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III YEARS BLOCK 8 – OESOPHAGUS SYMPOSIUM OBJECTIVES

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

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  1. 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

  2. THE SYMPOSIUM Applied Anatomy • Topographic anatomy - neck - mediastinum - abdomen • Organisation of muscles • The sphincter apparatus • Nerve Supply • Blood supply • Histology

  3. Applied Physiology Mechanism of swallowing Sphincter mechanism

  4. Pathology Degenerative and structural diseases • Diverticula • Fistulae (and sinuses) • Stenotic lesions including atresia • Tears (Mallory-Weiss) or Perforations (Boerhaave)

  5. Neoplastic Diseases • Benign (rare) • Malignant - squamous cell - adenocarcinoma Myoneural • Achalasia • Nutcracker oesophagus • pseudo bulbar palsy

  6. MYONEURAL DISORDERS Achalasia Nutcracker oesophagus Pseudo bulbar palsy

  7. Inflammatory diseases • Infective:- Candidiasis esp with HIV TB Other • Collagen vascular disorders Scleroderma • Chemical injury external acid/alkali ingestion acid/alkali reflux

  8. Pathophysiology Effects of fistulae – pulmonary aspiration Effects of reflux – oesophagitis and fibrotic stricture Effects of strictures – dysphagia Barretts Disease – premalignant Varicose veins (varices) - haemorrhage

  9. Cardinal Symptoms and Signs • Dysphagia • Heartburn and odynophagia • Haematemesis/melaena • Choking • Regurgitation/vomitting • Nutritional status

  10. SPECIAL DIAGNOSTIC INVESTIGATIONS Plain Radiograph especially for foreign body Radiographic Oesophagogram Videofluoroscopy Endoscopy Biopsy - cytology - histology Manometry Ambullatory pH metre

  11. PRINCIPLES OF TREATMENT Reflux Oesophagitis • Medical • Surgical - conventional - minimal access (endoscopic)

  12. HAEMORRHAGIC VARICES • Medical - β-blockers, somatostatin • Mechanical – balloon tamponade • Endoscopic - sclerosis - banding Surgical - oesophageal transaction -gastric devascularisation -portosystemic shunt incl TIPS

  13. CARCINOMA Curative treatment • surgical • radiation • chemotherapy • combination

  14. PALLIATIVE TREATMENT • Surgical • Radiation • Chemotherapy • Endoluminal intubation • Dilatation • other

  15. ACHALASIA Surgical – myotomy Dilatation Medical – Ca++ channel blockers, vaso- dilations Botulisation

  16. BARRETT’S OESOPHAGUS PREMALIGNANT • Treat Reflux • Mucosectomy • Oesophagectomy

  17. ADDITIONAL READING • Oxford Textbook of Surgery P J Morris and R A Malt • Textbook of Oesophageal Disease de Meester

  18. Oesophagus Case Study PROBLEM OF DYSPHAGIA

  19. 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

  20. Systemic & Social History • Type II diabetic x 6 years. On Glucophage & Diamicron. • HT x 4 years. On Coversyl. • Non – smoker. Minimal alcohol intake.

  21. Clinical examination • Chronically ill, wasted 62 year old male. • Systemic examination normal.

  22. Differential diagnosis • CA OESOPHAGUS • CA STOMACH • CHRONIC PEPTIC ULCER OESOPH • OESOPHAGITIS-?candidiasis/HIV • Achalasia

  23. Investigations What Order of Diagnostic Investigation

  24. 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.

  25. Blood Tests • HIV negative • Serum Albumin 14 • Serum Glucose 5.4

  26. Biopsy Result • Fibrosis with signs of chronic inflammation in distal oesophagus. • No sign of malignancy. • No columnar metaplasia in distal esophagus.

  27. Differential diagnosis • Oesophageal cancer • Complicated Gastro-Esophageal Reflux Disease (GERD) • Candidiasis

  28. 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.

  29. Clinical Course • Improved & gained weight on the ward. • Discharged on PPI & Fluconazole for review in one month.

  30. 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

  31. 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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