Oesophageal Disorders

Question 1

What are the properties of low oesophageal sphincter?

3

Answer 1

High resting pressure in smooth muscle
Striated muscle of right crus of diagram
Mucosal rosette formed by acute angle

Question 2

What are symptoms of oesophageal disease?

Answer 2

Heartburn

Dysphagia

Odynophagia

Question 3

What is heartburn

Answer 3

Retrosternal discomfort/burning
Due to reflux of acid/gastric contents into oesophagus

persistent relfux->GORD

Question 4

What is dysphagia

Location?

What do we need to enquire?

Answer 4

Difficulty swallowing
Enquiries:
-Type of food
-Pattern
-Associated features
Location:
Oropharyngeal/Oesophageal

Odynophagia- pain with swallowing

Question 5

What are the causes of oesophageal dysphagia?

Answer 5

-benign stricture
- malignant stricture (oesophageal cancer)
- motility disorders (eg achalasia, presbyoesophagus)
- eosinophilic oesophagitis
- extrinsic compression (eg in lung cancer)

Question 6

What are investigations for oesophageal disease?

Answer 6

• Oesophago-Gastro-Duodenoscopy (OGD)
• Upper GI Endoscopy (UGIE)

Contrast radiology - barium swallow

Oesophageal pH and manometry

Question 7

When is endoscopy used in oesophageal disease?

Answer 7

In oesophageal disease used in investigation of dysphagia or reflux symptoms with alarm features

Question 8

What is manometry used for?

Answer 8

Used in investigation of dysphagia / suspected motility disorder

Question 9

What does manometry measure?

Answer 9

-assesses sphincter tonicity, relaxation of sphincters and oesophageal motility.
checks if oesophagus contracting and relaxing properly

pH studies – used in investigation of refractory heartburn/reflux

Question 10

What are the motility disorders of the oesophagus?

Answer 10

Hypermotility

Hypomotility

Achalasia

Question 11

What portion of motility is controlled by the vagus nerve?

Answer 11

Contraction in the oesophageal body and relaxation of the LOS is mediated by the vagus nerve

Question 12

What is the appearace of hypermotility on a barium swallow?

Answer 12

Corckscrew appearance

Question 13

What is hypermotility often confused with and why?

Answer 13

Angina/MI becaue of episodic chest pain (with or without dysphagia)

Question 14

What is hypomotility associated with?

Answer 14

Associated with connective tissue disease,

diabetes, neuropathy

Causes failure of the LOS and therefore causes reflux symptoms

Question 15

What causes achalasia?

Answer 15

Functional loss of myenteric plexus ganglion cells in distal oesophagus and LOS

Question 16

What is teh cardinal feature of achalasia?

Answer 16

failure of LOS to relax and therefore distal obstruction of the oesophagus

Question 17

What are symptoms of achalasia?

Answer 17

• progressive dysphagia for solids and liquids
• weight loss
• Chest pain (30%)
• Regurgitation and chest infection

Question 18

What is the treatment for achalasia?

Answer 18

Pharmacological - Nitrates,

Calcium Channel blockers

Endoscopic - Botulinum Toxin

Pneumatic balloon dilation

Radiological - Pneumatic balloon

dilation

Surgical - Myotomy

Question 19

What are the complications of achalasia?

Answer 19

Aspiration pneumonia and lung disease

nIncreased risk of squamous cell oesophageal carcinoma

Question 20

What causes GORD?

Answer 20

Presence of acid and bile exposure in the lower oesophagus

Question 21

What are the symptoms of GORD?

Answer 21

Many may not experience any symptoms at all

Symptoms include: heartburn, cough, water brash, sleep disturbance

Waterbrash: a sudden flow of saliva associated with indigestion.

Question 22

What are the risk factors for GORD?

Answer 22

Pregnancy, obesity, drugs lowering LOS pressure (alcohol, nicotine, dietary xanthines), smoking, alcoholism, hypomotility

Question 23

Why is endoscopy a poor test for GORD?

Answer 23

Most patients (>50%) with reflux symptoms have no visible evidence of oesophageal abnormality when endoscopy is performed

Question 24

When must endoscopy be performed for GORD?

Answer 24

In the presence of alarm features eg dysphagia, weight loss, vomiting

Question 25

What are the aetiologies of GORD with normal anatomy?

Answer 25

–­ Increasing Transient relaxations of the LOS –Hypotensive LOS –Delayed gastric emptying –Delayed oesophageal emptying – Decreased Oesophageal acid clearance – Decreased Tissue resistance to acid/bile

Question 26

What are the 2 main types of hiatus hernia?

Answer 26

Sliding and para-oesophageal

Question 27

What part of the stomach moves proximally through the diaphtragmatic hiatus?

Answer 27

Fundus

Question 28

What are two risk factors for hiatus hernia?

