Dysphagia

Question 1

Describe the relationship between GORD & smoking/alcohol.

Answer 1

Smoking & alcohol increase the risk of oesophageal cancer, but predominantly oesophageal SQUAMOUS carcinoma rather than oesophageal adenocarcinoma - which is most strongly linked to GORD.

Heavy smoking and significant alcohol intake may influence pt’s management by causing lung or liver disease which may make certain forms of treatment more risky.

Question 2

A 54yo male px w/ a 3 month history of progressive dysphagia in context of long history of heartburn. Progressive picture with solids and now into thick liquids. FMHx of hiatus hernia. Heavy smoker & drinker. No supraclavicular lymphadenopathy or stigmata of chronic liver disease. Hyperexpanded chest.

DDx?

Answer 2

• stricturing process of lower esophagus (progressively becoming more narrow)
• peptic stricture
• oesophageal adenocarcinoma (more a/w GORD c.f. squamous cell carcinoma in smoking)
• external compression of esophagus
• neuromuscular disorders e.g. ineffective peristalsis or achalasia

Question 3

Ix of dysphagia

Answer 3

• barium swallow
• upper GI endoscopy
• biopsy of any abnormality
• esophageal manometry: most sensitive for Dx of neuromuscular disorders of oesophagus e.g. achalasia

Question 4

Answer 4

Stricture & hiatus hernia shown in barium swallow test

Question 5

What is the esophageal pathology?

Answer 5

Stricture & ulceration.

This is a typical picture of a stricture due to gastro-oesophageal reflux disease, however malignancy cannot be excluded.

Question 6

What do these esophagus biopsies show?

Answer 6

The biopsy on the left:

• squamous mucosa
• elongation of the lamina propria papillae due to hyperplasia
• thinning of the superficial mucosa with inflammation.

The biopsy on the right:

• inflammatory debris from the floor of one of the ulcers

Question 7

What is the pathology in the esophagus?

Answer 7

Hiatus hernia & Barret’s esophagus

Question 8

What is the pathology in this esophagus biopsy?

Answer 8

glandular structures and goblet cells in esophagus (c.f. squamous mucosa as it should be).

I.e. Barrett’s oesophagus.

Question 9

How do you Mx narrowed esophagus?

Answer 9

oesophageal dilation

performed using either a bougie (a flexible rubber or plastic cylinder of graduated size), or a balloon which can be passed through the working channel of the endoscope.

Symptomatic BUT underlying disease must be treated in order to reduce the chances that the stricture will reform. E.g. underlying reflux disease will need to be treated in order to achieve mucosal healing and maintain the luminal diameter. PPI would be helpful.

Question 10

Mx of complicated reflux disease that is refractory to medications (PPI) or totally dependent on PPIs

Answer 10

Fundoplication

the top of the stomach is wrapped around the lower oesophagus, and any hiatus hernia is reduced, with tightening of the crural diaphragm

Question 11

What are the common types of esophageal cancer & where in the esophagus do they occur?

Answer 11

Squamous carcinoma & adenocarcinoma: 2 most common esophageal cancers

Squamous:

• a/w smoking and alcohol
• middle and UPPER 1/3 of the oesophagus

Adenocarcinoma:

• a/w GORD & Barret’s esophagus (40x greater Ca risk)
• LOWER oesophagus

The rate of oesophageal squamous carcinoma is declining (probably due to a decline in smoking), but the rate of adenocarcinoma of the oesophagus is increasing dramatically, for reasons which are not clear.

Question 12

Mx of Barret’s esophagus

Answer 12

screening programme with regular endoscopy and biopsy of the Barrett’s mucosa to detect the development of dysplasia or carcinoma.

The frequency of endoscopy and biopsy is determined by the level of abnormality found.

• no dysplasia, every 3 years
• low grade dyspalsia: every 6 months
• high grade dysplasia/sarcinomas: Rx with mucosal ablation +/- surgery

Question 13

Discuss Mx of oesophageal cancer

Answer 13

• tumour must be staged to determine whether it is surgically resectable or not (metastatic). E.g. CT chest, endoscopic ultrasound & PET scan. Diagnostic laparoscopy to examine for peritoneal spread.
• consider fitness for surgery & pt’s wishes
• surgery: removal of esophagus & associated LN. GI continuity restored by creating a tube from the remaining stomach & anastomosing with lower end of remaining esophagus. If not possible, a piece of intestine can be brought up (e.g. colon).
• if metastatic, palliative: manage symptoms. Mx dysphagia with self-expanding metal stent acros tumour to hold it open +/- radiotherapy.