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*GI System - Pathology > Oesophageal Disorders > Flashcards

Oesophageal Disorders Flashcards

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1
Q

Where does the oesophagus begin and end?

A

Begins at lower level of cricoid cartilage (C6), terminates at T11-12 where it enters the stomach

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2
Q

What is its length in cm? How much of that is striated v smooth muscle?

A

approx 25cm

Upper 3-4cm = striated, rest is smooth

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3
Q

What is the epithelial lining of the oesophagus?

A

Stratified squmaous

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4
Q

Describe function of the oesophagus and how it acheives this

A

Transport food/liquid from mouth to stomach; oesophageal peristalsis produced by oesophageal circular muscles + propels swallowed materials distally into the stomach; co-ordinates with LOS relaxation

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5
Q

Contraction in oesophageal body (peristalsis) and relaxation of the LOS is mediated via what nerve?

A

Vagus

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6
Q

2 key symptoms in oesophageal disease?

A
  • Heartburn*
  • Dysphagia*
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7
Q

What is heartburn described as?

A

Retrosternal discomfort or burning

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8
Q

What can heartburn be associated with?

A

Waterbrash

Cough

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9
Q

What is heartburn a consequence of? Is it normal to experience it?

A

Heartburn is a consequence of reflux of acidic and/or bilious gastric contents into the oesophagus

Yes - almost everyone expeeriences it occasionally

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10
Q

What do certain drugs/foods do to LOS to cause increased reflux/heartburn? Give examples of what drugs

A

Reduce LOS pressure

e.g. alcohol, nicotine, dietary xanthines

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11
Q

What does persistent reflux and heartburn lead to?

A

Gastro-oesophageal reflux disease (GORD) - can cause long-term complications

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12
Q

What is dysphagia described as?

A

Subjective sensation of difficulty in swallowing food and/or liquids

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13
Q

What is odynophagia?

A

PAIN with swalling (may accompany dysphagia)

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14
Q

What 3 things should be inquired about when asking about dysphagia?

A
  • Type of food (solid v liquid)
  • Pattern (progressive, intermittent)
  • Associated features (weight loss, regurgitation, cough)
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15
Q

What are the 2 locations for dysphagia?

A

Oropharyngeal or oesophageal

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16
Q

Give 5 causes of oesophageal dysphagia

A
  • Benign stricture
  • Malignant stricture
  • Motility disorders (e.g. achalasia, presbyoesophagus)
  • Eosinophilic oesophagitis
  • Extrinsic compression (e.g. in lung cancer)
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17
Q

3 investigations which can be done for oesophageal disease?

A 
Endoscopy (OGD or UGIE)
Contrast radiology (barium swallow)

Oesophageal pH; manometry (investigates refractory heartburn/reflux; assesses sphincter tonicity, relaxation of sphincters and oesophageal motility)

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18
Q

2 ends of spectrum for motility disorders?

A

Hypermotility (e.g. diffuse oesophageal spasm)

Hypomotility (associated w connective tissue disease, diabetes, neuropathy)

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19
Q

How would a hypermotility disorder appear on Ba swallow?

A

Corkscrew appearance

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20
Q

What symptoms are associated with hypermotility? What does this mean it can be confused with?

A

Severe, episodic chest pain +/- dysphagia

Can be confused with angina/MI

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21
Q

What would the manometry for hypermotility show?

A

Exaggerated, uncoordinated, hypertonic contractions

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22
Q

Cause and Rx for hypermotility?

A

Cause unclear (idiopathic)

Rx smooth muscle relaxants

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23
Q

What does hypomotility cause? Leading to what?

A

Causes failure of LOS mechanism leading to heartburn and reflux symptoms

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24
Q

What is achalasia? (functional loss of…)

