What is heartburn?
Retrosternal discomfort or burning sensation
What other symptoms are often associated with heartbun?
Waterbrash (a sudden flow of saliva)
What causes heartburn?
USually a consequence of reflux of gastric contents into oesophagus.
Can be induced by certain drugs and foods which reduce pressure in the LOS such as alcohol, nicotine and dietary xanthines.
Define dysphagia and odynophagia?
Dys - Diffculty swallowing
Odyno - Pain on swallowing
What questions should be asked about dysphagia?
- Solids or liquids
- Progressive or intermittent
- Location? (oropharyngeal or oesophageal
- Associated features such as weight loss, regurgitation of cough
What can cause dysphagia?
A benign stricture Malignant stricture Motility disorder (E.g. Achalasia) Eosinophilic Oesophagitis Extrinsic compression (e.g. lung cancer)
What type of endoscopy is there for oesophageal disorders?
OGD - Oesophago-Gastro-Duodenoscopy
Also called Upper GI Endoscopy (UGIE)
What investigative tests can be done for oesophageal disorders?
Endoscopy (UGIE) Contrast Radiology (barium swallow) Oesophageal pH & Manometry
When is a barium swallow used?
When an UGIE isnt possible, particularly when investigation dysphagia
How is OEsophageal pH and manometry performed?
A probe with pressure and pH sensors is inserted through a naso-gastric catheter,
It measures muscle contraction and pH as you swallow
What is the use of a oesophageal pH and manometry?
- Tells us about dysphagia and motility disorders
- Assesses sphincter tonicity
- pH helps investigate refractory (stubborn) heart burn
Give an example of a hypermotility disorder?
Diffuse Oesophageal spasm
- Severe episodic chest pain (easily confused with angina)
- +/- dysphagia
How would oesophageal spasm appear on tests?
Corkscrew barium swallow
Manometry shows exaggerated, uncoordinated, hypertonic contractions
How do we treat oesophageal spasms?
Smooth muscle relaxants and wait for it end
What conditions are related to hypomobility of the oesophagus?
- connective tissue disorders
They cause the LOS to fail leading gastro-oesophageal reflux disease
What is achalasia?
Unable to properly open the LOS due to functional loss of the myenteric plexus ganglion cells in the distal oesophagus.
Essentially causing a functional obstruction of the distal oesophagus
What are the symptoms/complications of achalasia?
Progressive dysphagia Weight loss 30% get chest pain Regurgitation Chest infection
Can also be complicated by aspiration pneumonia
Also raises risk of squamous cell carcinoma
How do we treat achalasia?
Drugs - Nitrates, CCBs
Endoscopic - Botulinum toxin/Pneumatic balloon dilatation - Tend to relapse
Surgical - Myotomy - Definitive treatment
What is Gastro-oesophageal Relfux Disease? (GORD)
Pathological acid and bile exposure to the lower oesophagus
What are the symptoms of GORD?
Can often have no symptoms
What are the risk factors for GORD?
Pregnancy Obesity Smoking & alcholism Hypomotility Drugs lowering LOS pressure
Men and caucasians are most affected
How do we investigate/diagnose GORD?
Can diagnose on symptoms alone.
If there are any alarm features of malignancy an endoscopy is required (but will only show abnormalities 50% of the time)
What are the alarm features of malignancy in GORD?
Dysphagia, Weight loss, Vomiting
How does GORD occur?
One of two ways:
- Transient relaxation of the LOS
- > Delayed gastric emptying/oeosphageal emptying
- > Lower oesophageal acid clearance & acid regurg
Hiatus hernia distorts the GO junction leading to reduced acid clearance and regurg
Either way the mucosa is exposed to acid, pepsin and bile leading to inflammation i.e. erosive oesophagitis
What are the types of hiatus hernia and predisposing factors?
Sliding and para-oesophageal
Being old or fat
How is GORD complicated?
Glandular metaplasia (Barret’s Oesophagus)