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91 Cards in this Set
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What % of people with GORD get Barrett?
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10%
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Beefy red mucosa extending to oesophageal body
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Mechanism of cushing's/curlings ulcers?
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increased acid production and muscosal ischemia as a result of planchnic hyperperfusion
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Follow-up of barretts
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Manage reflux
Endoscopy after 1 year (if any question regarding adequacy of biopsy (e.g. four quadrant biopsies were not obtained) No dysplasia: followup every 3-5 yrs |
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Management of low grade dysplasia in barrets?
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surveillance endoscopy at intervals of 6-12m/radiofrequency abalation
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Management of high grade dysplasia
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Oesophagectomy only definitive therapy but also most morbid- use for younger, long segment barrets
endoscopic eradication therapy: endoscopic mucosal resection followed by radiofreq abalation |
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predisposing factors to duodenal ulcers
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H. pylori
genetic predisposition blood group O non-secretors of blood group antigen in saliva high circulating pepsinogen |
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Management of duodenal ulcer?
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initially resuscitate + NG decompression and irrigation with large bore NGT\IV omeprazole
endoscopy to rule out malignancy if obstruction due to oedema- will resolve with above measures definitive mx: obstruction enlarged/bypassed/resected\in elderly/unfit for surgery: dilatation of the stenotic area using a baloon catheter may be considered. |
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Mortality from ulcer bleeda
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most bleeds from erosion of medium sized artery in submucosa
10% mortality 85% stop bleeding spontaneously risk of re-bleeding depends on appearance- usually in 1st 72 hours |
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What do you need to do in order to test for H. pylori
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stop PPI for 2 weeks
PPI decreases organisms--> false negatives |
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What can an endoscopy see up to
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2nd part of the duodenum
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What assists viewing of mucosal detail in stomach?
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double contrast radiography- use of effervescent tablets to produce gasseous distension of stomach and duodenum and spread contrast in thin, even layers
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Efficacy of triple therapy for H.pylori eradication
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90% at 1-2 weeks
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Surgical options for management of gastric ulcer?
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1. Polya's gastrectomy- 2/3 of stomach removed--> get dumping syndrome
Truncal vagotomy+ drain- v.slow transit 3. Highly selective vagotomy- few side effects but 15% recur\ 3. vagotomy + antrectomy |
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What is the relationship between oesophageal motility and the occurrence of reflux
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Many people with reflux have disordered motility in their oesophagus
May be concequence and perpetuating factor rather than original cause |
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What is a Barrett's ulcer?
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A gastric ulcer in the gastric mucosa of the oesophagua
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Most common complication of severe gastro-oesophageal reflux?
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chronic blood loss leading to iron deficiency anaemia- most commonly seen in bed bound pts in the hospital setting
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Why does a hiatus hernia occur
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attenuation of hiatal attachments combines with the upwards pull of the longitudinal muscle of the oesophagus
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What part of the stomach herniates with a para-oesophageal hiatus hernia?
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anterior wall
This hernia can be huge and involve virtually all of the stomach |
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Symptoms associated with a paraoesophageal hiatus hernia?
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occasionally asymptomatic
pain and discomfort after meals intermittent twisting- more acute episodes of pain emergency presentation- strangulation of the hernia |
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Management of para-oesophageal hernias?
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can be left- but some believe all should be repaired
in practice many occur with sliding hernias and will have some reflux (mixed hernia)- hiatus is nattowed by approxing the muscle pillars of the hiatus posterior to the diaphragm. Then fundus of the stomach is fixed with sutres to the diaphragm |
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Which patients with reflux should be investigated further?
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atypical symproms, patients in whom high level therapy e.g. PPI are required to control symptoms
Undergo an endoscopy If no oesophagitis found- get the pH profile |
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Which patients are not suitable for anti-reflux surgery?
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shortened oesophagus
previous upper abdominal operations 2% rate of conversion to open |
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What is a functoplication
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fundus of the stomch is drawn around behind the oesophagus and stitched to itself behind the oesophagus
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Problem with fundoplication?
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holds gas in the stomach- can't belch
can't vomit dysphagia: for a number of reasons e.g. wrap is too tight 15% recurrent reflux |
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What % of oesophageal neoplasms are benign?
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<1%
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Most common oesophageal neoplasm?
