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OESOPHAGEAL DISEASE Anna Onochie-Williams and Saad Dosani 4 Year Medical Students, University of Manchester Disclaimer • This teaching session is taught by students/Doctors for students and is meant to be supplementary to your anatomy and TCD sessions, and not a replacement! (So you still have to go through OneMed ) • It is not comprehensive and is designed to provide a high-yield overview of certain conditions! • We will answer all questions at the end for the purposes of time ☺ Anatomy of the Oesophagus •Fibromusculartube - From cricoid cartilage (C6) to Stomachcardia (T11) •Crosses diaphragm–T10 •Layers - Similarto rest of GI tract •Sphincters • UOS - Anatomical • LOS - Physiological/functional •ABCD - physiologicalconstrictions •Neurovascular Supply • Thoracic vs Abdominal Oesophageal Physiology • 25 cm long muscular channel - transports food from pharynx to stomach • 2 sphincters- • UOS - prevents food regurgitating back into the airways • LOS – anti-reflux barrier that protects oesophagus from acidity of gastric secretions • Food enters mouth, mixes with saliva → bolus • Bolus reaches pharynx → swallowing → UOS relaxes → bolus enters oesophagus • Travels down oesophagus by peristalsis • Once reaches distal end of oesophagus → LOS relaxes → bolus enters stomach History Taking PC - Difficultyswallowing,painful swallowing,reflux HOPC- SOCRATESif pain, length of timeit has been going on for, progression (solids → liquids,or both from the start) Systemicsymptoms-RED FLAGS - unintentionalweight loss, fevers, night sweats, fatigue Systemsreview - Cardio-respiratory, GI, neurological, genito-urinary,musculoskeletal, dermatological PMH – GORD - increased risk of Barretts oesophagus, previous cancers DH - And allergies. Certain medicationscan cause oesophageal pathologiesas a S/E eg- ibuprofen, tetracyclines, bisphosphonates FH - Oesophageal disease SH - Smokingand alcoholconsumption-risk factors for GORD and oesophageal cancer Causes of Dyspepsia - Summary ▪ Common ▪ Less common ▪ Red flags ▪ GORD ▪ Cholelithiasis ▪ Upper GI Malignancy ▪ Oesophagitis ▪ Coeliac ▪ Coronary artery ▪ Peptic Ulcers ▪ Pancreatitis disease ▪ H Pylori ▪ Hypercalcaemia ▪ Functional ALARM Sx GORD – Gastro Oesophageal Reflux Disease • Definition: • Investigations • ACG - ‘Symptoms or complications resulting • 8 week trial of PPI (diagnostic and from the reflux of gastric contents into the therapeutic) oesophagus or beyond (oral cavity or lungs)’ • Consider - OGD • Important histology • Management • Oesophagus - squamous epithelial • Lifestyle • Stomach - columnar epithelial • Acid neutralization • PPI • S+S - dyspepsia, epigastric/retrosternal pain, • Surgery nausea, bloating. • Prognosis • Risk factors - Positive family history, hiatus hernia, • Usually good, patients respond well to obesity/smoking. PPI’s. • Complications • Strictures • Barrett’s Oesophagus • Oesophageal carcinoma Barretts Oesophagus • Definition • Constant reflux causes epithelialchanges. • Terminology:metaplasia vs dysplasia vs neoplasia • RF/History • Demographic • Heartburn/GORD • Investigations • Upper GIendoscopy with biopsy • Management • Non-dysplastic • Low grade dysplasia • High grade dysplasia • Neoplasia • Prognosis • Routineendoscopy surveillance (typicallyevery 2 years). H.Pylori, Oesophagitis and other causes H.pylori Oesophagitis • Definition • Definition • Inflammationof liningof oesophagus • Gram negative bacteria in stomach • Investigations • Investigations • Endoscopy • Urea breath test • Stool antigen test • Rapid urease test (during endoscopy) • Management • Oral corticosteroids • Management • Triple therapy • PPI • 2 antibiotics • Prognosis Other • Often very good • Functional • Peptic ulcers/perforation (rare) • Drug induced Causes of Dysphagia - Summary ▪ Oesophageal Causes ▪ Oropharyngeal Causes ▪ Oesophageal cancer ▪ Stroke ▪ Oesophageal webs ▪ Dementia ▪ Extrinsic masses ▪ Cerebral Palsy compressing on ▪ Multiple Sclerosis oesophagus ▪ Achalasia ▪ Parkinson’s Disease ▪ Oesophagitis Oesophageal Cancer • Around 2% of cancers in UK. 5-year survival- 15% • 2 main types- • Adenocarcinoma • Most common type, usually secondary to GORD and Barrett’s • Affects lower 1/3 • Squamous cell carcinoma • Affects upper 2/3 • Clinical features- • Progressive dysphagia- solids → liquids • Can be associated with odynophagia, anorexia, hoarse