageal sphincter

68
Q

When is myotomy used in DOS?

A

Reserved for the most severe cases

69
Q

Why must myotomy be used with caution in DOS?

A

Due to its invasive nature

70
Q

Describe the excision used in myotomy for DOS?

A

It is extensive, involving the entire spasmic segment and the lower oesophageal sphincter

71
Q

What other conditions are associated with oesophageal dysmotility?

A

A number of autoimmune and connective tissue disorders

72
Q

How is oesophageal dysmotility managed when it is secondary to another condition?

A

Treatment is directed at the underlying cause, with nutritional modification and PPIs as required

ANKI GI (43 decks)

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