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Leomyoma: solitary, well-encapsulated with intact overlying mucosa and grow slowly. <5cm- asymptomatic and incidental finding on barium study
rarer: papillomas, fibrovascular polyps, granular cell tumours, adenomas, hemangiomas, neurofibromas and lipomas |
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Do leomyomas turn into leomyosarcomas?
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no good evidence that they do
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Management of oesophageal leomyomas
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observe if small/asymptomatic
surgical removal if large (>5cm) or symptomatic occasionally oesophageal resection is necessary (large, annular tumours) |
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Difference in oesophageal cancer incidence between low and high incidence areas?
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50-100 fold
2-3/100000 in australia |
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Risk of oesophageal cancer if have another aerodigestive malignancy?
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5-8%
same carcinogens "field cancerization" |
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Most common oesophageal cancer?
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scc worldwide
adenocarcimoma in western countries: lower oesophagus and gastric cardia Together >90% of all cancers |
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Prevalence of adenocarcinoma in Barrett's oesophagus?
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13%
30-fold increase |
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What is the classification of adenocarcinomas within 5cm of the gastro-oesophageal junction
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Type 1: lowe oesophageal- many Barrett's (-5 to -1)
Type II: cardia (-1 to +2) Type III: (2-5) Suggested that the three types differ in pathological and clinical features |
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Typical patient with oesophageal cancer
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Male, >50
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Most common symptom of oesophageal cancer?
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rapidly progressive dysphagia
solid--> liquid in manner of weeks usually not felt until tumour is advanced |
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More likely diagnosis in patient with dysphagia and evidence of GI bleeding
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more likely to have adenocarcinomas of GE junction
SCC's of the oesophagus rarely bleed |
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Diagnosis of early mucosal lesions? (oesophageal cancer)
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biopsies + brush cytology
Lugol's iodine helps find dysplastic areas |
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What is best for T and regional N- staging of oesophageal cancer
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Endoscopic ultrasound (90% T, 80% N) and can do EUS-guided LN biopsy.
CT is better for distant metastases PET for distant node and systemic mets (not as good as local-regional staging) |
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Which oesophageal tumours are palliated from the outset?
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T4/TOF
IVb with visceral mets endoscopic +/- radiotherapy/chemo |
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Pre-operative optimization before oesophageal cancer management?
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smoking cessation- initiate active chest physio
Consider enteral/parenteral nutrition |
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Management of tumours in middle/lower 1/3 of oesophagus
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Lewis-Tanner procedure
Mobilise stomach via laparotomy, do pyloromyotomt/pyloroplasty, resect oesophagus into right thoracotomy, stomach delivered up to anastomose. |
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Management of type II + III tumours around the gastro-oesophageal junction.
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Extended total gastrectomy with distal oesophageal resection
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Lymph node management in surgery for oesophageal cancer?
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lymphadenectomy of the upper abdomen and mediastinum
some surgeons advoacte bilateral neck dissection- three field dissection as 30% have positive cervical LN |
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Most common complications after oesophageal surgery
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pulmonary> cardiac
Pulm: atelectasis, sputum retention, pleural effusion cardiac: most common is atrial arrhythmia: most often benign/responds to meds, but look for sepsis Prevent: chest physio, early tracheostomy in pts with poor cough effort/vocal cord paralysis |
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Incidence of anastomotic leak and mortality after oesophageal resection
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Anastomotic leak <5%: adequate drain, antibiotics, nurtitional support
<5% in dedicated centres |
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Is radiation alone useful for tumours of the oesophagus
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chemoradiation is better in patients who can tolerate it- response rate, local control and long-term survival
Radiotherapy alone- palliative role in pts who can't tolerate/brachytherapy also gives good palliation |
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Has neoadjuvant/adjuvant chemoradiotherapy been shown to improve survival above surgery alone
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no.
Only people with good response benefit cysplatin and 5FU |
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Management of very early mucosal lesions of oesophageal cancer?
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endoscopic mucosectomy
cancer is "raised" by injecting saline and is snared by an electrocautery loop as in polypectomy |
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Non-surgical palliative options for oesophageal cancer
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self-expanding metallic stents
laster therapy- repeated rx sessions often required |
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Prognosis in oesophageal ca
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83, 32, 13, 7 with resection alone
adeno ca > SCC |
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Which muscles make up the upper esophageal sphicter? What type of muscle is found in the esophagus? Epithelium? Nerve supply?
