Oesophageal Disorders

Question 1

Oesophageal peristalsis produced by

Answer 1

Oesophageal circular muscles

Question 2

Oesophageal peristalsis coordinates with

Answer 2

Lower oesophageal sphincter (LOS) relaxation

Question 3

Contraction in the oesophageal body

Answer 3

Peristalsis

Question 4

Peristalsis and LOS relaxation mediated by

Answer 4

Vagus nerve

Question 5

Symptoms of oesophageal disease

Answer 5

Heartburn

Dysphagia

Question 6

Heartburn

Answer 6

Retrosternal discomfort or burning sensation
consequence of reflux of acidic and/or bilious gastric contents into the oesophagus
A degree of reflux occurs physiologically (eg after swallowing)
Certain drugs/foods, (e.g. alcohol, nicotine, dietary xanthines) can reduce the LOS pressure resulting in increased reflux / heartburn
Persistent reflux and heartburn leads to GORD

Question 7

GORD

Answer 7

Gastro-oesophageal reflux disease

Due to pathological acid (and bile) exposure in lower oesophagus or abnormal anatomy (eg hiatus hernia)

Question 8

Dysphagia

Answer 8

Difficulty swallowing foods and/or liquids

Question 9

Pain swallowing foods

Answer 9

Odynophagia

Question 10

Causes of oesophageal dysphagia

Answer 10

Benign stricture
Malignant stricture (oesophageal cancer)
Motility disorders (eg achalasia, presbyoesophagus)
Eosinophilic oesophagitis
Extrinsic compression (eg in lung cancer)

Question 11

Oesophageal disease investigations

Answer 11

Endoscopy
Contrast radiography (barium swallow)
Oesophageal pH and manometry

Question 12

Motility disorders

Answer 12

Hypermotility
Hypermobility
Achalasia

Question 13

Hypermotility

Answer 13

Corkscrew appearance on barium swallow
Severe, episodic chest pain +/- dysphagia
Cause unclear (idiopathic)
Manometry shows exaggerated, uncoordinated, hypertonic contractions

Question 14

Hypomotility

Answer 14

Associated with connective tissue disease, diabetes, neuropathy
Causes failure of LOS mechanism leading to heartburn and reflux symptoms

Question 15

Achalasia pathology

Answer 15

Degeneration of inhibitory neurons (ganglion cells) in the myenteric plexus in the oesophagus
Often surrounded by lymphocytes- so an inflammatory aetiology is suspected

Question 16

Main feature and result of achalasia

Answer 16

Failure of LOS to relax - causes functional distal obstruction of oesophagus

Question 17

Symptoms of achalasia

Answer 17

Progressive dysphagia for solids and liquids
Weight loss
Chest pain
Regurgitation and chest infection

Question 18

Pharmacological treatment of achalasia

Answer 18

Nitrates

Calcium channel blockers

Question 19

Endoscopic treatment of achalasia

Answer 19

Botulinum Toxin

Pneumatic balloon dilation

Question 20

Radiological treatment of achalasia

Answer 20

Pneumatic balloon dilation

Question 21

Surgical treatment of achalasia

Answer 21

Myotomy

Question 22

Complications of achalasia

Answer 22

Aspiration pneumonia and lung disease

Increased risk of squamous cell oesophageal carcinoma

Question 23

Types of hiatus hernia

Answer 23

Fundus of stomach moves proximally through the diaphragmatic hiatus
Sliding - still one tube
Para-oesophageal - with a wee sac sticking out to the side

Question 24

GORD complications

Answer 24

Ulceration
Stricture
Carcinoma
Glandular metaplasia (Barrett’s oesophagus)

Question 25

Barrett's oesophagus

Answer 25

Intestinal metaplasia related to prolonged acid exposure in distal oesophagus Change from squamous to mucin-secreting columnar (ie gastric type) epithelial cells in lower oesophagus Precursor to dysplasia/ adenocarcinoma

Question 26

Barrett's oesophagus treatment

Answer 26

Endoscopic Mucosal Resection (EMR) Radio-Frequency Ablation (RFA) Oesophagectomy rarely

Question 27

GORD treatment

Answer 27

Mainly empirical in absence of alarm features

Question 28

Empirical treatment of GORD

Answer 28

Without investigation Lifestyle measures Pharmacological

Question 29

GORD treatment for refractory disease/symptoms following investigation

Answer 29

Anti-reflux surgery

Question 30

Oesophageal cancer types

Answer 30

Benign tumours rare Squamous cell carcinoma Adenocarcinoma

Question 31

Pesentation of oesophageal cancer

Answer 31

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

Question 32

Adenocarcinoma located

Answer 32

Distal oesophagus

Question 33

Squamous cell carcinoma located

Answer 33

Proximal and middle third of oesophagus

Question 34

Adenocarcinoma associated with

Answer 34

Barrett's oesophagus

Question 35

Squamous cell carcinoma associated with

Answer 35

Achalasia Caustic strictures Plummer-Vinson syndrome

Question 36

Risk factors for adenocarcinoma

Answer 36

Obesity Male Middle aged Caucasian

Question 37

Risk factors for squamous cell

Answer 37

Tobacco | Alcohol

Question 38

Squamous cell carcinoma preceded by

Answer 38

Dysplasia | Forms large, exophytic occluding tumours

Question 39

Oesophagus lacks a _____ allowing tumour invasion to adjacent structures to occur more easily

Answer 39

Serosal layer

Question 40

Tumours at presentation

Answer 40

Late | Normally regional node/liver metastases

Question 41

Oesophageal metastases

Answer 41

Hepatic Brain Pulmonary Bone

Question 42

Oesophageal cancer investigation

Answer 42

``` Diagnosis by endoscopy & biopsy Staging: CT Scan Endoscopic ultrasound PET Scan Bone Scan ```

Question 43

Oesophageal cancer treatment

Answer 43

Only potential cure is surgical oesophagectomy +/- adjuvant (after) or neoadjuvant (before) chemotherapy Palliative care

Question 44

Eosinophilic oesophagitis

Answer 44

Chronic immune-/allergen-mediated condition Eosinophilic infiltration of the oesophageal epithelium in the absence of secondary causes of local or systemic eosinophilia

Question 45

Presentation of eosinophilic oesophagitis

Answer 45

Dysphagia and food bolus obstruction

Question 46

Treatment of eosinophilic oesophagitis

Answer 46

Topical/swallowed corticosteroids Dietary elimination Endoscopic dilatation