voice, cough, vomiting • Red flag symptoms eg- unintentional weight loss, fatigue • Risk factors- • GORD and Barrett’s oesophagus • Obesity • Smoking • Achalasia • SCC associated with diet rich in nitrosamines (eg-cured meats) Oesophageal Cancer • Refer under urgent 2WW pathway if- • Dysphagia at any age, or if ≥55 with weight loss and one of the following- • Upper abdominal pain • Reflux • Dyspepsia • Investigations- • Bloods • OGD with biopsy • Staging CT-TAP- identify whether tumour is resectable or non-resectable • Management • MDT approach- depends on stage of tumour, type of cancer and patient’s overall health • If resectable- surgery, chemotherapy- better prognosis • If non-resectable or distant metastases- poorer prognosis- palliation, oesophageal stenting to relieve symptoms Achalasia • Failure of oesophageal peristalsis and relaxation of LOS- motility disorder • Auerbach’s plexus • Clinical features- • Dysphagia to both solids and liquids- not progressive • Heartburn • Regurgitation of food, especially at night → cough, aspiration pneumonia • Diagnosis- • Barium swallow • Beak deformity • Manometry • Lack of peristalsis • High resting LOS pressure • Treatment- • Endoscopy balloon dilatation of LOS- preferred • Surgery- Heller’s myotomy • Intrasphincteric Botox injections in high-risk surgical patients Oesophageal Webs • Thin membranes of oesophageal tissue - occur anywhere along length of oesophagus → obstruction • Asymptomatic, but can cause dysphagia and odynophagia • Congenital (lower oesophagus) or acquired (cervical region) • Seen in Plummer-Vinson syndrome • Dysphagia • Glossitis • IDA • Diagnosis- • Barium swallow • OGD • Treatment- • Endoscopic dilatation Questions You see a 56 y/o man who was admitted for an elective upper GI endoscopy due to longstanding GORD which has failed to improve on antacids and PPI’s. Your registrar suspects that this patient may have Barrett’s Oesophagus and asks you to define what it is. The most appropriate description of Barrett’s Oesophagus is: A. Metaplasia of the squamous epithelium of the lower third of the Oesophagus to columnar epithelium B. Metaplasia of the columnar epithelium of the Upper third of the Oesophagus to squamous epithelium C. Metaplasia of the columnar epithelium of the lower third of the Oesophagus to squamous epithelium D. Metaplasia of the squamous epithelium of the upper third of the Oesophagus to columnar epithelium E. Metaplasia of the squamous epithelium of the middle third of the Oesophagus to columnar epithelium Questions A 47 y/o woman presents to your clinic with a three-month history of dysphagia. There is no history of drastic weight loss and the patient experiences symptoms when swallowing solids and liquids. Which of the following is not an obstructive cause of dysphagia? A. Pharyngeal carcinoma B. Oesophageal web C. Retrosternal goitre D. Peptic stricture E. Achalasia Questions You see a 47 y/o man in clinic with a three-month history of epigastric dull abdominal pain. He states that the pain is worse in the mornings and is relieved after meals. On questioning there is no history of weight loss and the patient’s bowel habits are normal. On examination, his abdomen is soft and experiences moderate discomfort on palpation of the epigastric region. The most likely diagnosis is: A. Gastric ulcer B. GORD C. Duodenal ulcer D. Gastric carcinoma E. Gastritis Questions • A- Barrett’s oesophagus • B- Achalasia • C-Oesophageal web • D- Oesophageal cancer • 56 year old woman presents with difficulty swallowing over the last few months. Further questioning reveals she feels more tired than usual, but there is no history of recent weight loss. FBC shows low Hb and low MCV • 31 year old female with intermittent history of swallowing difficulties, occurring with both solids and liquids. There is no history of weight loss. • 69 year old male attends his GP with difficult swallowing. Originally he had problems with solid food, but now is struggling with a soft diet too. He has lost 3 stone, which he puts down to changes in his diet Thank you for Joining! • Fill out feedback form- slides and certificates will be sent out to you • Please check out our upcoming events! • Resources used • Zero to Finals, Teach Me Anatomy, Oxford Handbook, BMJ Best Practice, PassMed and a very small amount of previous knowledge. • Any further questions? • lapsoc@outlook.com • Instagram- @lapsoc_uom • Facebook- @lapsoc