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UES - Cricopharyngeous muscle and inferior fibres of pharyngeal constrictor muscles
Upper 1/3 incl hypopharynx striated, lower 2/3 smooth muscle Stratified squamous epithelium; inner circ outer long muscles with no serosa. Motor + sen via CNX, sympathetic supply from thoracic spinal nerves |
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What is primary peristalsis? Secondary peristalsis?
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Pri peristalsis - MAIN swallowing mechanism. Chewing, degluttation, airway protection (nose and larynx), UES opens briefly, orderly propulsion, LES opens briefly
Sec peristalsis - a response to distention, localized peristaltic wave starting just above disteded area assoc with LES relaxation Tertiary peristalsis = uncoordinated contraction |
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What is dysphagia? What do you need to clarify in a history of dysphagia?
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Dysphagia = difficulty swallowing
Hx: Duration Progressiveness/Intermittent Solids vs liquids vs both Location (usually well localized except with some distal lesions e.g. distal esophageal ca can be falsely localized more prox) |
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What are the patterns of dysphagia? Solids/liquids? Which disorders are associated with each?
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1. Mechanical obstruction - stricture/cancer:
problem solids>liq, constant, progressive 2. Motility disorders - achalasia: liq=solids, episodic, non-progressive |
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What is odonyphagia? What is it caused by?
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Odynophgia = painful swallowing
Usually caused by non-GERD esophagitis: Infx esp viral HSV CMV Radiation Drugs (bisphosphonates, tetracycline, potassium, aspirin, NSAIDs, Iron) Cancer Deep Barrett's ulcer Esophageal motor disorders |
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What is the investigation of choice in dysphagia?
Which studies can assess degree of reflux? What other investigations are used? |
BARIUM SWALLOW is THE investigation of choice in dysphagia
24hr pH study can assess the degree of reflux and relation of atypical symptoms to reflux episods Endoscopy and Biopsy Esophageal manometry - to assess muscle contraction on swallow CXR/CT Radionuclide scan to assess transit |
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What is primary peristalsis? Secondary peristalsis?
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Pri peristalsis - MAIN swallowing mechanism. Chewing, degluttation, airway protection (nose and larynx), UES opens briefly, orderly propulsion, LES opens briefly
Sec peristalsis - a response to distention, localized peristaltic wave starting just above disteded area assoc with LES relaxation Tertiary peristalsis = uncoordinated contraction |
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What is dysphagia? What do you need to clarify in a history of dysphagia?
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Dysphagia = difficulty swallowing
Hx: Duration Progressiveness/Intermittent Solids vs liquids vs both Location (usually well localized except with some distal lesions e.g. distal esophageal ca can be falsely localized more prox) |
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What are the patterns of dysphagia? Solids/liquids? Which disorders are associated with each?
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1. Mechanical obstruction - stricture/cancer:
problem solids>liq, constant, progressive 2. Motility disorders - achalasia: liq=solids, episodic, non-progressive |
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What is odonyphagia? What is it caused by?
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Odynophgia = painful swallowing
Usually caused by non-GERD esophagitis: Infx esp viral HSV CMV Radiation Drugs (bisphosphonates, tetracycline, potassium, aspirin, NSAIDs, Iron) Cancer Deep Barrett's ulcer Esophageal motor disorders |
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What is the investigation of choice in dysphagia?
Which studies can assess degree of reflux? What other investigations are used? |
BARIUM SWALLOW is THE investigation of choice in dysphagia
24hr pH study can assess the degree of reflux and relation of atypical symptoms to reflux episods Endoscopy and Biopsy Esophageal manometry - to assess muscle contraction on swallow CXR/CT Radionuclide scan to assess transit |
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What types of hiatus hernias are there? How to diagnose? Rx?
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Sliding 95% - GEJ and a position of stomach above diaphragm
Rolling/Paraesophageal 5% - GEJ remains below diaphragm while fundus herniates into mediastinum Dx: GERD or dysphagia with sliding hernias, CP if strangulated/incarcerated with paraesophageal, usually asymptomatic. (linear erosions along top of rugal folds in paraesophageal hernias can cause slow occult bleeding and Fe def) Rx: Sliding - medical Rx and lifestyle mod to decrease sx Paraesophageal: Gastropexy - stomach attached to rectus sheath, closure of the hiatus, to prevent gastric volvulus |
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What is waterbrash? Name other symptoms of GERD
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Waterbrash = hypersalivation. Other sx: heartburn, regurgitation of acid or food, chest pain, dysphagia, hematemesis (in elderly long-term recumbent pts)
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Typically postprandial or when supine
Fre |
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What is the mechanism behind GERD? Is excess acid involved?
