Oesophagial Disorders for final mbbs

1. Oesophagial Disorders
RW Seneviratne

2. Classification
• GORD/ Hiatus Hernia
• Non Reflux Oesophagitis- caustic, infective, oesinophilic,
inflammatary bowel disease,
• Motility Disorders-acalasia, DOS, Nutcracker Oesophagus,
HLOS, Non specific O. motility disorders
• Diverticula
• Oesophagial webs, rings, dysphagia lusoria
• Congenital oesophagial disease-TOF etc discussed under
paediatric surgery
• Oesophagial Perforation
• Benign Tumours of oesophagus
• Malignant Tumours of Oesophagus

3. GORD/Hiatus Hernia
Clinical condition resulting from reflux of gastric acidic
contents
• 30-50 yrs,genetic/diet/obesity
• Heartburn/upper abdo pain
• Regurgitation & waterbrash
• Dysphagia
• Resp symptoms-cough, CI, choking,weeze,
deteriorating Lung FT
• Laryngitis(hoarseness),dental caries
• Signs- nothing significant
• DD-pep ulcers, gs disease, pancreatitis,IBS,diverticulitis

4. Mx-GORD
• Diagnosis+Ix+Rx+followup/prevention
• If has 2 event or more a week or need medication
need to see a doctor
• UGIEndoscopy-a must if new symptom in over
50/Prev barretts/sinister features.may show
presence and severity of reflux,HH, and
complications such as barrettes /stricture
• If above negative but cf of gord-24 hr PH and
oesophagial manometry
• Symptamatic reflux or barrettes-43x risk of ca

5. Rx- conservative vs surgery
• Conservative-lifestyle and dietary modifications,
loose weight, acid suppression
• Surgery if
-Justified patient preference
-failure of medical therapy to control symptoms
-SE of medical Rx
-Complications-strictures, resp symptoms, bleeding
Surgery-fundoplication(laparoscopic/open) 90%
sucsess. Can rx HH at the same time
Complications-gas bloat, dysphagia,recurrence/failure

6. Non reflux oesophagitis-caustic
• Acetic acid(rubber-suicidal),house cleaning
liquids, batteries, KCL tablets
• Burn specially when passage is delayed
• Rx-dilute, abs,steroids if mild to moderate
• Later dilatations, gastrostomy or jujunostomy
• Secondary reconstruction with colon/jujenum

7. Achalasia
• Failure of motility and cordination of peristalsis leading
to chronic dysphagia
• Bimodal 20-40 and 70-90
• 1:100000
• Sporadic, infective (chagas) and familial varieties
described
• dysphagia for solids
• Postural regurgitation(typical),foul taste and breath,
cough, choaking, LOW,fear to eat, malnurished
• Ix- oes manometry, ba swallow, UGIE
• Rx-dilatation rpt or hellers myotomy(lap/open) 60-80%
sucsess
• If not rx risk of SCC high

8. Oesophagial Perforation
Causes
-spont-after bout of vomit,lower 1/3 left
Iatrogenic-dilatation, thrmoablation, sclerotherapy, banding,
Trauma-GS, blade
Infection, ulceration, tumour,FB
clinical features
Retrosternal /neck/abdo pain
Tacycardia,tachypnoea, fever, peritonitis, sob, mediastinal emphysema
Hammans mediastinal crunch
Macklers triad-vomiting, CP, sub cut emphysema
Ix- contrast swallow a must
Rx depends on site ,severity, time elapsed and pts gen condition
Smaller perfs in well patients and frail patients are mx conservatively-
abs, nutrition
Larger perfs are mx with sx ideally with in 24 hrs
Still risk of peri op death is 15-30%

9. Malignant neoplasms
• Benign tumours GIST>epithilial
• Secondaries rare except bronchial
• 6th commonest cancer varies worldwide
• 14/9.2 per 100000;75% adenoca;5yr servival 5-
10%;30day periop mortality 11% in UK
• Worldwide 85% of cas squamous
• Sq-vitc,l ow freshfruit/minerals, tobbaco,a lkohol
aflatoxin,nitrosomines,acalasia ,chronic oesophagitis,
caustic, plummer vinson, family history
• Adenoca-most arise in backgd of barretts-longstanding
reflux, barretts,obesity?

10. distribution
• 75% tumours in uk involve lower 1/3(adeno)
• SL- upper 2/3 but adeno increasing
• Lymphatics-early submucosal spread
(sattelite) , more often
caudally,haematogenious, local,
transperitonial

11. Clinical features
• Dysphagia –solids>liquids-late presentation
• Regurgitation, vomiting odynophagia, wt loss
• Resp symptoms, RLN palsy, horners, spinal pain,
diaphragmatic paralysis, SC LN
• Ix- endoscopy- histology,extent
• Ba swallow-useful if EC not possible or
dangerous-tight stenosis,achlasia, P pouch
• Blood tests- not very specific
• Accurate Staging vital in extensive Sx VS palliative
care decision

12. Staging Ix
• CXR
• CT- local /upper abdo spread- recectability
• US- endocopic (transmural/local) and
abdominal
• Bronchoscopy- upper 2/3 tumours
• Laparoscopy-visualize perit seedlings,
washouts for cytology
• PET

13. Palliative Rx
If-pt fit,haemat spread, contigous organ invasion,
perit spread, Present (2/3 of patients)
Ln mets(t3/t4/N1) multimodal therapy
No LN spread(t1/t2/N0) sx
PALLIATION
-aim to restore swallowing
-RT/CT- in pt with life exp 9/12
-EC-dilatation, alkohol injection,thermal
ablation(upper 1/3)
Stenting/intubation

14. EMQ-likely diagnosis
1)65 yrs male with progressive dysphagia for solids for 4
weeks
2)35 yrs old with dysphagia /regurgitation for 2 years
3)30 yrs old c/o dysphagia for 3 /12 following suicidal attempt
4)40 yrs old with burning epigastric pain radiating to chest
with distasteful fluid in mouth
5) 50 yrs old c/o central sharp CP and tachycardic after
Endoscopy
A)GORD
B)Stricture
c)Perforation of oesophagus
d)Carcinoma of stomach
e)Achalasia

15. EMQ-Most Appropriate investigation
1)Diagnosis of oes ca-EC
2)Motility disorders-24 hr PH/mannometry
3)Gord-EC
4)To assess Transmural spread of OCA-CT scan
5)Peritonial deposits-US

16. Following findings lead to palliative
approch
1)Ca oesophagus extending to lesser curve
2)Hard enlarged left sc lymph node
3)Mid oesophgial tumour detected on
bronchoscopy
4)Positive peritonial washings
5)Enlarged mediastinal lymph nodes

17. Curative RX
• Barrets /severe dysplasia-ablation or local resection
tried by some
• Cuarble-radical resection is the aim
• Neo adjuvant and adjuvant RT/CT are used
• Oesopahgectomy
• 2 phase lewis-tanner operation (r thorac/abdo which
may be laparoscopic)-preffered
• Transhiatal- lower 1/3 adeno
• Mckeown- 3 stage –upper tumours to get better
clearence
• 1/2/3 field lymphadenectomy
• Complications- anas leakage, chylothorax, RLN palsy