Benign and malignant Oesophageal and stomach disease Flashcards

(34 cards)

1
Q

Benign obstructive oesophageal disease mechanisms

A

Extrinsic/ extraluminal

Transmural

Neurogenic

Luminal

Functional

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2
Q

Examples of extrinsic/extraluminal benign obstructive oesophageal disease

A

Retrosternal goitre

Bronchogenic tumor

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3
Q

Examples of Transmural benign obstructive oesophageal disease

A

GIST (GI stromal tumour)
Rare–>can resect or enucleate.
- Interstitial, cajal GI cells.
- Low malignant potential, compared to others in GIT.

Leiomyoma

  • Smooth muscle tumour, more common than GIST
  • Treatment= Enucleating, resection
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4
Q

Examples of neurogenic benign obstructive oesophageal disease

A

Achalasia

CREST syndrome
- Connective tissue disorder

Chaga’s disease

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5
Q

Achalasia

  • Pathophysiology
  • Classification
A

Failure of LES to relax/open
- Due to degeneration of myenteric (Auerbach’s) plexus

Primary

  • Idiopathic (most common, in younf adulthood)
  • Secondary : Chaga’s disease)
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6
Q

Chaga’s disease

A

Parasitic disease- Trypanosoma cruzi.

- Can cause enlarged oesophagus, secondary achalasia

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7
Q

Causes of luminar benign obstructive oesophageal disease

A
  • Schatzki’s ring

- Benign stricture

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8
Q

Causes of functional benign obstructive oesophageal disease

A

Nutcracker oesophagus

Diffuse oesophageal spasms

Hypertensive LES.

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9
Q

Hiatus hernia

  • Description
  • Risk factors
  • Types
A

Herniation of some/ all of the stomach through the diaphragm, into the mediastinum.

Risk factors

  • M> F
  • Obesity, previous surgery

Types

  • Type 1, Reflux
  • Type 2, Rolling.
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10
Q

Type 1, reflux hiatus hernia

A

Hernia in which there is a shifting Z line
- Most common

Herniation is due to circumferential laxity of the phrenoesophageal membrane.
- May result in GORD

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11
Q

Type 2, rolling hiatus hernia

A

Hernia in which the Z-line is non-shifiting.

Herniation is due to focal weakness of phrenoesophageal membrane.
- Risk of strangulation which can cut off blood supply/ obstruction

Symptoms

  • Hiccough
  • Pressure in chest
  • Odynophagia
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12
Q

Gastric volvulus

  • Pathophysiology
  • Types
  • Treatment
A

Rotation of the stomach of >180 degrees, causing a closed loop obstruction.

Types:
Mesentericoaxial
- Rotates on an axial axis.

Organoaxial
- rotates around vertical axis of organ.

Treatment

  • RESUS if necessary
  • NBM
  • NGT decompression
  • Strangulation= surgery (fundoplication, gastropexy, venting PEG)
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13
Q

Three investigations for obstructive oesophagopathy

A

OGD

  • Shows mass
  • Herniation

Manometry

  • Rules out achalasia
  • Will show LES failing to relax

Barium swallow
- Depicts achalasia (rat’s tail)

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14
Q

Boerhaave’s syndrome

A

Transmural tear of oesophagus to due sudden increase in pressure from vomiting.

Cricopharyngeus muscle of pharynx fails to contract so bolus cannot escape, causing high pressure and rupture.

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15
Q

GORD

  • Definition
  • Complications
  • Risk factor
A

SYMPTOMATIC reflux of gastric content into the oesophagus, sometimes pharynx.

Complications

  • Oesophagitis
  • Stricture
  • Barrett’s oesophagus–>cancer
Risk factors
-	Smoking
-	Alcohol
-	Hiatus hernia
-	Pregnancy
Obesity
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16
Q

Pathophysiology of GORD

A

Lower oesophagus sphincter incompetency

  1. Prolonged relaxation
  2. Hypotensive
  3. Disruption of eosophago-gastric junction (hernia)
17
Q

Red flag signs in dyspepsia

A
  • Dysphagia
  • Vomiting
  • Weight loss
  • Iron deficiency
  • Blood loss
  • Mass
18
Q

Grades of reflux oesophagitis (1-5)

A
  1. Single or multiple erosions in single longitudinal fold
  2. Erosions on multiple folds
  3. Confluent, circular erosions. Friability
  4. Strictures, deep ulcers
  5. Barrett’s oesophagus
19
Q

