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Bioregulatory Systems: Upper GI Tract > Upper GI Tract [Complete] > Flashcards

Upper GI Tract [Complete] Flashcards

1
Q

Name the two main sphincters of the oesophagus.

A

Upper oesophageal sphincter

Lower oesophageal sphincter

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2
Q

Name the 5 regions of the oesophagus.

A

Cervical oesophagus

Upper thoracic oesophagus

Middle thoracic oesophagus

Lower thoracic oesophagus

Abdominal oesophagus

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3
Q

Different regions of the oesophagus have different types of muscles. Which type of muscle makes up the cervical muscle?

A

Skeletal

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4
Q

Which type of muscle makes up the upper thoracic oesophagus?

A

Smooth/Skeletal

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5
Q

Which type of muscle makes up the middle thoracic oesophagus?

A

Skeletal/Smooth

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6
Q

Which type of muscle makes up the lowerr thoracic oesophagus?

A

Smooth

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7
Q

An alternative name for the lower thoracic oesophagus is known as?

A

The esophagogastric junction (EGJ)

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8
Q

What are the average lengths of each component of the oesophagus?

A

Cervical: 5cm

Upper thoracic: 5cm

Middle thoracic: 5cm

Lower thoracic (EGJ): 10cm

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9
Q

Where does the cervical oesophagus begin and at what vertebral level?

A

Begins from the upper oesophageal sphincter at C5/6

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10
Q

What vertebral level does the oesophagus enter the diaphragm?

A

T10

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11
Q

What vertebral level does the oesophagus end at?

A

T11

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12
Q

What nearby structures are used as reference for the location of the begining of the oesophagus?

A

cricoid cartilage of the larnyx(oesophagus is located behind them)

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13
Q

What nearby structures are used as reference for the where the cervical oesophagus ends?

A

The sternal notch

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14
Q

What is the average length of the oesophagus?

A

20-25cm

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15
Q

The lower oesophageal sphincter does not have any sphincter related muscles to enable it to produce a closing effect. Instead there are nearby anatomical contributions which enable it to perform its function. List these 4 contributions.

A

Distal oesophagus 4-5cm within the abdominal cavity

Diaphragm sorrounding the LOS (right and left crux)

Oesophagus enters at an acute angle (Angle of His)

Phrenoesophageal ligament

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16
Q

The angle in which the oesophagus enters the stomach is known as?

A

Angle of His

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17
Q

What is the function of the angle of His?

A

Helps to prevents reflux of gastroduodenal contents from travelling back up the oesophagus.

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18
Q

What is the importance of the distal oesophagus being located within the abdominal cavity.

A

When there is positive intra-abdominal pressure, this enables the compression of this part of the oesophagus preventing regurgitation

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19
Q

What is the function of the right and left crux of the diaphragm?

A

Creates a pinch-cock effect

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20
Q

What is the purpose of the phrenoesophageal ligament?

A

Enables independant movement of the oesophagus and disphragm during respiration or swallowing.

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21
Q

Name the 4 main phases of swallowing?

A

Phase 0: Bolus phase

Phase 1: Pharyngeal phase

Phase 2: Upper oesophageal phase

Phase 3: Lower oesophageal phase

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22
Q

Summarise the bolus phase of swallowing

A

Chewing & saliva prepare bolus

Both oesophageal sphincters constricted during this

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23
Q

Summarise the pharyngeal phase of swallowing

A

Pharyngeal musculature guides food bolus towards oesophagus

Upper oesophageal sphincter opens reflexly

lower oesophageal sphincter is opened by vasovagal reflex (receptive relaxation reflex)

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24
Q

Summarise the upper oseophageal phase of swallowing

A

Upper sphincter closes

Circular muscle rings superior to bolus constrict to prevent regurgitation and inferior rings dilate to enable entry further down the oesophagus.

Sequential contractions of longitudinal muscle occurs to help guide bolus down the the oesophagus easier.

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25
Q

Summarise the lower oesophageal phase of swallowing

A

As food passes through the lower oesophageal sphincter, it begins to close

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26
Q

The opening of the lower oesophageal sphincter is triggered by which reflex?

A

The vasovagal reflex

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27
Q

Which of the sphincters stays open the most during the swallowing process?

A

The lower oesophageal sphincter (Opens at the same phase as the upper but continues to stay open for later phases.

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28
Q

What medical test can be performed to determine oesophageal motility?

A

A manometry

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29
Q

What is manometry?

