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Oesophagus Flashcards

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1
Q

Oesophagus pierces the diaphragm at level of ___, together with ___

A

T10, vagus nerve

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2
Q

Most common site of oesphageal perforation is at ___

A

cricopharyngeus (UES)

located at lower border of cricoid cartilage

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3
Q

Lower esophageal sphincter is created due to?

A

High pressure in right crus of diaphragm

Diaphragmatic fibers loop around oesophagus at oesophageal hiatus (OGJ), contracts when abdominal pressure increases

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4
Q

Muscles in diff parts of oesophagus

A

upper 1/3rd: striated
middle: striated + smooth
lower: smooth

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5
Q

Meissner’s plexus located in ____, Auerbach’s plexus located in ___

A

Submucosa

Muscularis propria

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6
Q

Read up on anatomy of thorax in page 100 of medbear

A

medbear

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7
Q

Pain with swallowing is known as

A

odynophagia

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8
Q

Two types of dysphagia

A

Oropharyngeal, oesophageal

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9
Q

What are the 4 Ts that cause mechanical dysphagia?

A

Thymus, thyroid, teratoma, terrible lymphoma

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10
Q

Dysphagia can be classified into

A

Neuromuscular disease

Mechanical lesions - intraluminal, mural, extramural

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11
Q

Neuromuscular causes of oropharyngeal dysphagia

A

Central: parkinson’s, stroke

Peripheral: myasthenia gravis, myopathies, peripheral neuropathy

Post-infectious: poliomyelitis, syphilis

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12
Q

Neuromuscular causes of oesophageal dysphagia

A

Primary motility disorder: achalasia, spastic disorders

Secondary motility disorders: scleroderma, multiple sclerosis, sjogren’s

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13
Q

What can cause strictures in the oesophagus?

A

Chemical - caustic ingestion
Peptic - GERD
Radiation
Medication
Malignancy
Eosinophilic oesophagitis

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14
Q

Causes of odynophagia

A

Chemicals
Drug-induced
Radiation
Infectious - candida, HSV
Ulcerative oesophagitis secondary to GERD

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15
Q

Oropharyngeal dysphagia is when ____, presents with ____, tends to be ___ cause

A

there is difficulty initiating swallowing

choking, coughing, nasal regurg, drooling, dysarthria

neuromuscular - parkinson’s, STROKE

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16
Q

Oesophageal dysphagia presenting complaint is ____, can be ___ or ___ cause

A

food getting stuck in throat/chest

neuromuscular, mechanical

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17
Q

Mechanical dysphagia: difficulty swallowing ___ more than ___

A

solid, liquid

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18
Q

Trouble swallowing liquid more than solid, or both trouble, hints to

A

achalasia, diffuse spasm, nutcracker oesophagus

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19
Q

Time pattern for development of trouble swallowing solids more than liquids hint to

A

rapidly progressing: red flag for malignancy

slowly progressing: strictures

intermittent: webs, rings

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20
Q

Risk factors for dysphagia

A

Reflux symptoms - heartburn, acid brash (sour taste in mouth), excessive salivation, postural aggravation

Smoking, alcoholism

Previous chemical ingestion

Systemic disease - neuromuscular issues (stroke, DM, myopathies)

Previous surgeries, radiation

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21
Q

Classic oesophageal appearances on barium swallow

A

Bird’s beak/rat tail - achalasia

Sharp right angled contour - malignant stricture

Smooth contour - benign stricture

Corkscrew - diffuse oesophageal spasm

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22
Q

For pt with suspected motility disorders, investigation is via ___

A

oesophageal manometry

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23
Q

What is achalasia

A

Failure of lower oesophageal sphincter to relax appropriately with swallowing

+ aperistalsis + increase LES tone

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24
Q

Types of achalasia

A

Primary: idiopathic (neuronal degeneration)

Secondary: Chagas disease (bite bug infection), diabetic autonomic neuropathy, dorsal motor nuclei lesions