Answer 28

Age and obesity

Question 29

What is the mucosa exposed to in GORD?

Answer 29

Acid-pepsin and bile

Question 30

What are the complications associated with GORD?

Answer 30

Ulceration (5%) Stricture (8-15%) Glandular metaplasia (Barrett’s oesophagus) Carcinoma

Question 31

What is the change in epithelium in barrett's oesophagus?

Answer 31

Change from squamous to mucin-secreting columnar (ie gastric type) epithelial cells in lower oesophagus

Question 32

What is barretts oesophagus the precursor for?

Answer 32

Precursor to dysplasia/ adenocarcinoma Dysplasia: Abnormal cells in a tissue which may signify a stage preceding the development of cancer.

Question 33

What is treatment for Barretts oesphagus?

Answer 33

–Endoscopic Mucosal Resection (EMR) –Radio-Frequency Ablation (RFA) –Oesophagectomy rarely (mortality ~10%)

Question 34

Without alarm features what is the treatment of GORD?

Answer 34

1. Lifestyle measures 2. Pharmacological Alginates (Gaviscon) H2RA (Ranitidine) Proton Pump Inhibitor (e.g. Omeprazole, Lansoprazole) For refractory disease following investigation Anti-reflux surgery (fundoplication)

Question 35

What is the incidence of benign tumours?

Answer 35

They are rare

Question 36

What are the two common types of oesphageal cancer?

Answer 36

Squamous Cell Carcinoma Adenocarcinoma

Question 37

What is the prevalence of adenocarcinoma and squamous cell carcinoma in Western europe / USA?

Answer 37

Western Europe/USA Adenocarcinoma \> Squamous Rest of World Squamous \>\> Adenocarcinoma

Question 38

What is the presentation of oesophageal cancer?

Answer 38

Progressive dysphagia (90%) Anorexia and Weight loss (75%) Odynophagia Chest pain Cough Pneumonia (tracheo-oesophageal fistula) Vocal cord paralysis Haematemesis

Question 39

Where does squamous normally occur in the oespohagus?

Answer 39

In the proximal and middle third of the oesophagus

Question 40

What are the risk factors for squamous cell carcinoma?

Answer 40

High incidence in Southern Africa, China, Iran Tobacco and alcohol significant risk factors Diet related (vitamin deficiency) Associated with Achalasia, Caustic strictures, Plummer-Vinson Syndrome

Question 41

Where does adenocarcinoma often occur in the oesophagus?

Answer 41

Occurs in distal oesophagus

Question 42

What are risk factors for adenocarcinoma?

Answer 42

Associated with Barrett’s oesophagus (progresses through dysplasia to cancer) Predisposing factors: obesity, male sex, middle age, caucasian

Question 44

Where do oesophageal cancers often spread?

Answer 44

To regional lymph nodes and or liver at No peritoneal (serosal) lining in mediastinum – local invasion (heart, trachea, aorta) often limits surgery Metastases - Hepatic, brain, pulmonary, bone

Question 45

Why does tumour invasion into adjacent structures occur more easily in the oesophagus?

Answer 45

Oesophagus lacks a serous layer

Question 46

Why does lymph node involvement occur early in oesophageal tumours?

Answer 46

Oespohagus lymphatic vessels are mucosal (lamina propria) Vs Rest of the GIT lymphatic vessels are mainly submucosal

Question 47

How do we diagnose oesphageal cancer?

Question 48

How do we stage oesphageal cancer?

Answer 48

–CT Scan –Endoscopic ultrasound –PET Scan –Bone Scan Disease stagin by TNM classification

Question 49

TNM classification

Answer 49

TNM staging T1- Tumor invades lamina propria or submucosa (a-lamina propria, b-submucosa) T2- Tumor invades muscularis propria T3- Tumor invades adventitia T4- Tumor invades adjacent structures N1- Regional lymph node metastasis M1- Distant metastasis Stage I- T1N0M0 Stage IIa- T2T3/N0M0 Stage IIb- T1T2/N1M0 Stage III- T3N1M0, T4, any N, M0 Stage IV- M1

Question 50

What is treatment for oesophageal cancer?

Answer 50

Only potential cure is surgical oesophagectomy +/- adjuvant (after) or neoadjuvant (before) chemotherapy Limited to patients with localised disease, without co-morbid disease, usually \<70 years of age Significant morbidity and mortality assoc with oesophagectomy (mortality ~ 10%) Long post operative recovery Require nutritional support Combined chemo and radiotherapy now offer some prospect of improved long-term survival (ie \> 1year) in patients with locally advanced inoperable disease - ? may ultimately offer non-surgical “cure”

Question 51

What is treatment for incurable disease? (most have incurable disease at presentation)

Answer 51

Symptom pallation (dysphagia) is often overriding priority OPTIONS: Endoscopic (stent, laser/APC, PEG) Chemotherapy Radiotherapy Brachytherapy