Oesophagus

Question 1

What causes GORD?

Answer 1

incompetent LOS - more frequent relaxation causing reflux of gastric contents

Question 2

What forms the UOS?

Answer 2

cricopharyngeus muscle

Question 3

What are the risk factors for GORD?

Answer 3

age
obesity
fatty and spicy foods
alcohol, caffeine, smoking

Question 4

What are the clinical features of GORD?

Answer 4

heartburn - burning, retrosternal sensation
worse after meals, lying down
cough
odynophagia

Question 5

What are red flags for someone with suspected GORD?

Answer 5

dysphagia
weight loss
need to rule out malignancy

Question 6

How is GORD diagnosed?

Answer 6

good history
resolution with PPI trial
OGD - rule out malignancy, complications of GORD
ambulatory pH monitoring (medical treatment failing)
manometry - ?motility disorders

Question 7

What lifestyle modifications are made for GORD?

Answer 7

smoking cessation
weight loss
avoid coffee, alcohol, fatty and spicy food

Question 8

What is the medical management of GORD?

Answer 8

antacids - symptomatic relief (no healing benefit)
PPIs (potentially lifelong)
H2 antagonists (ranitidine, cimetidine)

Question 9

When is surgical management considered in GORD?

Answer 9

failure to respond to medical therapy
complications of GORD
patient wants to avoid lifelong medication

Question 10

What is the surgical management of GORD?

Answer 10

360 degree Nissan fundoplication

gastric fundus is wrapped around GOJ
crura also tightened (crural repair)

Question 11

What are the complications of a fundoplication?

Answer 11

dysphagia
delayed gastric emptying (damaged vagus nerve)
recurrence
abdominal bloat

Question 12

What are the complications of GORD?

Answer 12

aspiration pneumonia

Barrett’s oesophagus

Question 13

What is Barrett’s oesophagus?

Answer 13

metaplasia of oesophageal mucosa
stratified squamous to columnar
premalignant

Question 14

What type of cancer usually occurs in the upper and middle 1/3rds of the oesophagus?

Answer 14

squamous cell carcinoma

associated with smoking and excessive alcohol

Question 15

What type of cancer usually occurs in the lower 1/3rd of the oesophagus?

Answer 15

adenomacarcinoma

associated with Barretts

Question 16

What are the clinical features of oesophageal cancer?

Answer 16

progressive dysphagia
weight loss (cancer and dysphagia related)
hoarseness
odynophagia

on examination:
evidence of weight loss
supraclavicular lymphadenopathy
metastatic signs - ascites, jaundice, hepatomegaly

Question 17

How is suspected oesophageal cancer investigated?

Answer 17

urgent OGD with biopsy 
CT CAP (mets)
endoscopic USS +/- FNA (for staging)

Question 18

What is the surgical management of oesophageal cancer?

Answer 18

oesophagectomy - stomach made into conduit tube
complications
- post op nutrition is hard (may require feeding jejunostomy)
- anastomotic leak

Question 19

What is the management of oesophageal cancer?

Answer 19

usually surgery
+/- chemo
+/- radiotherapy

Question 20

How are oesophageal tumours staged?

Answer 20

TNM

T1 - within mucosa 
T2 - muscularis propria 
T3 - adventitia 
T4a - local tissue spread 
T4b - distant mets §

Question 21

What is achalasia?

Answer 21

primary motility disorder of oesophagus

Question 22

What are the clinical features of achalasia?

Answer 22

progressive dysphagia
retrosternal pain
regurgitation
weight loss

Question 23

How is achalasia investigated?

Answer 23

OGD (to investigate dysphagia) - normal 
oesophageal manometry 
- absence of peristalsis 
- LOS failure to relax 
- high resting tone 
barium swallo (rarely done)
- birds beak oesophagus

Question 24

How is achalasia managed?

Answer 24

medical: CCBs or nitrates (temporary relief), botox injections (LOS)

endoscopic balloon dilatation (risk of perforation and need for further intervention)
surgery: laparoscopic Heller cardiomyotomy (need life long PPI)

Question 25

What is diffuse oesophageal spasm? How does it present?

Answer 25

uncoordinated multifocal high amplitude contractions of oesophagus (seen on manometry) presents with dysphagia and retrosternal chest pain

Question 26

What are oesophageal tears?

Answer 26

rupture to any part of the oesophageal wall

Question 27

What are the subtypes of oesophageal tears?

Answer 27

full thickness rupture | superficial mucosal tear (Mallory Weiss)

Question 28

What can cause an oesophageal rupture?

Answer 28

iatrogenic - endoscopy | severe, forceful vomiting (Boerhaave's syndrome)

Question 29

What is Boerhaave's syndrome?

Answer 29

oesophageal rupture caused by vomiting

Question 30

What does oesophageal rupture lead to?

Answer 30

leakage of stomach contents into mediastinum and pleural cavity severe inflammatory response physiological collapse, multiorgan failure, death

Question 31

What are the clinical features of an oesophageal rupture?

Answer 31

severe, sudden onset retrosternal pain respiratory distress subcutaneous emphysema

Question 32

What investigations are done for an oesophageal rupture?

Answer 32

high clinical suspicion - endoscopy in theatre routine bloods and group and save urgent CT CAP with IV and oral contrast (leakage of oral contrast, air or fluid in mediastinum or peural cavity)

Question 33

How is an oesophageal rupture managed?

Answer 33

ABCDE - high flow oxygen, IV access, fluid resus, broad spectrum antibiotics non surgical: resus, NG tube, chest drain - done if more stable (usually iatrogenic rupture) surgical: on table endoscopy (site of perforation), emergency thoracotomy (control leak and wash out chest)

Question 34

What is a Mallory Weiss tear?

Answer 34

laceration in oesophageal mucosa | generally small and self limiting

Question 35

What usually causes a Mallory Weiss tear?

Answer 35

vomiting

Question 36

How is dysphagia investigated?

Answer 36

OGD oesophageal manometry (barium swallow - rarely performed)

Question 37

What are the emergency causes of haematemesis?

Answer 37

oesophageal varices | gastric ulceration

Question 38

What are the non-emergent causes of haematemesis?

Answer 38

Mallory Weiss tear oesophagitis gastritis

Question 39

How is haematemesis investigated?

Answer 39

routine bloods, Group and Save OGD erect CXR (perforated peptic ulcer - pneumoperitoneum) CT abdo with IV contrast (triple phase)