Oesophagophyarngeal Conditions, Signs, Causes And Differentials

Question 1

What is a pharyngeal pouch?

AKA Zenker’s diverticulum

Answer 1

A posterior outpouching of the hypopharynx (laryngopharynx - below the oropharynx), just proximal to the upper oesophageal sphincter.

MOA: The Killian dehiscence is a triangular area of weakness in the posterior muscle wall below the thyropharyngeal muscle (oblique inferior pharyngeal constrictor fibres) and above the cricopharyngeal muscle (transverse inferior pharyngeal constrictor fibres). The mucosa and submucoas herniate through this weakness and can form a sac that may trap liquid or compress the cervical vertebrae.

Question 2

What are the signs and symptoms of a pharyngeal pouch?

AKA Zenker’s diverticulum

Answer 2

(Mostly occur in people >70)

Dysphagia

Regurgitation

Chronic cough

Aspiration

Weight loss

Globus sensation

Halitosis

Question 3

What are some differentials for dysphagia?

Answer 3

Neuro: Stroke, Parkinson’s disease

Pharyngeal: Pharyngitis, retropharyngeal abscess, zenker diverticulum, cricopharyngeal bar, oropharyngeal stenosis, Epiglotitis

Oesophagus: Barret’s oesophagus, Oesophageal candiadisis, idiopathic achalasia, benign tumour (lipoma/leiomyoma/polyp)
Carcinoma/metastases, foreign body, oesophageal diverticulum, oesophageal web
Gastrooesophageal muscular ring, nutcracker oesophagus, diffuse oesophageal spasm

Thyroid: thyromegaly

Lymphatic: cervical lymphadenopathy

Gastric: GORD,Hiatus hernia

Iatrogenic: Radiation exposure, Post-operative cervical spine surgery, vocal cord paralysis, caustic agents, pill-induced injury

Systemic: Multiple sclerosis, myasthenia gravis, scleroderma, Wilson’s disease

Question 4

What are the two broad categories of pathology of dysphagia?

Answer 4

1.Neuromuscular:
Muscular - (muscular dystrophy, myasthenia gravis etc)
Neurological - (PD, stroke, MS etc)
Both - weak muscles and impaired coordination (Elderly)

2. Obstructive - Narrowing of the pharynx or oesophagus:
   Cancer of pharynx/oesophagus
   Sacs or rings in the oesophagus
   Barrett’s oesophagus

Question 5

What is Barrett’s oesophagus?

Answer 5

Barrett’s is a premalignant metaplastic change from normal squamous epithelium to columnar (gastric epithelium - glandular) epithelium in the mucosa of the oesophagus.

MOA: Due to continued reflux of gastric acid up the oesophagus, the oesophagus adapts to this by epithelial metaplasia (squamous to columnar with goblet cells).

After metaplasia (ordered change in cell type), we have low grade dysplasia (disordered growth and change in cell type - loss of cell uniformity and tissue architecture), high grade dysplasia and then oesophageal Adenocarcinoma
It increases risk of oesophageal adenocarcinoma by 50 times that of a normal person.

Question 6

When looking for causes of dysphagia, what are the possible signs on examination?

Answer 6

General observation:
Evidence of weight loss (- oesophageal cancer)
Jaundice (- liver metastasis from oesophageal cancer)
Pallor (- blood loss)

Oral:
Dry mouth
Candida (- cause of dysphagia)

Neck:
Lymphadenopathy (-metastases)
Virchow’s node (- metastasis point for oesophageal cancer)

Abdomen: 
Scaphoid abdomen (-abdomen is sucked inward; malnutrition)
Abdominal tenderness (- hiatus hernia)
Hepatomegaly (- metastases)
Scars (- cancer scars)

Question 7

What are the symptoms of Barrett’s oesophagus?

Answer 7

Common:
Heartburn
Regurgitation
Dysphagia

Potentially:
Laryngitis
Cough
Chest pain
Dyspnoea
Wheeze

Question 8

In the differential diagnosis of dysphagia of solids but not of liquids, which aetiologies cause this profile?

Solid dysphagia
No liquid dysphagia

Answer 8

Solids dysphagia without liquid dysphagia suggests mechanical obstruction or stricture, since liquids can traverse the narrowing, causes:

Oesophageal cancer
Peptic stricture
Extrinsic compression of oesophagus

Question 9

In the differential diagnosis of dysphagia of solids AND liquids, which aetiologies cause this profile?

Solid dysphagia
Liquid dysphagia

Answer 9

Trouble swallowing liquids indicates that the oesophagus/oropharynx aren’t coordinated, causes:

Neurological
Achalasia

Question 10

What are the two most common types of oesophageal cancer?

Answer 10

Squamous cell carcinoma

Adenocarcinoma

Question 11

What are the symptoms of oesophageal cancer?

Answer 11

Dysphagia

Weight loss

Anaemia

Anorexia

Persistent vomiting

Dyspepsia - bloating, belching, abdominal discomfort

Question 12

What does oesophageal candidiasis look like on endoscopy?

Answer 12

Small white plaques - circumscribed and generally multiple in number

Unlike oesophageal cancer which will look asymmetric, irregular, maybe bleeding, and possibly on a stalk (pedunculated)

Question 13

What would oesophageal varices look like on endoscopy?

Answer 13

Distended veins sticking up out of a smooth tube.