Pathology of the Gastrointestinal Tract - Oesophagus

Question 1

What are the 7 pathologies of the oesophagus

Answer 1

Gastro-oesophageal reflux disease (GORD)
oesophageal carcinoma 
Barrett's oesophagus 
hiatus hernia
achalasia 
Zencker's diverticulum 
oesophageal varices

Question 2

Describe GORD

Answer 2

describes any symptomatic condition or structural changes due to reflux of the stomach contents into the oesophagus

Question 3

when does oesophagitis develop?

Answer 3

when the lower sphincter fails to act as an effective barrier to the entry of the gastric contents into the distal oesophagus

Question 4

regardless of cause, what does acute oesophagitis cause?

what are the effects of oesophagitis? - 2 points

Answer 4

a burning pain in the chest that may stimulate the pain of heart disease
superficial ulcerations = most typical of reflux and the oesophagus is often dilated with loss of effective peristalsis

Question 5

what exam is often carried out for GORD?
what would be seen? - 1 points

what exam is best?
what would be seen? - 4 points

Answer 5

often an endoscopy exam
ulcerated ‘streaks’ may be visualised on the flat mucosa of the distal oesophagus

double contrast barium study
hiatus hernia, a widened hiatus, strictures of the oesophagus and smooth strictures at the junction in the distal oesophagus

Question 6

what is the treatment for GORD?

Answer 6

life style modifications to include weight loss, changes to diet and medication to reduce acidity = first lines of treatment

Question 7

what symptom is likely to often result in a diagnosis of oesophageal cancer?
why is there a dismal prognosis?

Answer 7

progressive dysphagia in over 40s

the symptoms tend to appear late in the course of the disease

Question 8

what are the two main histological types of oesophageal cancers?
what is the incidence?

Answer 8

squamous cell carcinoma (81-95%)
adenocarcinoma (4-19%)
higher in men than in women

Question 9

what is there a direct link to in adenocarcinomas?

what is strong link with oesophageal cancers?

Answer 9

Barrett’s oesophagus

excessive alcohol intake and smoking

Question 10

what are the earliest radiographic appearances on a barium swallow?

Answer 10

flat plaque-like lesions (sometimes with central ulceration) that involves one wall of the oesophagus

Question 11

what modality has become integral for oesophageal carcinomas and why?
what other modality is used and why?

Answer 11

CT - for staging the disease

PET scans - help with evidence of tumour spread

Question 12

what are used to manage symptoms? - 2 points

what else is offered? - 3 points

Answer 12

stenting or gastrostomy

endoscopic resection of the tissue layers, chemotherapy, radiotherapy

Question 13

what is the prognosis for oesophageal cancers?

Answer 13

not good because the cancer is well established by the time the symptoms present

Question 14

what is Barrett’s oesophagus?

Answer 14

related to severe reflux oesophagitis where the squamous cell lining of the oesophagus is damaged and replaced by columnar epithelium (similar to that in stomach) over time

Question 15

what does Barrett’s oesophagus have an usually high tendency for ?

Answer 15

developing malignancy in the columnar cell-lined portion - these tumours are nearly always adenocarcinomas which otherwise very rare in the oesophagus

Question 16

what are the symptoms for Barrett’s oesophagus? -3 points

what are pre-disposing factors?

Answer 16

long-term burning indigestion, dysphagia, reflux

overweight, smoking, alcohol (regular large amounts), spicy or fatty foods

however not all patients exhibit symptoms and Barrett’s may be an incidental finding

Question 17

how many of those with Barrett’s will go on to develop oesophageal cancer?

Answer 17

1-5%

Question 18

what is the radiographic appearance of Barrett’s oesophagus? - 2 points

Answer 18

the Barrett’s ulcer is usually separated from the hiatus hernia by a variable length of normal-appearing oesophagus
fibrotic healing of the ulcer often leads to a smooth, tapered stricture

Question 19

What is the treatment for Barrett’s oesophagus? - 4 points

Answer 19

antacids/protein pump inhibitors
avoiding alcohol & tobacco
endoscopic treatment (resection of abnormal cells, radiofrequency ablation (surgical removal of body tissue), photodynamic therapy, cryotherapy)
surgery (fundoplication - strengthens oesophageal sphincter, or resection of lower oesophagus)

Question 20

what is the prognosis for Barrett’s oesophagus?

