Oesophageal Disorders Flashcards

Question

What are the symptoms and signs of progression of sphincter dysfunction?

Answer 1

1. Progressive Dysphagia – Initially no frank dysphagia, but slowed eating ( left behind at meals). Difficulty swallowing both solids and liquids. Progresses to obvious dysphagia, retrosternal discomfort, regurgitation and weight loss 2. Regurgitation – Food and liquid may come back up, increasing aspiration risk. 3. Chest Pain & Discomfort – Due to food retention and spasms. 4. Weight Loss & Malnutrition – Caused by difficulty eating. Nocturnal Coughing & 5.Aspiration – Can lead to pneumonia if food enters the airways. When these symptoms are reported later in life they must be distinguished from oesophageal cancer.

Answer 2

- presence of symptom when not swallowing - Is the difficulty with solids/liquids or both? - Exact location of symptom - duration and progression of symptom - presence of regurgitation between meals -presence of reflux symptoms - PMH - Drug history - social history

Answer 3

1. Endoscopy is essential, in older patients, show a secondary cause such as infiltration of the distal oesophagus by malignant disease 2. Contrast study confirms delay at the lower spinchter and give a characteristic 'rats tail' appearance 3. Manometry shows incomplete relaxation of the lower sphincter in response to a swallow.

Answer 4

Medical treatment with muscle relaxants is usually unrewarding. The three effective methods for achalasia are: Balloon/ pneumatic dilatation - Leads to resolution of symptoms in 80% - May have to be repeated - carries a small risk of oesophageal perforation. Longitudinal myotomy of the gastro-oesophageal junction (known to surgeons as the Heller's cardiomyotomy) -involves making a lengthwise incision through the muscle layers of the lower esophagus and upper stomach - open surgery or laparoscope or thoracoscope -surgeons generally combine myotomy with an anti-reflux procedure because of the increased risk of GORD after the myotomy. -surgical intervention leads to symptoms relief in 85% of patients. Endoscopic injection of Botulinum toxin into the oesophageal wall: - Paralyse the LES - effective but lasts only for a few months - repeated injections are possible and this strategy is and effective management plan for those unsuitable for surgery.

Answer 5

Barrett’s esophagus is a condition where the normal squamous lining of the esophagus is replaced by intestinal-type columnar cells

Answer 6

Gastro-Oesophageal Reflux Disease (GORD) is a chronic condition where stomach acid and digestive enzymes flow back into the oesophagus, causing irritation and inflammation. This occurs due to weakness or dysfunction of the lower oesophageal sphincter (LES), which normally prevents acid reflux. However, reflux is particularly a symptom of abnormalities at the diaphragmatic hiatus even though GORD occurs in association with many oesophageal conditions.

Answer 7

Heartburn – Burning sensation in the chest, worse after eating or lying down. Regurgitation – Sour or bitter taste due to acid rising into the throat or mouth. Dysphagia (Difficulty Swallowing) – Due to oesophageal irritation or narrowing.

Answer 8

If either acid or strongly alkaline secretions reach the lower oesophagus, the lower oesophageal mucosa becomes inflamed. Although in most patients this is seen at oesophagoscopy as superficial oesophagitis, two complications may result from long-term inflammation: 1. Stricture – an inflammatory reaction in the mucosa and submucosa and can develop into a fibrous narrowing. 2. Metaplastic change – this leads to the development of gastric-type columnar epithelium in the lower oesophagus known as Barrett’s oesophagus , which is a premalignant lesion. - patients with Barrett’s oesophagus must have regular surveillance of the lower oesophagus to assess for malignant transformation.

Answer 9

1. GORD with concomitant hiatus hernia 2. GORD with normal anatomy

Answer 10

Hiatal Hernia – The stomach moves up into the chest, weakening the LES. 1. Type I (Sliding Hiatus Hernia): GOJ moves above the diaphragm into the chest. 2. Type II (Paraoesophageal Hiatus Hernia): GOJ remains in the abdomen, but part of the stomach herniates into the chest. 3. Type III (Mixed Hiatus Hernia): Combination of Type I and II, where both the GOJ and part of the stomach move into the chest.

