iii years block 8 oesophagus symposium objectives
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III YEARS BLOCK 8 – OESOPHAGUS SYMPOSIUM OBJECTIVES

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III YEARS BLOCK 8 – OESOPHAGUS SYMPOSIUM OBJECTIVES. • Recognition of common diseases of the oesophagus. Cancer and reflux • Principal manifestations of oesophagus disease • Dysphagia • Heartburn • Odynophagia • Haemorrhage • Principles of diagnosis and treatment. THE SYMPOSIUM.

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iii years block 8 oesophagus symposium objectives
III YEARS BLOCK 8 – OESOPHAGUS SYMPOSIUMOBJECTIVES

• Recognition of common diseases of the oesophagus.

Cancer and reflux

• Principal manifestations of oesophagus disease

• Dysphagia

• Heartburn

• Odynophagia

• Haemorrhage

• Principles of diagnosis and treatment

the symposium
THE SYMPOSIUM

Applied Anatomy

• Topographic anatomy - neck

- mediastinum

- abdomen

• Organisation of muscles

• The sphincter apparatus

• Nerve Supply

• Blood supply

• Histology

slide3
Applied Physiology

Mechanism of swallowing

Sphincter mechanism

pathology
Pathology

Degenerative and structural diseases

  • Diverticula
  • Fistulae (and sinuses)
  • Stenotic lesions including atresia
  • Tears (Mallory-Weiss) or

Perforations (Boerhaave)

neoplastic diseases
Neoplastic Diseases
  • Benign (rare)
  • Malignant - squamous cell

- adenocarcinoma

Myoneural

• Achalasia

• Nutcracker oesophagus

• pseudo bulbar palsy

myoneural disorders
MYONEURAL DISORDERS

Achalasia

Nutcracker oesophagus

Pseudo bulbar palsy

inflammatory diseases
Inflammatory diseases
  • Infective:- Candidiasis esp with HIV

TB

Other

• Collagen vascular disorders

Scleroderma

• Chemical injury

external acid/alkali ingestion

acid/alkali reflux

pathophysiology
Pathophysiology

Effects of fistulae – pulmonary aspiration

Effects of reflux – oesophagitis and fibrotic stricture

Effects of strictures – dysphagia

Barretts Disease – premalignant

Varicose veins (varices) - haemorrhage

cardinal symptoms and signs
Cardinal Symptoms and Signs
  • Dysphagia
  • Heartburn and odynophagia
  • Haematemesis/melaena
  • Choking
  • Regurgitation/vomitting
  • Nutritional status
special diagnostic investigations
SPECIAL DIAGNOSTIC INVESTIGATIONS

Plain Radiograph especially for foreign body

Radiographic Oesophagogram

Videofluoroscopy

Endoscopy

Biopsy - cytology

- histology

Manometry

Ambullatory pH metre

principles of treatment
PRINCIPLES OF TREATMENT

Reflux Oesophagitis

• Medical

• Surgical - conventional

- minimal access (endoscopic)

haemorrhagic varices
HAEMORRHAGIC VARICES
  • Medical - β-blockers, somatostatin
  • Mechanical – balloon tamponade
  • Endoscopic - sclerosis

- banding

Surgical - oesophageal transaction

-gastric devascularisation

-portosystemic shunt incl TIPS

carcinoma
CARCINOMA

Curative treatment

• surgical

• radiation

• chemotherapy

• combination

palliative treatment
PALLIATIVE TREATMENT
  • Surgical
  • Radiation
  • Chemotherapy
  • Endoluminal intubation
  • Dilatation
  • other
achalasia
ACHALASIA

Surgical – myotomy

Dilatation

Medical – Ca++ channel blockers, vaso- dilations

Botulisation

barrett s oesophagus
BARRETT’S OESOPHAGUS

PREMALIGNANT

• Treat Reflux

• Mucosectomy

• Oesophagectomy

additional reading
ADDITIONAL READING
  • Oxford Textbook of Surgery

P J Morris and R A Malt

• Textbook of Oesophageal Disease

de Meester

oesophagus case study

Oesophagus Case Study

PROBLEM OF DYSPHAGIA

history
History
  • Progressive dysphagia.
  • Dysphagia for solids x 2 months.
  • Odynophagia – retrosternal.
  • Severe weight loss – 15 kg in 3 months.
  • No history of
    • Heartburn
    • Symptoms not related to recumbency
systemic social history
Systemic & Social History
  • Type II diabetic x 6 years. On Glucophage & Diamicron.
  • HT x 4 years. On Coversyl.
  • Non – smoker. Minimal alcohol intake.
clinical examination
Clinical examination
  • Chronically ill, wasted 62 year old male.
  • Systemic examination normal.
differential diagnosis
Differential diagnosis
  • CA OESOPHAGUS
  • CA STOMACH
  • CHRONIC PEPTIC ULCER OESOPH
  • OESOPHAGITIS-?candidiasis/HIV
  • Achalasia
investigations

Investigations

What Order of Diagnostic Investigation

oesophagoscopy
Oesophagoscopy
  • Mild distal oesophagitis with Candidiasis
  • Tight oesophageal stricture at oesophago-gastric junction. Clinically benign.
  • Stricture easily dilated to 15 mm.
  • 5 cm hiatus hernia.
  • Multiple biopsies taken.
blood tests
Blood Tests
  • HIV negative
  • Serum Albumin 14
  • Serum Glucose 5.4
biopsy result
Biopsy Result
  • Fibrosis with signs of chronic inflammation in distal oesophagus.
  • No sign of malignancy.
  • No columnar metaplasia in distal esophagus.
differential diagnosis33
Differential diagnosis
  • Oesophageal cancer
  • Complicated Gastro-Esophageal Reflux Disease (GERD)
  • Candidiasis
clinical course
Clinical Course
  • Admission
  • Treatment
    • High protein diet.
    • Oral diabetic
    • Anti-hypertensives
    • PPI
  • Repeat oesophagoscopy & biopsies: same as before, benign.
  • 24 hour pH-metry & oesophageal manometry: Normal but on PPI.
clinical course35
Clinical Course
  • Improved & gained weight on the ward.
  • Discharged on PPI & Fluconazole for review in one month.
clinical course36
Clinical Course
  • The patient was followed up after one month.
  • Symptoms had recurred:
    • Progressive dysphagia.
    • Weight loss.
  • Repeat oesophagoscopy, dilatation & biopsy: No change.
  • Sent home on PPI
clinical course37
Clinical Course
  • Patient was readmitted after one month – symptoms had again recurred.
  • Fourth oesophagoscopy + biopsies + dilatation was performed.
  • A repeat 24 hour pH-metry & manometry was booked, this time PPI was stopped one week prior to test: Normal
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