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Alimentary > S2: The Oesophagus and Its Disorders II > Flashcards

S2: The Oesophagus and Its Disorders II Flashcards

1
Q

What is Achalasia?

A

Disorders of motility or perisalsis of oesophagus (assess the motor function of the UOS, LOS and oesophageal body)

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2
Q

What is GORD?

A

Reflux of stomach acids into oesophagus; regurgitation (weak LOS)

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3
Q

What is Aphagia?

A

Swallowing difficulty (must determine the cause)

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4
Q

What are oesophageal spasms?

A

Abnormal oesophageal contractions and food is not effectively reaching the stomach

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5
Q

What are diffuse oesophageal spasms?

A

Chest pain coming from oesophagus (feel like angina)

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6
Q

What happens in a patient with Achalasia?

A

Achalsia is characterised by a loss of coordinated peristalsis, spasms of LOS and failure of LOS to relax.

This causes a hypertensive LOS (high pressure) There is also a failure to develop the wave of peristaltic contractions at the distal oesophagus
Food and liquids hence tend to get stuck and fail to reach the stomach

As a result of this there ends up being long periods of sporadic dysphagia (difficulty swallowing), regurgitation of food and spasm disorders (chest pain, but not of cardiac cause, so could be misdiagnosed as angina).
Another thing associated with achalasia is stacking of food within the oesophagus, this is a rare incidence but can present at any age.

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7
Q

Cause of achalasia

A
  • Damage to the innervation of the oesophagus (means a loss of sensory and motor input, needed to massage food down oesophagus)
  • There may be degenerative lesions of the vagus nerve
  • Loss of ganglionic cells in the oesophagus

The. initiating factor is thought to be autoimmune or triggered by infection.

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8
Q

Symptoms of Achalasia

A
  1. Dysphagia: Difficulty or painful swallowing
  2. Vomiting
  3. Heartburn
    - Retrosternal burning sensation due to oesophageal dysmotility
    - Retention of ingested acidic food
    - Generation of lactic acid in the process of decomposition of retained food
    - heartburn could be caused by the retention of small quantities of acid reflux in the oesophagus due to poor emptying and incomplete relaxation of LOS
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9
Q

How is Achalasia diagnosed?

A
  • Clinical examination
    1. Radiography by doing a barium swallow. In achalasia, dilation of oesophagus would be seen with ‘beak’ deformity at lower end.
    2. Oesophageal manometry
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10
Q

What is achalasia associated with?

A
  • Oesophageal motor disorder
  • Increase in LOS pressure
  • Discoordination of LOS relaxation
  • Absence/failure of peristalsis
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11
Q

Function of oesophageal manometry

A

Oesophageal manometry tests if the oesophagus is contracting and relaxing properly:

  • it can be used to diagnose swallowing problems (does LOS contract and relax properly)
  • allows evaluation of strength of coordination of muscle contractions and also the relaxation functions of LOS
  • assesses achalasia or GORD
  • can determine cause of non cardiac pain
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12
Q

Normal and abnormal results for oesophagus manometry

A

Normal:

  • Normal LOS pressure and normal muscle contractions upon swallowing
  • Muscle contractions follow a normal pattern down the oesophagus

Abnormal:
- Presence of muscle spasms in the oesophageal body

Low LOS pressure:

  • Suggests GORD
  • Presence of weak contractions along the length of the oesophagus

High LOS pressure:

  • Achalasia
  • > 200mmHg is called nutcracker achalasia
  • High LOS pressure which fails to relax after swallowing
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13
Q

Why can GORD occur in people with normal LOS pressure?

A

It is natural that LOS will open frequently when food goes through, so gastric chyme may flux up into oesophagus. The saliva we secrete should be able to clear this acidic material to be pushed into the gut

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14
Q

Describe the procedure of an oesophageal manometry

A
  1. Anaethetise through local anaesthetic/numbing gel
  2. Lubricated pressure sensitive tube is inserted in notril–> throat –> oesophagus –> stomach
  3. Deep breath and swallow water
  4. Measure the strength and coordination of muscle contractions and strength and relaxation function of LOS
  5. Remove catheter and acquire data
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15
Q

How is Achalsia treated?

A
  • We can do an endoscopic balloon dilation of the LOS or perform surgery to weaken the sphincter.
  • If reflux occurs, we may want to perform a fundoplication, this is where we get some fundal tissue and wrap it around the oesophagus
  • inhibit the release of acetylcholine, because the contractile effects of the LOS are mediated by Ach, this can be done by injecting botulinum toxin into the LOS.
    Botulinum toxin injections are well tolerated, safe and efficacious (successful in producing the desired consequences). It blocks cholinergic nerve endings in the ANS. This option is taken if there is a high surgical risk.
    .
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16
Q

What is achalsia a risk factor for?

A

Achalasia is a risk factor for squamous carcinoma of the oesophagus, so it is important we treat it

17
Q

What happens in Gastro-oesophageal reflux disease (GORD)?