Answer 11

The proximal stomach ascends into the chest through an enlarged diaphragmatic opening, carrying a cuff of peritoneum. The acute gastro-oesophageal angle is reduced, leading to increased risk of reflux. Reflux occurs even if the intrinsic lower oesophageal sphincter remains normal

Answer 12

obesity increase in abdominal contents (pregnancy) ageing male gender

Answer 13

Reflux, heartburn, and occasional lower-left chest pain, often occurring shortly after eating. Rule out cardiac origin of the pain. Vague indigestion: Rarely caused by sliding hernia and requires further clinical evaluation and investigation for other potential causes.

Answer 14

1. Patients with the recent onset of symptoms, particularly if they are elderly : investigate for possible oesophagogastric cancer. 2. Barium contrast studies: Historically used to diagnose hiatus hernia. 3. Endoscopy: - Now the preferred investigation method. Allows visualisation of the oesophagogastric junction (though identification may be challenging). - Assesses the severity of oesophagitis. - Enables biopsy for tissue diagnosis if needed.

Answer 15

Lifestyle: Weight loss: Especially for obese patients. Elevate head of the bed: Reduces nocturnal reflux. Medications: Alginate-containing antacids: Reduce stomach liquid volume, decreasing reflux. H2-receptor antagonists: Examples include cimetidine and ranitidine. Proton pump inhibitors (PPIs): Examples include omeprazole and lansoprazole. Next steps if medical management fails: Consider operative intervention for symptom control or if the patient prefers to avoid long-term medication.

Answer 16

Oesophagitis – Chronic inflammation of the oesophagus. Barrett’s Oesophagus – Precancerous changes in the oesophageal lining due to long-term acid exposure. Oesophageal Strictures – Narrowing of the oesophagus due to scarring, leading to difficulty swallowing. Aspiration Pneumonia – Acid reflux can enter the lungs, causing respiratory issues.

Answer 17

Usually performed laparoscopically known as Nissen's fundoplication. Surgical steps: 1. Reduction of herniated stomach: Pull stomach back below the diaphragm. 2. Removal of peritoneal Sac: Remove circumferential sac around the hernia. 3. Re-establish Gastro-oesophageal angle: Restore normal angle to prevent reflux. 4. Suturing Crura: Close intercrural space by suturing the crura behind the oesophagus. Fundolipication: Wrap Stomach's fundus around terminal oesophagus Increases intra abdominal pressure to compress the oesophagus, preventing reflux

Answer 18

One complication of such a procedure may occasionally be the inability to belch and, in consequence, bloating – a sensation of unrelieved fullness of the stomach. Some patients experience postoperative dysphagia, which is usually transient. However, the outcome is usually good The reported success rate with Nissen’s fundoplication is 80–90% in patients with GORD.

Answer 19

Many patients have symptoms of GORD without any demonstrable anatomical abnormality at endoscopy or manometry. In some obesity is a factor Others may have hyperchlorhydria with or without a demonstrable peptic ulcer. In the majority, a definite cause is not identified. Features of heartburn and dyspepsia are universal, with regurgitation of gastric contents in some.

Answer 20

Many patients are probably treated symptomatically in general practice without investigation. However, those with troublesome features should have a barium swallow and/or endoscopy.

Answer 21

Medical management is often sufficient. For those with oesophagitis, which is unresponsive to treatment (rare) and for patients who are not keen on long-term acid suppression therapy, an anti-reflux operation, such as Nissen’s fundoplication should be considered.

Answer 22

Oesophageal rupture (also known as Boerhaave syndrome) is a life-threatening condition where there is a full-thickness tear or perforation in the wall of the oesophagus. This tear allows the contents of the oesophagus, including food, stomach acid, and digestive enzymes, to spill into the chest cavity, potentially causing severe infections (like mediastinitis) and shock. Mallory-Weiss syndrome refers to a tear in the mucosal lining of the oesophagus near the gastro-oesophageal junction (GOJ), often caused by forceful vomiting or retching. Unlike oesophageal rupture, the tear is typically superficial and does not involve the full thickness of the oesophageal wall.

Answer 23

1. may not take place if vomiting is artificially induced, or the individual is confused – usually from excessive consumption of alcohol. 2. In such circumstances, intragastric pressure forces stomach contents into the distal oesophagus, dilating it. 3. The oesophagus may rupture with emptying of stomach contents into the left pleural cavity. 4. Because the relatively elastic muscle in the oesophageal wall has a greater capacity for stretch than does the folded mucosa and submucosa, quite often only these are split to produce a longitudinal mucosal tear at the oesophagogastric junction (Mallory–Weiss syndrome). 5. These tears are usually managed conservatively once identified.

