Oesophagus

Question 1

what is GORD and what is the pathophysiology

Answer 1

condition whereby gastric acid leaks up into the oesophagus

dysfunction of the lower oesophageal sphincter - it relaxes too much and allows the reflux of gastric contents into the oesophagus

this results in pain and mucosal damage in the oesophagus

Question 2

risk factors for GORD

Answer 2

age, obesity, male gender, alcohol, smoking, caffeine intake and spicy foods

Question 3

clinical features of GORD

Answer 3

chest pain - burning retrosternal, worse after meals and when laying down or straining

belching, chronic cough, nocturnal cough

Question 4

red flags for suspected upper GI malignancy

Answer 4

patients with dysphagia

any patient >55yrs with weight loss, upper abdo pain, dyspepsia or reflux

Question 5

management of GORD

Answer 5

conservative; avoid caffeine, alcohol, spicy foods, weight loss, smoking cessation, PPIs - lifelong

surgical; fundoplication - wrap fundus around oesophagus to recreate LOS lower down - side effects include dysphagia, bloating and inability to vomit

Question 6

what are the 2 main subtypes of oesophageal cancer

Answer 6

squamous cell carcinoma and adenocarcinoma

Question 7

what are the differences in aetiology between adenocarcinoma and squamous cell carcinomas of the oesophagus

Answer 7

squamous cell = developing countries, upper/middle third of the oesophagus, associated with smoking and excessive alcohol consumption

adenocarcinoma = developed world, lower third of oesophagus, arises as a consequence of Barrett’s oesophagus, associated with GORD, obesity and high fat intake

Question 8

if a patient presents with dysphagia, what is it important to think about/rule out

Answer 8

oesophageal cancer

Question 9

what are the common clinical features of oesophageal cancer

Answer 9

most common is progressive dysphagia (difficulty swallowing - starting with solids them transitioning to liquids aswell)

weight loss, odynophagia (painful swallowing), hoarseness

Question 10

what are the red flag signs for oesophageal malignancy that require urgent upper GI endoscopy

Answer 10

any patient with dysphagia

any patient >55yrs with weight loss and upper abdo pain, dyspepsia, or reflux

Question 11

initial investigations into suspected oesophageal malignancy

Answer 11

first line is an upper GI endoscopy (OGD - oesophagogastroduodenoscopy)

any malignancy then biopsied and sent for histology

Question 12

what staging investigations is it important to do in a patient with oesophageal malignancy

Answer 12

CT chest-abdo-pelvis and PET-CT scan ; both used to assess for distant metastases

endoscopic ultrasound ; measures penetration into the oesophageal wall

staging laparoscopy ; look for intra-peritoneal mets

Question 13

management of oesophageal cancer

Answer 13

only a small proportion of oesophageal cancers are suitable for surgical intervention

the survival rate is poor due to presentation with already advanced disease - therefore approx 70% are treated palliatively

chemo and radiotherapy are the main options with surgical resection possible in very few patients with early disease

Question 14

what subtype of oesophageal cancer is most common in developing countries

Answer 14

squamous cell carcinomas; smoking and alcohol association

Question 15

what are the 2 main sub-categories of oesophageal tears

Answer 15

mallory-weiss tears; superficial mucosal tears

full thickness ruptures

Question 16

what is oesophageal perforation and how does it lead to death

Answer 16

= full thickness rupture of the oesophageal wall

results in leakage of stomach contents into the mediastinum and pleural cavity, which triggers a severe inflammatory response which will rapidly become overwhelming, leading to physiological collapse, multi organ failure and death

Question 17

what are the most common causes of oesophageal rupture

Answer 17

iatrogenic - e.g. endoscopy

or after severe forceful vomiting

Question 18

what are the classic clinical features of a ruptured oesophagus

Answer 18

severe sudden onset retrosternal chest pain

respiratory distress

subcutaneous emphysema (air becomes trapped under the skin)

Question 19

investigations into suspected oesophageal tears

Answer 19

routine bloods + group and save

gold standard = urgent CT-chest-abdo-pelvis with IV and oral contrast

urgent endoscopy when in theatre

Question 20

management of oesophageal perforation

Answer 20

urgent and aggressive resus required; high flow oxygen, fluid resus, broad spectrum abx - all given immediately

principles of definitive management;

• control the leak
• wash out and remove the mediastinal and pleural contamination
• decompress oesophagus
• nutritional support

those with spontaneous perforations require surgery to control the leak and wash out the chest - this is done via thoracotomy

those with iatrogenic perforations can be managed non-operatively

Question 21

what are mallory-weiss tears and how do they occur

Answer 21

lacerations in the oesophageal mucosa - usually at the gastro-oesophageal junction

they tend to occur after a period of profuse vomiting

Question 22

how do mallory-weiss tears present and what is their management

Answer 22

present with a short period of haematemesis

they are usually small and self limiting

most cases managed conservatively

Question 23

how long is the oesophagus

Answer 23

25cm

Question 24

what type of muscle is present in each third of the oesophagus

Answer 24

upper third = skeletal muscle

middle third = transition zone of both skeletal and smooth muscle

lower third = smooth muscle

Question 25

what is the function of both the upper and lower oesophageal sphincters and what type of muscle is each comprised of

Answer 25

UOS = skeletal muscle; prevents air entering the GI tract

LOS = smooth muscle; prevents reflux from the stomach

Question 26

what controls the peristaltic waves of the oesophagus

Answer 26

oesophageal myenteric neurones

Question 27

what controls the primary and secondary waves of peristalsis in the oesophagus

Answer 27

primary wave = under control of the swallowing centre

secondary wave = activated in response to distension

Question 28

what is Achalasia

Answer 28

primary motility disorder of the oesophagus

failure of relaxation of the LOS and the absence of peristalsis along the oesophageal body

Question 29

what is the believed pathophysiology of achalasia

Answer 29

progressive destruction of the ganglion cells in the myenteric plexus (controls peristalsis)

Question 30

clinical features of Achalasia

Answer 30

progressive dysphagia + regurgitation of food

nocturnal cough, aspiration, chest pain, dyspepsia, weight loss

symptoms are vague and therefore results in a delay in diagnosis

Question 31

investigations into achalasia

Answer 31

upper GI endoscopy first to exclude cancer

gold standard = oesophageal manometry; measures pressure of LOS sphincter and surrounding muscle

Question 32

management of Achalasia

Answer 32

sleep with multiple pillows to reduce regurgitation, eat slowly, plenty of fluids with meals

pharmacological options; use of CCBs to inhibit LOS contraction, Botox injections into LOS via endoscopy - both only provide short lived respite

surgery; provide long term improvements, however come with some side effects

Question 33

what is diffuse oesophageal spasm and what causes it

Answer 33

disease characterised by multi-focal high amplitude contractions of the oesophagus

thought to be caused by dysfunction of the oesophageal inhibitory nerves

Question 34

clinical features of diffuse oesophageal spasm

Answer 34

severe dysphagia to both solids and liquids

central chest pain

Question 35

diffuse oesophageal spasm vs angina

Answer 35

both respond to nitrates - making it difficult to distinguish between the two

however DOS is not exertional like angina

Question 36

investigations into diffuse oesophageal spasm and management

Answer 36

oesophageal manometry - shows pattern of repetitive, simultaneous and ineffective contractions of the oesophagus

management; CCBs limit strongest contractions

Question 37

what condition is characterised by a ‘bird peak’ appearance on barium swallow

Answer 37

achalasia

Question 38

what type of epithelium lines the lumen of the oesophagus

Answer 38

stratified squamous non-keratinized