A

Measure of changes in pressure and movement within the oesophagus to help determine any abnormality.

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30
Q

What is the average pressure generated from peristaltic waves?

A

40mmHg

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31
Q

What is the avergae resting pressure of the lower oesophageal sphincter

A

20mmHg

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32
Q

During receptive relaxation of the LOS, what happens to the pressure?

A

Pressure decreases to less than 5mmHg

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33
Q

relaxation of the LOS is mediated by which neurones?

A

Mediated by inhibitory noncholinergic nonadrenergic (NCNA) neurons of myenteric plexus

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34
Q

In order for dysphagia to be caused by a functional disorder of the oesophagus, what must there be an absence of?

A

A stricture

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35
Q

What is an oesophageal stricture?

A

A abnormal narrowing of the oesophagus

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36
Q

What are the two main pathological causes for the diagnosis of a functional oesophageal disorder?

A

Abnormal oesophageal contractions

Failure of protective mechanisms for reflux

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37
Q

Give an example of a functional oesophageal disorder characterised by failed protective mechanisms for reflux.

A

GERD (Gastrooesophageal reflux disorder)

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38
Q

Give 3 examples of types of abnormal oesophageal contractions.

A

Hypermotility (e.g. achlasia)

Hypomotility (e.g. scleroderma)

Disordered coordination (e.g. corkscrew oesophagus)

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39
Q

Diffculty in swallowing is known as?

A

Dysphagia

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40
Q

Dysphagia can present itself in different ways. What characteristics must be considered when distinguishing differences?

A

Location

Whether its intermittent or progressive

Whether it occurs when swallowing liquids or fluid

Whether its precise or vague in apprecitation (detection)

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41
Q

What are the two main locations where dysphagia can occur in?

A

Cricopharyngeal sphincter

Distal oesophagus

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42
Q

Pain in swallowing is known as?

A

Odynophagia

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43
Q

Define regurgitation

A

Regurgitation refers to return of oesophageal contents from above an obstruction

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44
Q

What are the two main types of regurgitation?

A

Functional

Mechanical

45
Q

What is the difference between reflux and regurgitation?

A

Regurgitation is return of oesophageal contents whereas reflux is passive return of gastroduodenal contents

46
Q

Define reflux

A

Return of passive gastroduodenal contents towards the mouth

47
Q

Give an example of a functional oesophageal disorder caused as a result of hypermotility.

A

Achlasia

48
Q

What is achlasia?

A

A gastrooesophageal disorder characterised by the inability of the LOS to relax

49
Q

What is the physiological cause of achlasia?

A

Due to loss of ganglion cells in Aurebach’s myenteric plexus which innervate the LOS wall leading to a decrease in activity of the NCNA neurones.

50
Q

Name the myenteric plexus which innervates the LOS

A

Aurebach’s myenteric plexus

51
Q

What are the primary and secondary causes of achlasia?

A

Primary cause is unknown in terms of aetilogy

Secondary causes is diseases which lead to oesophageal motor abnormalities

52
Q

Give 5 examples of diseases which can lead to secondary causes of achlasia

A

Chagas’ Disease (parasitic infection)

Protozoa infection

Amyloid

Sarcoma (Cancer)

Eosinophilic Oesophagitis

53
Q

Explain how achlasia leads to dysphagia

A

Hypermotility leads to increase in resting pressure in the LOS.

Increase in pressure caused due to a delayed and weak receptive relaxation of the LOS.

This constriction leads to a build up of food within the oesophagus leading to further buildup of pressure, leading to dilation of the oesophagus.

54
Q

How does achlasia present itself in terms of onset?

A

Onset is insidious (Is present for many years prior to seeking treatment).

55
Q

How is the oesophagus affected if achlasia is not treated?

A

Leads to dilation of oesophagus if untreated.

56
Q

What morbidity has an increased incidence in individuals with achlasia?

A

Oesophageal cancer (28 fold increase)

57
Q

Name the non-surgical invasive option used for treating achlasia?

A

Pneumatic dilation

58
Q

Explain how pneumatic dilation can help in the treatment of achlasia

A

PD weakens LOS by circumferential stretching it & in some cases, tearing of its muscle fibres, enabling food to pass into the stomach.

59
Q

What is the efficacy of a pneumatic dilation procedure?

A

Initially effective in 75-90% of patients however many relapse over time

60
Q

What are the three surgical procedures used to treat achlasia?