Answer 24

Traumatic injury to the oesophagus, in response to a variety of insults is a serious event with potentially devastating consequences. After Perforation: Negative intrathoracic pressure causes air, food, and fluids (if stomach is full) to be drawn into the mediastinum and pleural cavity. Consequences: 1. Chemical pleuromediastinitis develops initially. 2. Progresses to bacterial mediastinitis. 3. Can lead to septic shock and multiorgan failure if untreated. Immediate and appropriate treatment is crucial to prevent severe complications.

Answer 25

1. Iatrogenic 2. Traumatic 3. Spontaneous (Boerhaave’s syndrome) 4. Tumour

Answer 26

1. The patient will have had an episode of forceful vomiting, which may be recalled 2. Vomiting may also have been induced either in a glutton or in someone who is mentally disturbed with a history of excessive eating but with the paradoxical desire not to gain weight (bulimia). 3. There will be sharp left-sided pleuritic pain. This is known as Boerhaave’s syndrome and named after Herman Boerhaave, the 18th century physician who first described spontaneous oesophageal rupture. 4. Machler’s triad: vomiting or retching (90–100%), chest pain (90%) and subcutaneous emphysema (38%) on examination. Classic triad is unusual as patients may also present with other respiratory or epigastric symptoms.

Answer 27

1. The effect of gastric content within the chest is to rapidly produce signs of severe sepsis with fever and circulatory disturbance. 2. A left pleural effusion is present as usually the left posterolateral wall of the lower third of the oesophagus is perforated. 3. The course is downhill with all the features of systemic inflammatory response syndrome. 4. Occasionally, however, the rupture is localized and the patient is less ill with localized pleural signs and features of sepsis, which are less severe.

Answer 28

Vomiting blood (hematemesis) – This is often the most prominent symptom. Chest pain – A dull or burning sensation, sometimes mimicking a heart attack. Abdominal pain – Often from the intense vomiting or straining that caused the tear. Lightheadedness or dizziness – Due to blood loss.

Answer 29

-Detailed history of the presenting episode and past medical history to ascertain fitness for a major surgery should be taken. -The key aspects of management are early resuscitation, early drainage, antibiotics, aggressive organ support and response to secondary sepsis. -Parenteral or enteral (jejunostomy) nutrition is used until healing is assured, although patient mortality from oesophageal rupture remains high. -Non-operative management is feasible in patients with small leaks when the mediastinal and pleural contamination is at a minimum. These patients need careful monitoring with nutritional support in a high-dependency setting. - surgical management

Answer 30

Key Factors: Time since presentation, mediastinal/pleural contamination, patient condition. Primary Repair: Simple closure + drainage; best within 24 hours; high leak risk. Repair & Reinforcement: Uses intercostal muscle, pleura, omentum; still high leak risk. T-Tube Repair: Large bore T-tube placed in esophageal tear for controlled fistula; useful in late/early presentation; wide bore drains in mediastinum, pleural cavities, abdomen. Resection: Used for strictures; high morbidity in delayed reconstruction.

Answer 31

Squamous Cell Carcinoma (SCC) and Adenocarcinoma (AC). SCC: More common in the Far East (Japan, China, South Africa). AC: More common in the West, rising incidence, especially in the UK.

Answer 32

High correlation with cigarette and alcohol consumption. Diet: High nitrosamines (from food preservatives), low vitamins A & B3, iron deficiency. Achalasia (poor oesophageal clearance) may increase cancer risk. Geographical variation linked to environmental and social factors

Answer 33

Barrett’s oesophagus: Columnar metaplasia from long-standing GORD is a key risk factor. Incidence of AC has overtaken SCC in the UK (2:1 ratio). Risk factors: Dysplastic changes, length of Barrett’s mucosa, and history of reflux.

Answer 34

Combination of narrowing and ulceration. Spread through direct invasion into nearby structures (trachea, pericardium, chest wall). Lymph node involvement (mediastinal, stomach area). Distant metastases in the liver, lung, and brain.