A

Functional loss of myenteric plexus ganglion cells in distal oesophagus and LOS

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25
Incidence of achalasia?
1-2/100,000 Usually 3rd-5th decade
26
Cardinal feature of achalasia? Resulting in what?
Failure of LOS to relax resulting in functional distal obstruction of oesophagus
27
4 symptoms of achalasia
Progressive dysphagia for solids and liquids Weight loss Chest pain (30%) Regurgitation and chest infection
28
4 modalities of treatment for achalasia are pharmacological, endoscopic, radiological and surgical - give examples for each
Pharmacological - *nitrates, CCBs* Endoscopic - *botulinum toxin, pneumatic balloon dilatation* Radiological - *pneumatic balloon dilatation* Surgical - *myotomy*
29
2 possible complications of achalasia?
Aspiration pneumonia and lung disease Increased risk of SC oesophageal carcinoma
30
Do patients with frequent, pathological episodes of acid/bile reflux always experience symptoms?
NO! Many do not
31
4 symptoms of GORD
Heartburn Cough Water brash Sleep disturbance
32
Give risk factors for GORD
Pregnancy Obesity Drugs lowering LOS pressure Smoking Alcoholism Hypomotility
33
What can the typical reflux syndrome be diagnosed on the basis of?
The characteristic symptoms, without diagnostic testing
34
Is endoscopy a good diagnostic test for GORD? When would it be used?
No, it is a poor diagnostic test - most patients with reflux symptoms have **no visible evidence** of oesophageal abnormality when endoscopy is performed Endoscopy must be performed in presence of **'alarm'** features suggestive of malignancy (e.g. **dysphagia, weight loss, vomiting**)
35
What are the possible aetiologies of GORD without abnormal anatomy?
Increased transient relaxations of the LOS; hypotensive LOS; delayed gastric emptying; delayed oesophageal emptying; decreased oesophageal acid clearance; decreased tissue resistance to acid/bile
36
What is the aetiology of GORD due to hiatus hernia?
Anatomical distortion of the OG junction
37
What happens in a hiatus hernia?
Fundus of stomach moves proximally through the diaphragmatic hiatus
38
2 main types of hiatus hernia?
Sliding - stomach and section of the esophagus that joins the stomach slide up into the chest through the hiatus (more common) Para-oesophageal - OG junction remains where it belongs, but part of the stomach is squeezed up into the chest beside the esophagus (more concerning - needs surgery when causing symptoms)
39
What 2 factors predispose hiatus hernia?
Obesity Age
40
What happens during GORD at the mucosal level and what does it lead to?
Mucosa exposed to acid-pepsin and bile Increased cell loss and regenerative activity (i.e. inflammation) Leads to *erosive oesophagitis*
41
4 complications of GORD?
Ulceration (5%) Stricture (8-15%) **Glandular metaplasia (Barrett's oesophagus)** **Carcinoma**
42
What is Barrett's oesophagus?
Intestinal metaplasia related to prolonged acid exposure in distal oesophagus
43
What do the squamous cells in the lower oesophagus change to in Barrett's?
Mucin-secreting columnar (i.e. gastric type) epithelial cells
44
What is Barrett's a precursor to?
Dysplasia/adenocarcinoma | (cancer rate ~0.3% per year)
45
Is Barrett's more common in men or women?
Men
46
Overall risk of progression from Barrett's is 0.3%, but patients with *high grade dysplasia* the risk is 6%, so how is this treated? (3 ways)
- Endoscopic Mucosal Resection (EMR) - Radio-Frequency Ablation (RFA) - Oesophagectomy (rarely as mortality ~10%)
47
48
GORD is usually treated empirically (w/o investigation) by lifestyle measures and pharmacological measures - what are 3 drugs used?
- Alginates (Gaviscon) - H2RA (Ranitidine) - Proton Pump Inhibitor (e.g. Omeprazole, Lansoprazole)
49
What is the treatment for GORD for refractory disease/symptoms following investigation?
Anti-reflux surgery (fundoplication - full/partial wrap)
50
What are the 2 types of oesophageal cancer?
* Squamous Cell Carcinoma* * Adenocarcinoma* (benign tumours rare)
51
Who is oesophageal cancer more common in men v women? Which type is most common in western europe/USA?
Men:Women 3:1 Adenocarcinoma more common europe and USA; rest of the world - squamous much more common
52
Presentation of oesophageal cancer? (2 **key** features then others)
**Progressive dysphagia (90%)** **Anorexia and weight loss (75%)** Odynophagia Chest pain Cough Pneumonia Vocal cord paralysis Haematemesis
53
Which type of oesophageal cancer occurs in proximal and middle thirds of oesophagus?
Squamous cell carcinoma
54
What is SCC oesophagus preceded by?
Dysplasia and carcinoma in situ
55
2 significant risk factors for SCC oesophagus? (common ones)
Tobacco Alcohol
56
3 conditions SCC oesophagus is associated with?
Achalasia Caustic strictures Plummer-Vinson syndrome
57
Which type of oesophageal cancer occurs in distal oesophagus?
**Adenocarcinoma**
58
What condition is adenocarcinoma oesophagus associated with?
Barretts oesophagus
59
4 predisposing factors for adencarcinoma oesophagus?
Obesity Male sex Middle age Caucasian
60
Does oesophageal cancer usually present early or late?
LATE - tumours have commonly spread to regional nodes and/or liver at presentation
61
What often limits oesophageal cancer surgery?
Local invasion to heart, trachea, aorta (due to no peritoneal (serosal) lining in mediastinum meaning invasion is easier)
62
Where does oesophageal cancermetastasise to?
Liver, brain, lungs, bone
63
Prognosis for oesophageal cancer?
**Poor**; 5 yr survival \<10%
64
What investigations are used to diagnose oesophageal cancer?
Endoscopy and biopsy
65
What 4 modalities are used to stage oesophageal cancer?
CT scan Endoscopic ultrasound PET scan Bone scan
66
How is oesophageal cancer treated?
Surgical oesophagectomy +/- adjuvant or neoadjuvant chemo = only potential cure (limited to patients with localised disease, without co-morbid disease, usually \<70yrs; long post-op recovery; significant mortality ~10%; requires nutritional support) Chemo + radio now offers prospect of improved long-term survival in patients with locally advanced inpoerable disease
67
Most patients with oesophageal cancer present with incurable disease, in this case what is the priority?
Symptom palliation (mainly dysphagia)
68
4 methods for symptoms palliation in oesophageal cancer?
Endoscopic - stent, laser/APC, PEG Chemo Radiotherapy Brachytherapy
69
What type of condition is eosinphilic oesophagitis?
Chronic immune/allergen-mediated condition
70
How is eosinophillic oesophagitis defined clinically v pathologically?
Clinically by symptoms of oesophageal dysfunction Pathologically by an eosinophilic infiltration of the oesophageal epithelium (≥15 eosinophils per high-power microscopy field on oesophageal biopsy) in the absence of secondary causes of local or systemic eosinophilia
71
Who is eosinophilic oesophagitis more commonly seen in?
Children and young adults Males \> females
72
Presentation of eosinophilic oesophagitis?
Dysphagia and food bolues obstruction
73
Endoscopic findings
74
3 methods of treatment of eosinophillic oesophagitis?
- Topical/swallow corticosteroids - Dietary elimination to reduce symptoms and inflammation - Endoscopic dilatation

*GI System - Pathology (8 decks)

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