Oesophageal Disorders

Question 1

At what vertebral level does the oesophagus begin?

Answer 1

C6 and ends at T11-12

Question 2

What is the epithelium of the oesophagus?

Answer 2

Stratified squamous non keratinised

Question 3

How does food move through the oesophagus?

Answer 3

Oesophageal peristalsis produced by oesophageal circular muscles and propels swallowed materials distally into the stomach

Coordinates with lower oesophageal sphincter (LOS) relaxation

Question 4

What nerve is responsible for peristalsis and LOS relaxation?

Answer 4

Vagus nerve

Question 5

Describe the lower oesophageal sphincter

Answer 5

• High resting pressure in distal smooth muscle

* Striated muscle of right crus of diaphragm

Question 6

Name two main symptoms of oesophageal disease

Answer 6

Heartburn and dysphagia

Question 7

Describe heartburn

Answer 7

• Retrosternal discomfort or burning
• May be associated with: Waterbrash, cough
• Consequence of reflux of acidic &/or bilious gastric contents into the oesophagus

Question 8

Describe the pathology and complications of heartburn

Answer 8

• Reflux occurs physiologically (i.e. after swallowing)
• Certain drugs/oods (i.e. alcohol, nicotine, dietary xanthines) can reduce the LOS pressure resulting in increased reflux/heartburn
• Persistent reflux and heartburn leads to gastro-oesophageal reflux disease (GORD) which can in turn cause long-term complications

Question 9

What is dysphagia?

Answer 9

• Subjective sensation of difficulty in swallowing foods and/or liquids
• Odynophagia: pain with swallowing (may accompany)

Question 10

What do you need to ask about in the history of dysphagia?

Answer 10

• Type of food (solid vs. liquid)
• Pattern (progressive, intermittent)
• Associated features (weight loss, regurgitation, cough)
• Location - oropharyngeal or oesophageal

Question 11

What are five causes of dysphagia?

Answer 11

• Benign stricture
• Malignant stricture (oesophageal cancer)
• Motility disorders (i.e. achalasia, presbyoesophagus)
• Eosinophilic oesophagitis
• Extrinsic compression (i.e. in lung cancer)

Question 12

Name three different investigations used for oesophageal disease

Answer 12

• Endoscopy
• Contrast radiology (barium swallow)
• Oesophageal pH and Manometry

Question 13

Name two different types of endoscopies and the general use

Answer 13

• Oesophagi-gastro-duodenoscopy (OGD)
• Upper GI endoscopy (UGIE)

Diagnostic takes 2-3mins, or used therapeutically with sedation

Question 14

What in contrast radiology (barium swallow) used to investigate?

Answer 14

Dysphagia (but endoscopy preferred)

Question 15

What does pH and manometry measure?

Answer 15

pH in reflux disease and pressure waves in oesophagus (peristalsis)

Using nasogastric catheter containing sensors placed in oesophagus with probes at level of both sphincters (UOS and LOS)

Question 16

What is manometry?

Answer 16

Used in investigation of dysphagia/suspected motility disorder (usually after endoscopy). It assesses sphincter tonicity, relaxation of sphincters and oesophageal motility

Question 17

Name two mobility disorders

Answer 17

Hyper and hypomotility

Question 18

What is the presentation hypermotility?

Answer 18

• ‘corkscrew appearance’ on Ba swallow
• Severe, episodic chest pain +/- dysphagia
• Often confused with angina/MI
• Idiopathic
• Manometry shows exaggerated, uncoordinated, hypertonic contractions
• Treatment: smooth muscle relaxants

Question 19

What is the presentation of hypomotility?

Answer 19

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

Question 20

What is alchalsia?

Answer 20

Functional loss of myenteric plexus ganglion cells in distal oesophagus and LOS due to degeneration of inhibitory neurons

• Cardinal feature: failure of LOS to relax
• Result: functional distal obstruction of oesophagus

Question 21

Describe the manometry in alchalsia?

Answer 21

• High pressure in the LOS at rest
• Failure of the LOS to relax after swallowing
• An absence of useful (peristaltic) contraction in the lower oesophagus

Question 22

What are four symptoms of alchalsia?

Answer 22

• Progressive dysphagia for solids and liquids
• Weight loss (late presentation)
• Chest pain
• Regurgitation and chest infection

Question 23

What is the treatment of alchalsia?