Answer 35

Early disease: No symptoms or mild feeling of something stuck. Later stages: Progressive dysphagia, weight loss (10-15% in 4–6 weeks). Pain from tumour penetration, productive cough, and hoarseness (recurrent laryngeal nerve involvement).

Answer 36

Weight loss in clinical exam Palpable lymphadenopathy ( especially in supraclavicular region). Signs of liver metastasis: hepatomegaly, jaundice, ascites.

Answer 37

Endoscopy: Gold standard for diagnosis, allows biopsy and cytology. Endoscopic Ultrasound (EUS): Staging and lymph node involvement. CT scan: Detects distant metastases and assesses tumor size. PET-CT: Identifies metastases not seen on CT, crucial for treatment decisions. Staging laparoscopy: In some cases, for advanced tumors.

Answer 38

Screening programs for oesophageal cancer in the UK are a topic of ongoing research and development, particularly as the incidence of adenocarcinoma (AC) has risen in recent years, largely due to Barrett’s oesophagus (BO) as a result of chronic gastro-oesophageal reflux disease (GORD).

Answer 39

The main focus of oesophageal cancer screening in the UK is on Barrett’s oesophagus (BO), a condition where the normal squamous epithelium of the oesophagus is replaced by columnar epithelium, which predisposes patients to adenocarcinoma. The key population targeted for surveillance are those with long-standing GORD and other risk factors for Barrett’s. Endoscopic surveillance is performed to detect early malignant changes. This includes upper GI endoscopy to assess for signs of dysplasia (abnormal cell growth). If dysplasia is found, biopsy and further follow-up are recommended. For those with confirmed Barrett’s oesophagus, the surveillance may be done every 2-3 years, depending on the severity of the dysplasia.

Answer 40

NHS guidelines suggest endoscopic surveillance for patients with GORD who also have additional risk factors, such as male gender, age over 50, and longer duration of reflux.

Answer 41

Oesophageal motor disorders are a group of conditions characterised by abnormal motility of the oesophagus. This can lead to dysphagia, chest pain, regurgitation. The disorders range from failure of relaxation (achalasia) to excessive contractions (hypertensive peristalsis).

Answer 42

Diffuse oesophageal spasm Ineffective oesophageal Motility Achalasia

Answer 43

Loss of inhibitory neurons in the myenteric plexus → failure of LOS relaxation and absent peristalsis Clinical features are dysphagia, regurgitation and chest pain and weight loss Diagnosed with Barium swallow "bird beak appearance". Manometry (absent peristalsis, high LOS pressure), Endoscopy (to exclude malignancy) Managed with pneumatic dilation and botox

Answer 44

Pathophysiology: Motility disorder characterised by uncoordinated, non-peristaltic contractions of the oesophagus, leading to intermittent dysphagia and retrosternal chest pain due to abnormal neural control of 0esophageal smooth muscle. Clinical features: Intermittent dysphagia to solids and liquids, retrosternal chest pain that mimics angina, and occasional regurgitation, often triggered by hot or cold foods. Diagnosed using oesophageal manometry, which shows simultaneous, uncoordinated contractions with normal lower oesophageal sphincter (LOS) relaxation, and can be supported by barium swallow ("corkscrew oesophagus") or oesophagogastroduodenoscopy (OGD) to rule out structural causes. Managed by Calcium channel blockers (e.g., diltiazem) or nitrates to relax smooth muscle, proton pump inhibitors (if reflux is present), botulinum toxin injections, and in refractory cases, surgical myotomy or peroral endoscopic myotomy (POEM).

Answer 45

Characterized by weak or absent peristaltic contractions in the distal oesophagus, leading to impaired bolus transit due to dysfunction of oesophageal smooth muscle and abnormal vagal or enteric nervous system control. Mild, intermittent dysphagia to solids and liquids, sensation of food sticking in the chest, and sometimes regurgitation or heartburn, often associated with gastroesophageal reflux disease (GORD). Diagnosed by Oesophageal manometry, which shows low-amplitude or failed peristaltic contractions in ≥50% of swallows and may be supported by barium swallow (showing delayed bolus transit) or (OGD) to rule out structural causes. Managed by focusing on treating underlying causes such as GERD with proton pump inhibitors (PPIs), dietary modifications (small, frequent meals, avoiding triggers), prokinetic agents in select cases, and supportive measures like swallowing therapy if symptoms persist.

Oesophageal Disorders Flashcards

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