Differentials for GORD [7]

A

Infection: CMV, herpes, Candida

Peptic ulcers
Gastric cancer
Achalasia
Oesophagitis

20
Q

Investigations for GORD

A

Bloods:
- FBC, U+E, CRP, LFT

OGD

24 Hr oesophageal pH measurement

  • 8%, pH<4
  • Used when: atypical symptoms, treatment not working, pre-surgery, no oesophagitis in OGD

LES manometry
- Rules out achalasia

21
Q

Indications for surgical management of GORD

A
  1. Failed medical management
    - Side effects
    - No symptomatic relief
  2. Consideration of quality of life and long-term medication despite medical management
  3. Complications of GORD
    - Barrett’s
    - Strictures
    - large volume reflux with aspiration risk
  4. Extra-oesophageal manifestations
22
Q

Extra-oesophageal manifestations of GORD

A
  • Asthma
  • Cough
  • Aspiration
  • Hoarse voice
  • Chest pain
23
Q

Surgical procedures for GORD

A

Nissen’s fundoplication
- Wrap the fundus of stomach, 360, around lower oesophagus

Toupet Partial fundo
- Fundus is only partially wrapped around oesophagus. Less aggravation of dysphagia.

Belsey Mark IV

Hill repair
- Partial wrap of fundus around oesophagus

Gastropexy
- Suture the stomach to abdominal wall or diaphragm

24
Q

Achalasia

  • Presentation
  • complications
A

Slowly progressive dysphagia
- Initially worse for fluids, than solids

Later disease
- Regurgitation of undigested food

Weight loss

Aspiration pneumonia

Complications
- Oesophageal SCC

25
Diffuse oesophageal spasm - Description - Diagnosis
Acute pain along the esophagus induced by ingestion (odynophagia) - May be accompanied with dysphagia - Due to uncoordinated contraction Diagnosis - Barium swallow shows 'corkscrew' appearance - Manometry= diffuse hypertonicity - Endoscopy= rules out malignancy
26
Achalasia | - Management
Palliative - CCB - Nitrates - Lifestyle changes Interventions - Endoscopic guided controlled balloon dilatation: need multiple procedures, but successful in most patients. - Botulinum toxin injections Surgery - Heller myotomy= cut out muscle layer of lower oesophagus, but not inner layer. Complications: reflux, obstruction at GOJ, oesophageal perforation - Dor patch= Partial wrapping of stomach around oesophagus. Makes low pressure valve.
27
Diffuse oesophageal spasm | - Management
Medications - Oral CCB - Relaxants= benzos - Long acting nitrates Pneumatic dilatations - usually repeated Surgical - Open myotomy (rare)
28
Pharyngeal pouch - Description - Causes - Presentation
Also called Zenker's diverticulum Acquired diverticulum arising from tissue between inferior constrictor and cricopharyngeus muscle of the oesophagus. - Typically affects elderly Cause - Inappropriate relaxation of cricopharyngeus= increased pressure on tissue above during swallowing - Lower CN dysfunction Presentation - Supper cervical dysphagiia - Intermmittent lump appearing when swallowing - Regurgiation of undigested food - Nocturnal aspiration
29
Pharyngeal pouch | - Diagnosis
Observation of swallowing - Transient neck swelling appears Video barium swallow - Filling of pouch Gastroscopy avoided
30
Pharyngeal pouch | - Treatment
Stapled pharyngoplasty - Endoscopic - Staple pouch to upper oesophagus
31
Hiatus hernia treatment - Lifestyle - Medical - Surgical (indications
Lifestyle - Stop smoking - Weight loss - Reduce alcohol consumption Medical - PPIs - Antacids - Promote gastric emptying: metoclopramide Surgical
32
Hiatus hernia treatment - Surgical (indications - Procedures
Indications - Persistent symptoms despite maximal medical management - Complications of rolling hernia Procedures - Gastropexy (with crural plication) - Fundoplication (Nissen's) for GORD - Gastrectomy (rare)
33
Hiatus hernia | - diagnosis
CXR - Gas bubble/ fluid in chest Upper Gi series - Barium examination of GIT= diagnostic OGD (reflux symptoms) - Oesophagitis 24 pH manometry - Excludes achalasia, dysmotility
34
Upper GI cancer referral symptoms/ signs
Nausea and vomiting Dyspepsia Upper abdominal pain Reflux Haematemesis Anaemia/ Thrombocytopenia