Oesophageal Disorders

Question 1

What is heartburn a consequence of?

Answer 1

Acid and/or bilous gastric content reflux into the oesophagus

Question 2

What causes gastro-oesophageal reflux disease?

Answer 2

Reduction in lower oesophageal sphincter pressure resulting in persistent reflux and heartburn

Question 3

What percentage of adults experience daily GORD symptoms?

Answer 3

7%

Question 4

What is the typical presentation of GORD?

Answer 4

Heartburn
Cough
Water brash
Sleep disturbance

Question 5

What are the risk factors for GORD?

Answer 5

Pregnancy 
Smoking 
Obesity 
Drugs lowering LOS pressure 
Alcoholism 
Hypomotility

Question 6

Typical reflux syndrome can be diagnosed on the basis of

Answer 6

characteristic symptoms, without diagnostic testing

Question 7

Why is endoscopy a poor diagnostic test for GORD?

Answer 7

Most patients with reflux (>50%) will have no visible evidence of oesophageal abnormality on endoscopy

Question 8

Under what circumstances should an endoscopy be performed in reflux disease?

Answer 8

In the presence of alarm features suggestive of malignancy

Question 9

What is the aetiology of GORD?

Answer 9

Increased transient relaxations of LOS, LOS hypotension, delayed gastric and oesophageal emptying, decreased oesophageal acid clearance and tissue resistance to acid/bile

Question 10

What is the aetiology of GORD due to hiatus hernia?

Answer 10

Anatomical distortion of the OG junction

Question 11

What is the pathophysiology of GORD?

Answer 11

Mucosa exposed to acid, pepsin and bile, increased cell loss and inflammation, erosive oesophagitis

Question 12

What are the possible complications of GORD?

Answer 12

Ulceration
Stricture
Glandular metaplasia
Carcinoma

Question 13

What are the treatment options for GORD?

Answer 13

Lifestyle changes
Pharmacological - alginates and proton pump inhibitors
Anti-reflux surgery for refractory disease

Question 14

What are the two types of hiatus hernia?

Answer 14

Sliding

Para-oesophageal

Question 15

What are the risk factors for a hiatus hernia?

Answer 15

Obesity

Increasing age

Question 16

What happens in Barrett’s Oesophagus?

Answer 16

Intestinal metaplasia due to prolonged acid exposure in the distal oesophagus - change from squamous to mucin-secreting columnar epithelial cells

Question 17

What two conditions can develop from Barrett’s oesophagus?

Answer 17

Dysplasia

Adenocarcinoma

Question 18

What are the treatment options for Barrett’s oesophagus?

Answer 18

Endoscopic mucosal resection
Radio-frequency ablation
Oesophagectomy (rarely)

Question 19

What is dysphagia?

Answer 19

Difficulty swallowing foods and/or liquids

Question 20

What is odynophagia?

Answer 20

Pain when swallowing

Question 21

What are the two types of dysphagia?

Answer 21

Oropharyngeal

Oesophageal

Question 22

What are the symptoms associated with dysphagia?

Answer 22

Weight loss
Regurgitation
Cough

Question 23

What are the causes of oesophageal dysphagia?

Answer 23

Benign stricture 
Malignant stricture 
Motility disorders 
Eosinophilic oesophagus 
Extrinsic compression

Question 24

Give an example of a motility disorder which might cause oesophageal dysphagia

Answer 24

Achalasia

Presbyoesophagus

Question 25

What investigations would you do in oesophageal disease?

Answer 25

Oesophago-gastro-duodenoscopy Upper GI endoscopy Contrast radiology Oesophageal pH and manometry

Question 26

What are the symptoms of hypermotility?

Answer 26

Severe episodic chest pain | Dysphagia

Question 27

What would be seen in manometry of hypermotility?

Answer 27

Uncoordinated, exaggerated hypertonic contractions

Question 28

What is hypermotility?

Answer 28

Diffuse oesophageal spasm

Question 29

What conditions is hypomotility associated with?

Answer 29

Connective tissue disease Diabetes Neuropathy

Question 30

What is caused by hypomotility?

Answer 30

Failure of the lower oesophageal sphincter mechanism leading to heartburn and reflux

Question 31

What is achalasia?

Answer 31

Functional loss of the inhibitory neutrons in the myenteric plexus ganglion cells in the distal oesophagus and lower oesophageal sphincter

Question 32

At what age is the usual onset of achalasia?

Answer 32

30-50 years

Question 33

What is the cardinal feature of achalasia?

Answer 33

Failure of the lower oesophageal sphincter to relax

Question 34

What does achalasia result in?

Answer 34

Functional distal obstruction of the oesophagus

Question 35

What are the symptoms of achalasia?

Answer 35

``` Progressive dysphagia Weight loss Chest pain Regurgitation Chest infection ```

Question 36

What are the possible treatments for achalasia?

Answer 36

Pharmacological - nitrates and CCBs Endoscopic - Botulinum Toxin Radiological - pneumatic balloon dilation Surgical - myotomy

Question 37

What are the possible complications of achalasia?

Answer 37

Aspiration pneumonia and lung disease | Squamous cell oesophageal carcinoma

Question 38

What are the most common histological types of oesophageal carcinoma?

Answer 38

Squamous cell carcinoma | Adenocarcinoma

Question 39

What is the 5 year survival of oesophageal carcinoma?

Answer 39

< 10%

Question 40

What are the possible presentations of oesophageal cancer?

Answer 40

``` Progressive dysphagia Anorexia and weight loss Odynophagia Chest pain Cough Pneumonia Vocal cord paralysis Haematemesis ```

Question 41

What are the typical characteristics and location of squamous cell oesophageal cancer?

Answer 41

Usually large, exophytic, occluding tumours | Occur in proximal and middle thirds of oesophagus

Question 42

What are the major risk factors for squamous cell oesophageal carcinoma?

Answer 42

Smoking | Alcohol abuse

Question 43

What is squamous cell oesophageal cancer associated with?

Answer 43

Achalasia Caustic strictures Plummer-Vinson syndrome

Question 44

In what part of the oesophagus does adenocarcinoma typically occur?

Answer 44

Distal third

Question 45

What is oesophageal adenocarcinoma associated with?

Answer 45

Barrett's oesophagus

Question 46

What are the risk factors for oesophageal adenocarcinoma?

Answer 46

Obesity Male sex Middle age Caucasian

Question 47

What investigations would be done for oesophageal carcinoma?

Answer 47

Endoscopy and biopsy | Staging: CT, EUS, PET scan, bone scan

Question 48

What are the treatment options for oesophageal carcinoma?

Answer 48

Oesophagectomy +/- adjuvant/neoadjuvant chemotherapy - only potentially curative option Combined chemo and radiotherapy Palliative care

Question 49

What options are there for palliative care of oesophageal carcinoma?

Answer 49

``` Endoscopic stent APC PEG chemo/radiotherapy brachytherapy ```