A

Heller’s myotomy (Weakens the sphincter muscles)

Dor fundoplication (Wraps fundus around the oesophageal sphincter)

Peroral endoscopy myotomy (POEM)

61
Q

What is a Heller’s Myotomy?

A

A continuous myotomy performed for 6 cm on the oesophagus & 3 cm onto the stomach

62
Q

What is a Dor Fundipulation?

A

Procedure where anterior fundus folded over oesophagus and sutured to right side of myotomy

63
Q

Besides a Heller’s myotomy and dor fundipolation procedure? What other surgical intervention can be used to treat achlasia?

A

Peroral endoscopic myotomy (POEM)

64
Q

Explain the main steps in a POEM.

A

(A)Mucosal incision

(B) Creation of submucosal tunnel

(C & D) Myotomy

(E) Closure of mucosal incision

65
Q

What is a common diease which leads to hypomotility of the oesophagus?

A

Scleroderma (autoimmune disease)

66
Q

How does sclerodoma lead to hypomotility?

A

Sclerodema is autoimmumne disease.

Targets muscle innervation leading to muscle atrophy

67
Q

How does sclerodoma lead to GERD?

A

Sclerodoma is autoimmune condition which leads to atrophy of smooth muscle in the oesophagus.

Peristalsis in the distal portions of the oesophagus ceases over time, leading to decrease in resting pressure in the LOS.

Low pressure leads to acid reflux and development of GERD over time.

68
Q

What subtype of sclerodoma is often associated with development of GERD?

A

CREST syndrome

69
Q

What are the 2 main treatment options for individuals with sclerodoma?

A

Exclude organic obstruction

Improve force of peristalsis with prokinetics (e.g. cisapride)

70
Q

The presentation of which condition in patients with sclerodoma often determines when oesophageal dysfunction is no longer treatable?

A

Presentation of peristaltic failure

71
Q

Give an example of a oesophageal disorder characterised by disordered coordination of contractions?

A

Corkscrew Oesophagus

72
Q

What are the 2 main symptoms which present themselves in patients with a corkscrew oesophagus?

A

Dysphagia

Chest pain

73
Q

What is the physiological reason why corkscrew oesophagus occurs?

A

Hypertrophy of circular muscles

74
Q

How can a corkscrew oesophagus be diagnosed?

A

Presentation of dysphagia and chest pain

Barium swallow test shows a corkscrew oesophagus

Upper GI endoscopy

75
Q

What are the treatment options for patients with corkscrew oesophagus and how effective is treatment?

A

May respond to forceful pneumatic dilation of cardia

Results not as predictable as achalasia

76
Q

Name 2 vascular abnormalities which may lead to dysphagia?

A

Double aortic arch

Dysphagia lusoria (Abnormal right subclavian artery)

77
Q

What is an oesophageal perforation and where does it tend to occur?

A

Formation of a hole in the oesophagus.

Tends to occur in anatomical positions where there is more constriction of the oesophagus (e.g. cricopharyngeal constriction, aortic and bronchial constriction, diaphragmatic constriction).

Also occurs in areas where there is pathological narrowing (e.g. cancer, foreign object)

78
Q

What is the most common cause of oesophageal perforation?

A

Iatrogenic causes (e.g. medical intervation)

79
Q

List 5 other causes of oesophageal perforation

A

Spontaneous (Boerhaave’s) - 15%

Foreign body - 12%

Trauma - 9%

Intraoperative - 2% (occur during surgery)

Malignant - 1%

80
Q

What is the most common cause of iatrogenic oesophageal perforation? What 2 disease can increase the risk of this occuring?

A

Gastroscopy (aka OGD)

Perforation risk increases in patients with cancer or diverticula (pouches in oesophagus)

81
Q

List 4 iatrogenic causes of perforation and their incidences

A

OGD = 0.03% (lowest incidence)

Stricture dilatation = 0.1-2%

Sclerotherapy = 1-5%

Achalasia dilatation = 2-6% (highest incidence)

82
Q

Which iatrogenic interventions leads to the highest and lowest risk of perforation?

A

Achalasia dilatation (Highest)

OGD (lowest)

83
Q

What is Boerhhaves syndrome?

A

Sudden increase in intraoesophageal pressure and negative intra thoracic pressure leading to perforation of the distal oesophagus

84
Q

What is the main cause of Boerhhave’s Syndrome and which portion of the distal oesophagus is affected by this?

A

Vomitting against a closed glottis

Left posterolateral aspect of the distal oesophagus

85
Q

What is the incidence of Boerhhave’s Syndrome?