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Excess acid is NOT involved
Mechanisms: Lax LES - but in MOST, resting pressure is NORMAL Increase freq and duration of transient LES relaxation Reduced secondary peristaltic activity/clearance Impaired mucosal defence Hiatus Hernia Pregnancy - raised intraab P and progesterone) Delayed gastric emptying |
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What are some complications of GERD?
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Reflux esophagitis (inflammation due to acid/pepsin contact in LE)
Peptic stricture Barrett's esophagus Esophageal cancer Esophageal spasm - non cardiac CP Airway complications - asthma, laryngeal irritation Dental - thinned enamel Bleeding from interrupted mucosa, Iron deficiency resulting |
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When is endoscopy useful in GERD Dx?
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ONLY when there is Reflux Esophagitis, otherwise completely normal
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Other studies:
Esophageal pH studies - when dx in doubt Ba swallow Therapeutic trial of acid suppression |
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What are the therapeutic options for GERD?
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Lifestyle - avoid alc, choc, fatty foods, smoking; gap between food intake and bedtime
Acid suppression - PPI (omeprazole/pantoprazole) or H2R antagonists, prokinetics (cisapride - no longer used cos of cardiac SE), Fundoplication (restore LES to intra-abdominal pos, wrap stomach to extrinsically bolster LES, repair patulous hiatus) |
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What is reflux esophagitis grading (LA, A-D) based on?
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Endoscopic - depends on length of
Vertical mucosal breaks and Bridging around the circumference of the esophagus |
A precursor of peptic stricture and Barrett's esophagus
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How does a peptic stricture develop?
How would you treat? |
Due to severe GERD, repair of reflux esophagitis causes fibrous collagen deposition
Leads to mechanical obstruction - dysphagia, bolus impaction |
Treated by balloon dilatation of stricture + acid suppression therapy to prevent recurrence
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What is the hallmark of Barrett's esophagus?
How would you treat? |
Presence of columnar epithelium incl intestinal metaplasia in LE (beefy red mucosa extending into esophageal body)
Premalignant, incidence of adenoCa ~1 per 200 patient-years of f/u (40x gen pop) |
PPIs long term and surveillance endoscopy with bx every 3 years to check for dysplasia
Endoscopic resection, radiofrequency ablation |
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What are the clinical features of eosinophilic esophagitis?
What is it associated with? |
Dysphagia, CP, bolus impaction, heartburn resistent to PPI
50% assoc with ATOPY (asthma, eczema, hay fever, allergic rhinitis, environmental or food allergens) |
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How would you diagnose eosinophilic esophagitis?
What is the treatment? |
Characteristic clinical features +
>15 eosinophils per high-power field on eso biopsy, despite PPI Endoscopy: multiple rings, furrows, whitish exudates, tramtracks running parallel to eso Peripheral eosinophilia Raised serum IgE |
Rx: Swallowed fluticasone
Elimination diets via allergy clinic Montelukast (LT receptor antagonist) Careful dilatation |
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What is the prognosis for esophageal cancer (5ysr)?
How is it diagnosed? |
AdenoCa and SCC
Poor px - <10% 5ysr Endoscopic US + CT chest/abdo |
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What are the premalignant conditions predisposing to esophageal cancer?
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Usually a complication of Barrett's esophagitis
GERD Achalasia Alkali injury Celiac disease Rarely from embryonic remnants of columnar epithelium in esophagus |
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How would you treat esophageal cancer?
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Surgery
XRT Palliative - endoscopic stenting |
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What do esophageal dysmotility syndromes usually present with?
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Dysphagia +/- chest pain (similar to angina)
Classically attributed to smooth muscle spasm, irritable esophagus or lowered visceral pain threshold for distension/acid |
Achalasia
Diffuse esophageal spasm Nutcracker esophagus Non-specific dysmotility disorder (majority have normal manometry) |
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What is Achalasia due to?