*pseudo-achalasia: caused by malignancy, presents with features of achalasia

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25
What causes achalasia
Degeneration of Auerbach's plexus Hypertensive LES Failure of LES to relax w swallowing
26
Investigations for dysphagia
Oestogastroduodenoscopy Barium swallow Manometry
27
Clinical presentation of achalasia
Progressive difficulty in swallowing both solid & liquid Immediate regurgitation of undigested food/water/saliva Retrosternal chest pain due to oesophageal spasm
28
Complications of achalasia
Aspiration pneumonia Stasis of food -> friability, erosions, candida esophagitis Increased risk of oesophageal SCC
29
Medical therapy for achalasia
1) CCB 2) Botulinum toxin injection aim to decrease LES tone
30
Definition of GERD
reflux of stomach contents causing distressing/troublesome symptoms and/or complications
31
Risk factors for GERD
oesophageal motility disorders increased gastric acid GOO, delayed gastric emptying LES decreased tone, hiatal hernia increased IAP - tight clothes, pregnancy, obesity smooth muscle relaxants
32
What maintains gastro-oesophageal continence?
1) LES 2) Angle of His 3) Diaphragmatic crus 4) pressure difference b/w oesophagus & intra-abdominal stomach
33
Syndromes caused by GERD
1) oesophageal syndromes 1a) symptomatic syndromes - chest pain 1b) injury syndromes - oesophagitis, stricture, barrett's, adenoCA 2) extraoesophageal syndromes 2a) established - cough, laryngitis, asthma, dental erosions 2b) proposed - sinusitis, pharyngitis
34
What is heartburn?
Post-prandial retrosternal burning sensation. Aggravated by lying down May be relieved by antacid. >2times a week significant
35
Complications of GERD
Benign peptic strictures, Barrett's esophagus respi cx - recurrent pneumonia throat cx - halitosis, chronic cough/laryngitis/sinusitis
36
Investigations for oesophagitis
1) OGD - evaluate esophagitis, take samples for Barrett's, rule out malignancy 2) 24 hours oesophageal pH probe - gold standard 3) manometry - check location & function of LES, exclude oesophageal motility disorder 4) barium swallow, follow-through
37
Surgical therapy for GERD is via ___
fundoplication - Nissen (360deg wrap) or Partial wrap of fundus of the stomach around the oesophagus
38
What is Barrett's oesophagus?
Metaplasia of columnar epithelium with gastric/intestinal features that replace normal stratified squamous epithelium
39
Risk factors of Barrett's oesophagus?
Longstanding GERD (>5yr) males, smoking, central obesity Presence of hiatal hernia - 80% of BE cases
40
in healthy ppl, the ___ junction is the same level as the ___. Known as the __ line
squamocolumnar gastroesophageal z-line
41
Cx of Barrett's
Oesophageal ulcers (4 Bs): bleed, burrow, burst, block Oesophageal scarring & strictures *INCREASED RISK OF ADENOCARCINOMA (40%)
42
In Barrett's, the SCJ is shifted ___ from the GEJ
proximally
43
Omeprazole standard dosing
20mg BD = 40mg OD
44
Most common types of esophageal cancer
Squamous cell carcinoma Adenocarcinoma
45
Risk factors for SCC oesophagus
Smoking, alcohol hot beverages, nutrition deficiency betel nut chewing Achalasia
46
Risk factors for adenoCA
Barrett's oesophagus Chronic GERD Obesity -> hiatus hernia -> reflux
47
SCC typically occurs in ___ of oesophagus, adenoCA occurs in ___
middle 1/3rd distal 1/3rd
48
Clinical presentation of esophageal CA
1. dysphagia - liquid > solid 2. odynophagia (late) 3. regurgitation of undigested food 4. anaemia (+- melena, haematemesis)
49
SCC tends to spread ___, AdenoCA spreads ___
intra-thoracic intra-abdominal
50
Features of complicated oesophagus cancer
- bleeding - obstructive: malnutrition, aspiration pneumonia - hoarseness (RLN invasion) - Horner's syndrome - Respiratory (tracheo-oesophageal fistula)
51
T staging for cancer is by ___ of tumour invasion
depth
52
Where are tumours located in gastroesophageal junction tumours?
- Type 1: 5 cm of distal esophagus - Type 2: cardia (GEJ) - Type 3: sub-cardial (within 5cm below GEJ)
53
Treatment for GEJ tumours
Type 1: treat as esophageal cancer (esophagectomy) Type 3: treat as gastric cancer (total/proximal gastrectomy) Type 2: resection of parts/whole of esophagus and stomach
54
Impt cx of hiatal hernia
Gastric volvulus: ischemia - septic shock, multi-organ failure Clinical presentation of Borchardt's triad - epigastric/chest pain, retching without vomiting, inability to pass NG tube
55
Classification of hiatal hernias
Type 1: sliding Type 2: rolling Type 3: mixed Type 4: giant
56
Type 1 hiatal hernia
Sliding: GEJ displaced only upper stomach + lower oesophagus slides into chest when pt lies down - oesophagitis w heartburn
57
Type 2 hiatal hernia
Rolling: only fundus of stomach herniates fundus rolls up through hiatus in front of oesophagus can cause lesions - linear gastric erosions that cause GI bleeding
58
Type 3 hiatal hernia
Mixed hernia Both GEJ & fundus of stomach displaced
59
Type 4 hiatal hernia
Giant hernia Presence of additional organ (eg. colon, spleen, omentum) in the hernia sac
60
Where does oesophageal perforation most commonly occur
Left lateral wall of oesophagus, 3-5cm above GEJ
61
Risk factors for oesophageal perforation
iatrogenic (OGD, dilatation etc.) Boerhaave's syndrome - often due to trauma from severe vomiting caustic chemical ingestion foreign body
62
Presentation of oesophageal perforation
subcutaneous emphysema (cervical crepitation/swelling) pain, fever Hartmann's sign - mediastinal crunching on auscultation (pneumomediastinum)
63
Mackler's triad seen in ___, 3 symptoms ____
Boerhaave's syndrome vomiting, chest pain, subcutaneous emphysema
64
Distal oesophageal perforation leads to ___ Mid-thoracic perforation leads to ___
left sided pleural effusion right sided pleural effusion

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