A

3.1 per 1,000,000 (rare)

86
Q

List 5 foreign objects that often lead to perforation

A

Disk batteries growing problem (Cause electrical burns if impact in mucosa)

Magnets

Sharp objects

Dishwasher tablets

Acid/Alkali

87
Q

Oesophageal perforation within the neck and thorax regions occurs more commonly in which type of trauma?

A

Neck = penetrating trauma

Thorax = Blunt trauma (e.g. car accident)

88
Q

Oesophageal perforation caused by trauma is difficult to diagnose. What are however some of the signs that indicate a traumatic perforation?

A

Dysphagia

Blood in saliva

Haematemesis

Surgical empysema (Shortness of breath and accumulation of air within the subcutaneous tissue)

89
Q

What are 4 intraoperative causes of oesophageal perforation?

A

Hiatus hernia repair

Hellers Cardiomyotomy

Pulmonary surgery

Thyroid surgery

90
Q

Malignant causes of oesophageal perforation often have a poor prognosis. Give 4 examples of some malignant causes

A

Advanced cancers

Radiotherapy

Dilatation

Stenting

91
Q

What are the most common presentations in a person with oesophageal perforation?

A

Pain 95 %

Fever 80 %

Dysphagia 70 %

Emphysema 35 %

92
Q

What tests can be performed to diagnose oesophageal perforation? (4)

A

CXR (Chest X-ray showing pleural effusion)

CT

Swallow (gastrograffin) (Contrast used in X rays to see what happens during swallowing)

OGD (Shows rupture on camera)

93
Q

Chest X-ray showing pleural effusion in a patient with oesophageal perforation.

A
94
Q

Swallow test in a patient with oesophageal perforation.

A
95
Q

What are the initial management plans for a patient with oesophageal perforation?

A

NBM (Nil by mouth)

IV fluids

Broad spectrum A/Bs &

Antifungals

96
Q

After initial management of oesophageal perforation, what are the next set of actions to be taken?

A

ITU/HDU level care (Intensive unit/ High dependency unit)

Bloods (including G&S [group and screen to check blood type]

Tertiary referral centre

Surgical emergency
• 2x ↑mortality if 24h delay in diagnosis

97
Q

Operative management in patients with oesophageal perforation should be the immediate default course of action unless?

A

Minimal contamination

Contained

Unfit

98
Q

What surgical options are there for patients with oesophageal perforation?

A

Primary repair where the perforation is

Oesophagectomy (removal of parts oesophagus and direct attachment to stomach) [This is for larger perforations]

99
Q

What is the main protective mechanism against acid reflux?

A

Closed LOS

100
Q

List 6 factors that can increase pressure within the LOS to inhibit acid reflux.

A

High intra-abdominal pressure

Acetylcholine (eggs, meats, fish)

Hormones

Histamine

Protein rich food

alpha-adrenergic agonists (hypertension)

101
Q

List 6 factors that can deceasae pressure within the LOS to promote acid reflux.

A

Smoking

Fat

Hormone

Beta-adrenergic agonists (asthma, bradycardia)

Chocolate

Acid gastric juice

102
Q

Sporadic reflux is a normal occurence. What are the main causes of this? (3)

A

Pressure on full stomach

swallowing

Transient sphincter opening

103
Q

After reflux has occured, what 3 mechanisms are there which prevents it from causing any further damage?

A

Volume clearance - oesophageal peristalsis reflex

pH clearance: saliva

Epithelium: barrier properties

104
Q

Give 6 examples of causes for failures in defensive mechanisms against reflux.

A

Low saliva prodiction (Sleep + Xerostomia (dry mouth)

Decreased buffering capacity of saliva (e.g from smoking)

Abnormal peristalsis

Defective mucosal protective mechanism (e.g. alcohol)

Hiatus hernia

Decrease in sphincter pressure

105
Q

Acid reflux can result in the development of which condition? What is a potential long-term outcome of this?

A

Reflux oesophagitis

Can lead to epithelial metaplasia and eventually a carcinoma

106
Q

What are the two types of hiatus hernias?

A

Rolling

Sliding

107
Q

What is a sliding hiatus hernia?

A

Herniation formed when the stomach and the lower part of the esophagus slide up through the diaphragm

108
Q

What is a rolling hiatus hernia?

A

A type of herniation where part of the stomach pushes (protrudes) up through the hole in the diaphragm next to the oesophagus.

109
Q
A

Bioregulatory Systems: Upper GI Tract (13 decks)

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