Oesophageal disease

Question 1

Where does the oseophagus begin? and end?

Answer 1

The end of the Cricoid cartilage (C6), ends T11-12

Question 2

What nerve mediates peristalsis?

Answer 2

vagus

Question 3

What is the most common symptom of oesophageal disease?

Answer 3

Heart burn

Question 4

What is heartburn caused by?

Answer 4

Acid/alkaline environments in the bottom of the oesophagus, can be due to:
-slower emptying of the stomach/into the stomach
- issues with teh Lower Oesophageal; sphincter

Does occur commonly on swallowing

Question 5

What is GORD?

Answer 5

Gastro-Oesophageal Reflux disease
(long term heart burn)

Question 6

Whiuch foods etc can affect gord?

Answer 6

Anything that might affect the abikity of th eoesophageal sphincter to stay shut:
- alcohol, nicotine, dietary xanthines

Question 7

Corncernng symptom of oesophagus?

Answer 7

Dysphagia - difficulty swallowing

Question 8

What is Odynopohaia?

Answer 8

Pain with swallowing

Question 9

Presentation of dysphagia, quesions to ask:

Answer 9

Food types
Pattern (regular/irregular]
Other esp alarming symptoms: weight loss, regurgitation, cough

Could do with finding out where the difficulty is; oropharyngeal or oesophageal?

Question 10

What can be the common causes of dysphagia?

Answer 10

Strictures (benign/malig)
Motility disorders (eg achalasia)
Eosinophillic Oesophagitis
Extrinsic compression

Question 11

Oesophageal investigations

Answer 11

Primary:
Endoscopy (upper GI (UGIE) or Oesophago-Gastro-Duodenoscopy (OGD)

Barium swallow was an investigation but isn’t used nearly as much now

Question 12

Is there a small role for contrast radiology? What is it superseeded by?

Answer 12

Yes, mainly for dysphagia. Has been superseeded by endoscopy

Question 13

What is a pH metry?

Answer 13

Prope down oesophagus, measures pH.

Nowadays can do with clips wirelessly and patients press when they have symptoms

Question 14

What doies a manometry measure?

Answer 14

Pressure down the oesophagus (contractions) - useful if dysphagia/suspected motility diorder (after endoscopy)

Question 15

What are he 2 catergories of motility diseases?

Answer 15

Hyper and hypo motile

hyper eg spasms - severe chest pain, potentially dysphasia, confused with MI. Treatment smooth muscle relaxants

Hypo - connective tissue disease/neurpothy - heartburn and reflux symptoms

Question 16

Symptoms of diffuse oesophageal spasm?

Answer 16

Severe chest pain +/- dysphagia

Question 17

Treatment of hypermotility?

Answer 17

Smooth muscle relaxants - questionable - apparently they don’t work.

SO: Botox, surgery (cuts), balloon stenting

Question 18

Most important hypermotality disorder? Causes? Symptoms? Age rang? Gender?

Answer 18

Achalasia

Degenaration of inhibitory neurons in myenteric plexus in oesophagus

-progressive dysphagia
-chest pain
-weight loss (rare)
-regurgitation/Chest infection

Late 20s - 50 yo

Male:Female 1:1

Question 19

Characteristic appearance on barium swallow for Achalasia? Treatment options?

Answer 19

Rats tail

Balloon stenting, botox, surgery (myotomy - opens up contracted area)

Pharmacological: Nitrates/CCB (relax smooth muscle

Question 20

Best long term surgery / other tratment options achalisa? Long term complications ?

Answer 20

Surgery best long term

Complications: Aspiration pneumonia and increased risk of squamous cell oesophageal carcinoma

Question 21

Most common oesophageal disease?

Answer 21

GORD (Gastro - Oesophageal Reflux Disease

Question 22

GORD Causes? SYmptoms? Risk factors: Men or women more common? Ethnic disparity? Does it require a diagnostic test? WHen would you perform an edoscopy?

Answer 22

Causes:
Anything thats pathologically going to cause acid and bile exposurein the lower oesophagus… so anything that causes the lower oesophageal sphincter to not work as well.
- Hypotensive LOS, transient relaxations of LOS
-Delayed gastric emptying
-Delayed oesophageal empytying
-hiatus hernia

More common in men

More common in caucasians > black > asian

Does NOT require a diagnostic test unless alarming symptoms (dysphagia, weight loss, vomit etc), in which case you would perform one.