Answer 20

treatment should improve acid reflux symptoms and should keep Barrett’s oesophagus from getting worse but won’t reverse the changes that may lead to cancer

Question 21

what is a Hiatus Hernia?

Answer 21

herniation of the stomach through the oesophageal hiatus (pause or break in continuity) of the diaphragm

Question 22

what are the two types of hiatus hernia?

which is the most common?

Answer 22

sliding or rolling hiatus hernia

sliding hiatus hernia (95%)

Question 23

describe a sliding hiatus hernia

Answer 23

where the gastro-oesophageal junction is displaced by more than 1cm above the hiatus and the hiatus is abnormally widened (3-4cm when the upper limit of normal is 15mm)
gastric fundus may also be above the diaphragm and present as a retro-cardiac mass on a CXR (presence of air-fluid level in mass)

Question 24

when ?cause is uncertain what can happen with a hiatus hernia ….

Answer 24

found as an incidental finding on a barium meal exam

Question 25

what is achalasia?

Answer 25

functional obstruction of the distal section of the oesophagus - causes a delay in the emptying of the oesophageal contents into stomach due to failure of the relaxation of the oesophago-gastric sphincter (caused by abnormality of the neurones that control the sphincter)

Question 26

what may produce dilation of the distal end of the oesophagus?

Answer 26

lack of motility in the oesophagus further restricts the movement of food

Question 27

what are the symptoms for achalasia?

Answer 27

regurgitation dysphagia heartburn

Question 28

what is the radiographic appearance for achalasia?

Answer 28

barium study - tapered, smooth, conical, 1-3cm narrowing of the distal oesophagus ('rat-tail' or 'bird-beak' appearance) on sequential images, with patient upright, small spurts of barium seen to pass through the narrowed segment to enter the stomach

Question 29

what is the treatment for achalasia?

Answer 29

medication before meals to assist in relaxing the oesophageal sphincter can be tried but if symptoms not controlled, an endoscopic balloon dilation may be done last resort is surgery - to open up the sphincter

Question 30

what are oesophageal diverticula ?

Answer 30

outpouchings - common lesions that either contain all layers of the wall or are composed of only mucosa and submucosa herniating through the muscular layer

Question 31

what can result from diverticulum filling with food or secretions

Answer 31

aspiration pneumonia

Question 32

where do Zencker's diverticula arise from? who does it commonly affect?

Answer 32

the posterior wall of the upper oesophagus - can become so large that they almost occlude the oesophageal lumen the elderly in their 70s and 80s

Question 33

what are the symptoms for Zencker's diverticulum? - 4 points

Answer 33

feeling of food/liquid getting 'stuck' in their gullet dysphagia halitosis (bad breath) regurgitation

Question 34

what exam is performed and why?

Answer 34

barium swallow - may demonstrate the diverticulum at the level of c5/c6 (best seen on lateral view)

Question 35

what is the treatment for Zencker's diverticulum?

Answer 35

none required unless they interfere with swallowing in which case the diverticulum is resected and repaired with endoscopic stapling or laser surgery

Question 36

what are oesophageal varices?

Answer 36

dilated veins, within the walls of the oesophagus, most commonly the result of increased pressure in the portal venous system (portal hypertension) - hence, usually the result of cirrhosis in the liver

Question 37

what occurs in patients with portal hypertension?

Answer 37

much of the portal blood cannot flow along its normal pathway through the liver to the IVC and onto the heart, so instead goes via a circuitous collateral route and the increased blood flow through these veins causes the development of oesophageal varices

Question 38

which is one choice of examination but why is this difficult?

Answer 38

barium swallow is not a sensitive test and so must be performed carefully with close attention to the amount of Barium used and the degree of oesophageal distention

Question 39

what would be seen on the radiographs? what % of oesophageal varices are detected by barium swallows?

Answer 39

multiple, diffuse rounded and oval filling defects may be demonstrated 50%

Question 40

what is the modality of choice for oesophageal varices?

Answer 40

CT - excellent for detecting moderate to large oesophageal varices and for evaluating the whole of the portal venous system (aid underlying cause of hypertension)

Question 41

what is the treatment for oesophageal varices?

Answer 41

vasoconstrictors used to constrict dilated vessels, if varices = bleeding then the main aim is to stem blood loss - using balloon tamponade (balloon introduced endoscopically and inflated to stop bleeding) or variceal ligation/banding (application of bands to capture the varix (protrusion from vein) so it would then receive no blood supply = necrose = slough off