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 l.jpg
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


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THE SYMPOSIUM

Applied Anatomy

• Topographic anatomy - neck

- mediastinum

- abdomen

• Organisation of muscles

• The sphincter apparatus

• Nerve Supply

• Blood supply

• Histology


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Applied Physiology

Mechanism of swallowing

Sphincter mechanism


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Pathology

Degenerative and structural diseases

  • Diverticula

  • Fistulae (and sinuses)

  • Stenotic lesions including atresia

  • Tears (Mallory-Weiss) or

    Perforations (Boerhaave)


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Neoplastic Diseases

  • Benign (rare)

  • Malignant - squamous cell

    - adenocarcinoma

    Myoneural

    • Achalasia

    • Nutcracker oesophagus

    • pseudo bulbar palsy


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MYONEURAL DISORDERS

Achalasia

Nutcracker oesophagus

Pseudo bulbar palsy


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Inflammatory diseases

  • Infective:- Candidiasis esp with HIV

    TB

    Other

    • Collagen vascular disorders

    Scleroderma

    • Chemical injury

    external acid/alkali ingestion

    acid/alkali reflux


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Pathophysiology

Effects of fistulae – pulmonary aspiration

Effects of reflux – oesophagitis and fibrotic stricture

Effects of strictures – dysphagia

Barretts Disease – premalignant

Varicose veins (varices) - haemorrhage


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Cardinal Symptoms and Signs

  • Dysphagia

  • Heartburn and odynophagia

  • Haematemesis/melaena

  • Choking

  • Regurgitation/vomitting

  • Nutritional status


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SPECIAL DIAGNOSTIC INVESTIGATIONS

Plain Radiograph especially for foreign body

Radiographic Oesophagogram

Videofluoroscopy

Endoscopy

Biopsy - cytology

- histology

Manometry

Ambullatory pH metre


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PRINCIPLES OF TREATMENT

Reflux Oesophagitis

• Medical

• Surgical - conventional

- minimal access (endoscopic)


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HAEMORRHAGIC VARICES

  • Medical - β-blockers, somatostatin

  • Mechanical – balloon tamponade

  • Endoscopic - sclerosis

    - banding

    Surgical - oesophageal transaction

    -gastric devascularisation

    -portosystemic shunt incl TIPS


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CARCINOMA

Curative treatment

• surgical

• radiation

• chemotherapy

• combination


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PALLIATIVE TREATMENT

  • Surgical

  • Radiation

  • Chemotherapy

  • Endoluminal intubation

  • Dilatation

  • other


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ACHALASIA

Surgical – myotomy

Dilatation

Medical – Ca++ channel blockers, vaso- dilations

Botulisation


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BARRETT’S OESOPHAGUS

PREMALIGNANT

• Treat Reflux

• Mucosectomy

• Oesophagectomy


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ADDITIONAL READING

  • Oxford Textbook of Surgery

    P J Morris and R A Malt

    • Textbook of Oesophageal Disease

    de Meester


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Oesophagus Case Study

PROBLEM OF DYSPHAGIA


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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


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Systemic & Social History

  • Type II diabetic x 6 years. On Glucophage & Diamicron.

  • HT x 4 years. On Coversyl.

  • Non – smoker. Minimal alcohol intake.


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Clinical examination

  • Chronically ill, wasted 62 year old male.

  • Systemic examination normal.


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Differential diagnosis

  • CA OESOPHAGUS

  • CA STOMACH

  • CHRONIC PEPTIC ULCER OESOPH

  • OESOPHAGITIS-?candidiasis/HIV

  • Achalasia


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Investigations

What Order of Diagnostic Investigation


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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.


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Blood Tests

  • HIV negative

  • Serum Albumin 14

  • Serum Glucose 5.4


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Biopsy Result

  • Fibrosis with signs of chronic inflammation in distal oesophagus.

  • No sign of malignancy.

  • No columnar metaplasia in distal esophagus.


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Differential diagnosis

  • Oesophageal cancer

  • Complicated Gastro-Esophageal Reflux Disease (GERD)

  • Candidiasis


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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.


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Clinical Course

  • Improved & gained weight on the ward.

  • Discharged on PPI & Fluconazole for review in one month.


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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


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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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