A
  • The gastric contents are irritating and if they flux up into the oesophagus, this will cause the symptoms of GORD.
  • Reflux is brief, relatively infrequent and often occurs after meals in normal individuals (due to transient spontaneous LOS relaxation leading to gastric chyme entering up into oesophagus).
18
Q

Causes of reflux in individuals with GORD

A
  • It may be in GORD that the resting LOS pressure is too weak to resist the pressure within the stomach
  • Or that sudden relaxation of the LOS is not induced by swallowing (i.e. at times the LOS relaxes in the absence of swallowing, causing acid to move up and reach the oesophagus) - e.g. lying flat
  • Transient spontaneous LOS relaxation (tsr)

A malfunction of extrinsic and intrinsic components of LOS = GORD

19
Q

Factors that contribute to the severity of GORD

A
  • Weak or uncoordinated oesophageal contractions (may be a result of oesophageal irritation from reflux disease itself)
  • Length of time oesophagus is bathed in refluxed acid (if swallowing of ones saliva is not occurring properly/not enough saliva)
  • Increased gastric acid secretion coupled with the presence of bile in gastric contents
    = Severe damage
  • The amount of pressure placed on the anti-reflux barrier (if a lot of pressure placed on it, a lot of chyme will go into oesophagus)

Overall, reflux occurs after eating, lying down and when there is delayed gastric emptying. This occurs especially when there is high fat food.
Impaired gastric emptying may also lead to GORD.

20
Q

Does reflux happen in all of us?

What natural body mechanism do we have to counteract this?

A
  • Usually reflux (which happens in all of us) stimulates salivation, saliva is an effective natural antacid. This dilutes and neutralises any refluxed gastric contents. A low rate of salivation or a lack of ability to swallow ones own saliva, would lead to the reflux material remaining in contact with our oesophagus for a prolonged period. This can lead to oesophageal irritation and oesophageal damage.

Secondary peristalsis causes secretion of saliva which neutralises acid in the oesophagus (in normal individuals).

21
Q

Risk factors for GORD

A
  • Pregnancy or obesity
  • Fat, chocolate, coffee or alcohol ingestion (alcohol is an irritant, chocolate contains chemicals that induce relaxation)
  • Large meals, tomatoes, orange juice, onions etc.
  • Cigarettes
  • Drugs (e.g. anticholinergic agents, calcium channel blockers and nitrate drugs)
22
Q

Complications of GORD + potential long term effects

A

Oesophagus has squamous mucosa, acid reflux can cause desquamation of oesophageal cells (injury of squamous mucosa).
Increased cell loss can result in basal cell hyperplasia.

Excessive desquamation can result in ulceration, ulcers may haemorrhage, perforate or heal by fibrosis with strictures.

Barrett’s oesophagus and oesophageal cancer may form also!

23
Q

How is GORD investigated?

A
  • Low does proton pump inhibitor (PPI)
  • Upper GI endoscopy
  • Manometry
  • 24 hr pH monitor
24
Q

Explain the link between pregnancy and GORD

A

When pregnant, the foetus increases pressure on abdominal contents, this pushes terminal segments of oesophagus into the thoracic cavity.
The last part of pregnancy is associated with increased abdominal pressure and this forces gastric contents into the oesophagus.
HCl from the stomach irritates the oesophageal walls, leading to pain (heartburn).

Heartburn subsides in the last months of pregnancy as the uterus descends into the pelvis.

25
Q

When does heartburn often occur?

A

Often occurs after large meals
- A less efficient LOS
Gastric contents get episodically refluxed into the oesophagus and thus you get heartburn. This can lead to ulceration, scarring and then obstruction or perforation of the lower oesophagus.

26
Q

Symptoms of GORD

A

Manometry will be ordered if you have symptoms of:

  • Heartburn or nausea after eating (GORD)
  • Problems swallowing (feeling that food is stuck behind breastbone, this would be achalasia)
27
Q

Management of GORD (non drug)

A
  • Life – style changes! For example raising head of bed at end of night, so any chyme in oesophagus can drain into stomach
  • Decreasing intake of food and drink which precipitate attacks
  • Anti-reflux surgery (such as a fundoplication, where we wrap the fundus around the LOS)
28
Q

Management of GORD (drug)

A
  • Take antacids
  • Use H2 (histamine) receptor antagonists and proton pump inhibitors
  • Metoclopramide/domepridone may enhance peristalsis and help aid clearance (of acid, in GORD)
29
Q

List lifestyle changes that can alleviate symptoms of GORD

A
  • Avoiding large meals
  • Losing weight (if overweight)
  • Avoid foods that lower oesophageal sphincter pressure
  • Avoid foods that slow gastric emptying
  • Avoid foods that increase gastric acidity e.g. onions
  • Avoid some drugs and smoking
  • Decrease total fat intake

Basically, if you know what aggravates the symptoms, you can try to implement life-style changes that may help alleviate the onset -> ‘what do you think triggers your reflux

30
Q

What do Antaacids do?

A

Antacids neutralise gastric acid and increase pH of the gastric lumen. They inhibit peptic activity and stop acid secretion.

e.g. Magnesium salts -> diarrhoea
Aluminium salts -> constipation

Alginic acid and saliva form a raft which floats on the contents of the gastric lumen and protects the oesophageal mucosa from reflux.

Alimentary (18 decks)

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