Answer 23

• Pharmacological: nitrates, CCB
• Endoscopic: Botox, pneumatic balloon dilation
• Radiological: pneumatic balloon dilation
• Surgical: Myotomy (best long-term effect)

Question 24

Name two possible complications of alchalsia

Answer 24

• Aspiration pneumonia and lung disease

* Increased risk of squamous cell oesophageal carcinoma

Question 25

What are the symptoms of gastro-oesophageal reflux disease?

Answer 25

Many patients with frequent, pathological episodes of acid/bile reflux do not experience any symptoms Symptoms: heartburn, cough, water brash, sleep disturbance

Question 26

What are risk factors for GORD?

Answer 26

Pregnancy, obesity, drugs lowering LOS pressure, smoking, alcoholism, hypomotility anything that increases pressure o Men > women o Caucasian > Black > Asian

Question 27

How is GORD diagnosed?

Answer 27

Usually on the basis of the characteristic symptoms • Endoscopy is a poor diagnostic test as usually have no visible oesophageal abnormality

Question 28

When should an endoscopy be performed in GORD?

Answer 28

In the presence of alarm features suggestive of malignancy (i.e. dysphagia, weight loss, vomiting).

Question 29

What is the aetiology of GORD?

Answer 29

With abnormal anatomy • Increase transient relaxations of the LOS • Hypotensive LOS • Delayed gastric emptying • Delayed oesophageal emptying • Decreased oesophageal acid clearance • Decreased tissue resistance to acid/bile

Question 30

What are the two types of hiatus hernias?

Answer 30

* Sliding | * Para-oesophageal

Question 31

Describe the GORD pathophysiology

Answer 31

* Mucosa exposed to acid-pepsin and bile * Increased cell loss and regenerative activity (i.e. inflammation) * Erosive oesophagitis

Question 32

What are the different treatment options for GORD?

Answer 32

Mainly empirical (i.e. without investigation) in absence of alarm features 1. Lifestyle measure: weight & diet 2. Pharmacological: a. alginates (gaviscon) b. H2RA (ranitidine) c. Proton pump inhibitor (i.e. omeprazole) For refractory disease/symptoms following investigation 3. Anti-reflux surgery (fundoplication – full / partial wrap)

Question 33

What's Barrett's Oesophagus?

Answer 33

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

Question 34

What is the treatment of high grade dysplasia?

Answer 34

Risk of developing oesophageal cancers To prevent cancer: • Endoscopic mucosal resection (EMR) • Radiorefquency ablation (RFA) of epithelium to allow new cells to grow • Oesophagectomy (rare)

Question 35

What are the most common types of oesophageal cancer?

Answer 35

Squamous cell carcinoma and adenocarcinoma

Question 36

What are the features of squamous cell carcinoma oesophageal cancers?

Answer 36

* Occurs in proximal and middle third of oesophagus | * Tobacco and alcohol significant risk factors

Question 37

What are the features of adenocarcinoma?

Answer 37

* Occurs in distal oesophagus * Associated with Barrett’s oesophagus (progresses through dysplasia to cancer) * Predisposing factors: obesity, male, middle age, Caucasian

Question 38

What are the features of oesophageal cancer metastases

Answer 38

• Tumours have commonly spread to regional nodes and/or liver at presentation • No peritoneal (serosal) lining in mediastinum o Due to lack of serosal layer, tumour invasion into adjacent structures easier o Lamina propria has a rich lymphatic supply, so lymph node involvement occurs early in oes. Tumours • Metastases – hepatic, brain, pulmonary, bone

Question 39

How is oesophageal cancer diagnosed?

Answer 39

Endoscopy and biopsy

Question 40

How is oesophageal cancer staged?

Answer 40

* CT scan: chest, abdomen and pelvis * Endoscopic USS (T and N staging) * PET scan * Bone scan

Question 41

What is oesophageal cancer treated?

Answer 41

Only possible cure: surgical oesophagetomy +/- adjuvant (after) or neoadjuvant (before) chemotherapy

Question 42

What are treatment options for oesophageal cancer?

Answer 42

* Endoscopic (stent, laser/APC, PEG) * Chemotherapy * Radiotherapy * Brachytherapy (radiotherapy where a sealed radiation source is placed inside or next to the area requiring treatment)