What are the symptoms? |
Failure of LES to relax, loss of degeneration of inhibitory ganglion cells in the myenteric plexus of the esophageal body and LES
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Dysphagia - often intermittent and longstanding
Pseudo-heartburn Inability to belch (can't relax LES) Cough, aspiration |
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What would you see on CXR in achalasia? Barium swallow? endoscopy? Manometry?
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CXR - grossly dilated esophagus with A-F level
Barium Swallow - smoothly tapering beak narrowing distally Endoscopy - grossly dilated eso body containing food/saliva Manometry - lack of peristalsis in body of esophagus, elevated LES pressure, absent or incomplete relaxation of LES in response to swallowing, progressive dilatation and intraesophageal pressures |
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How is achalasia treated?
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Surgical Heller's procedure + anti-reflux fundoplication procedure
Pneumatic dilatation (bigger than stricture dilatation) Botulinum toxin injection of LES (not durable) |
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What is pseudo-achalasia? Who would you suspect it in?
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Achalasia secondary to carcinoma
E.g. 2/2 gastric cancer of the fundus (exclude with endoscopy) May be paraneoplastic or metastatic (lung ca, hepatoma, pancreatic ca, lymphoma, prostate ca) Suspect in OLDER patient with first-time symptoms |
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What does diffuse esophageal spasm show on manometry? Barium swallow?
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Normal peristalsis interspersed with frequent high-pressure non-propogated tertiary waves and multi-peaked waves
Ba swallow - corkscrew pattern |
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What does nutcracker esophagus show on manometry?
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Peristalsis normally propogated but high-amplitude and prolonged duration
Nitrates and CCB used but of little proven benefit |
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Differentiate oral dysphagia from pharyngeal dysphagia
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Oral - drooling, spillage of food from mouth, inability to chew or propel food backwards, trouble initiating swallow, dysarthria
Pharyngeal - immediate bolus hold-up in neck, choking, coughing, nasal regurgitation assoc with swallow, repeated swallow to clear pharynx, aspiration, dysphonia |
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What connective tissue and neuro disorders are assoc with oropharyngeal dysphagia?
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Stroke, MS, MND
Parkinson's MG polymyositis/dermatomyositis amyloidosis, sarcoidosis, SLE DRUGS - phenothiazines, penicillamine, statins, amiodarone |
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What is the typical history of a schatzki ring?
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Longstanding intermittent dysphagia or episodic food bolus impaction with meat ('steakhouse syndrome'), often when eating out/rushing meals
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Treat with dilatation
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What is Boerhaave's syndrome? What is it caused by?
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Spontaneous esophageal rupture
Typically with vomiting but ANY transient elevation of IAP (lifting, straining) p/w pain, vomiting, SUBCUT EMPHYSEMA in supraclavicular fossa/neck, pneumothorax/pneumomediastinum, dysphagia EMERGENCY, shock, hypotension |
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Do all patients with esophageal candidiasis have oral thrush? How to treat?
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Pts with esophageal candidiasis DO NOT necessarily have oral thrush.
Assoc with immunosuppression, steroids, diabx, abx Treat with topical/oral antifungal |
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What is the difference between globus sensation and dysphagia?
How to treat? |
Globus sensation - NON-painful sensation of lump or fullness in the throat, often NOT present when swallowing
May be manifestation of GERD (Dysphagia = difficulty swallowing liquids/solids) Treat with trial of PPI to r/o GERD cause and REASSURE |
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What is Zenker's diverticulum? What are some complications?
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Outpouching posterior between fibres of inferior pharyngeal constrictor muscles: proximal to the cricopharingeus
Shifts left with enlargement May fill with food preferentially and extrinsically compressing the esophagus Cx: Regurgitation of old food Aspiration with left sided neck mass Perforation during endoscopy |
Occurs in a variety of circumastances predisposing to herniation within Killian's triabgle e.g. abnormal oesophageal motility, oesophageal shortening or disorders associated with UES dysfunction.
Endoscopic rx |
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What is the progression of pathophysiology in scleroderma esophagus?
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Small BV damage -> neuronal dysfunction in esophageal wall -> muscle damage and fibrosis hence hypotensive LES and weak non-propulsive contractions
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How would you treat esophageal varices?
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Beta blocker propranolol
Band ligation Tamponade TIPS/portosystemic shunts |
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