Question 23

What are the 2 types of hiatus hernias?

Answer 23

Sliding (stomach slides up through the oesophageal opening)

Para-oesophageal (new hole)

Question 24

What can make you more likely to get a hiatus herna?

Answer 24

Obesity and aging

Question 25

What is the most dangerous and least common hiatus hernai?

Answer 25

Para-oesophageal

Question 26

GORD complications?

Answer 26

Ulceration, stricture, glandular metaplasia (Barrett's oesophagus), carcinoma

Question 27

What is Barretts oesophagus?

Answer 27

Metaplasia of the cells where the damage is occuring (iturn from startified squamous cells into columar cells with mucus glands (more like stomach).

Question 28

What is barrets a precursor for?

Answer 28

Dysplasia and cancer

Question 29

What is risk of progression of baretts oesophagus?

Answer 29

6%

Question 30

High grade dysplasia treatment

Answer 30

Chop out dysplasia nodules (Endoscopic Mucosal Resection (EMR) and burn (radio-frequency ablation (RFA) other parts to stop dysplasia. Don't really want ot do an oesophagectomy as there is a high mortality rate (10%)

Question 31

Why is an oesophagectomy rare for high displasia?

Answer 31

High mortality

Question 32

If no alarm features what is GORD tratment?

Answer 32

1. Lifestyle measures 2. meds: Antacids (gaviscon) Proton pump inhibitor eg Omeprazole Stubborn disease might do surgery (fundoplication - full/partial wrap)

Question 33

Oesophageal cacers - benign tumours common or rare?

Answer 33

rare

Question 34

Men or women more common oesophageal cancer?

Answer 34

Men

Question 35

median age?

Answer 35

65 but decreasing

Question 36

geopgraphic distribution of adenocarcinoma or squamous cell carcinos?

Answer 36

Europe/USA = adenocarcinoma Rest of world = squamous more common

Question 37

presentation of Oesophageal cancer?

Answer 37

dysphasia (progressive) Anorexia/weight loss Odynophagia cough pheumonia (tracheo-oesophageal fistula) Vocal chord paralysis HAematemesis (blood vomit)

Question 38

Where is the squamous cell cancinoma? What does it lead from ?

Answer 38

Mid/Upper oesophagus dysplasia and carcinoma in situ

Question 39

Squamous cell carcinoma risk factors/ diet?

Answer 39

ALCOHOL AND TOBACCO!! Maybe related to diet

Question 40

Where is Adenocarcinoma? Associated with what disease? Risk factors adenocarcinomas?

Answer 40

Distal Oesophagus, associated with Barrett's oesophagus Risk factors: Obesity, male, middle age, Caucasian

Question 41

Osophageal cancer progonsis, why? Where are metastases

Answer 41

Very poor due to late presentation and because it is easy for cancer to spread to the local big organs such as the heart (no peritoneum and close proximity). Metastases commonly hepatic, brain, pulmonary and bone

Question 42

Oesophageal Cancer investigation and staging by what?

Answer 42

Diagnosis by Endoscopy. Investigation and staging though TNM: CT Endoscopic ultrasound PET scan/Bone scan

Question 43

Oesophageal Cancer treatment

Answer 43

If fit and non metastatic (localised) cancer then surgery! (Oesophagectomy) +/- neoadjuvant/adjuvant chemotherapy. High mortality rate. Long recovery. Can do radical treatment but still progressing.

Question 44

Incurable - palliative measures

Answer 44

Stenting, palliative choemo/radio/brachy therapy. Symptom control

Question 45

What is eosinophilic oesophagitis?

Answer 45

Inflammation of the oesophagus due to some sort of allergic reaction - loadsa eosinophils.

Question 46

Eoinophillic osphagitis presentation anc characteristic endoscopic findiungs. What is the treatment?

Answer 46

Presentation: Dysphagia and food bolus obstruction. looks like thin stripy strictures down the oesophagus. Treatment is topical/swallowed corticosteroids, dietry elimination and potentially endoscopic dilatation