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OESOPHAGUS (CARCINOMA (CLINICAL FEATURES (dysphagia in elderly men with…
OESOPHAGUS
CARCINOMA
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remaining oesophageal growths occur more often in men, usually elderly men
nowadays distal tumours more common than tumours of mid-third with upper oesophageal tumours being least common
oesophageal ca RF tobacco
sqaumous carcinoma also linked to alcohol, achalasia and coeliac disease
adenocarcinoma may occur in assoc with Barrett's oesophagus, also assoc with obesity
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PATHOLOGY
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microscopically, majority are now adenocarcinomas arising at lower end of oesophagus either in gastric metaplasia (BARRETT'S OESOPHAGUS) or result of invasion of oesophagus from a tumour developing at the ardiac end of stomach
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SPREAD
lymphatic - to para-oesophageal, tracheobronchial, supraclavicular and subdiaphragmatic nodes
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LOCAL - into the mediatinal structures - trachea, aorta, mediastinal pleura and lung
CLINICAL FEATURES
secondary deposits - enlarged neck nodes, occassionally jaundice and/or hepatomegaly
general manifestations of malig disease - loss of weight, anorexia, anaemia
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dysphagia in elderly men with short hx is almost invariably due to carcinoma of oesophagus or upper end of stomach
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hoarseness and a bovine cough suggest invasion of the left recurrent laryngeal nerve by an upper oesophageal tumour
SPECIAL IX
oesophagoscopy - enables the tumour to be inspected and a biopsy taken. May be combined with endoluminal US to evaluate local invasion
endoscopic US - enables assessment of tumour's depth of invasion and detection of local and lymphatic spread; also facilitates FNA of lymph nodes to facilitate preop staging
CT of thorax and abdo to assess the primary growth, local invasion and secondary spread to the liver and lymph
Positron emision tomography [PET] - in conjunction with CT may also be used to screen for metastatic disease and stage the tumour, but is not useful to assess the primary tumour
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TREATMENT
curative resection
when cure is possible, resection is undertaken following course of chemotherapy. the growth is removed and the defect is usually bridged by mobilising the stomach up into the chest, with anastomosis to residual oesophagus or to the pharynx in the neck. Even with successful resection, survival is poor
palliation
radiotherapy
either external beam or intraluminal, is useful for squamous tumours
endoscopic laser therapy
may vaporise the growth and restore the lumen, repeated courses may be necessary, but disease progression rapidly overtakes the patient
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chemotherapy
particularly with a platinum based regimen has shown increasing promise when combined with radiotherapy
avg expectation of life is in the region of 3 mths with a maximum survival of about 1 yr but at least the pt is sared the misery of total dysphagia
ACHALASIA OF THE CARDIA
neuromuscular failure of relaxation at the lower end of the oesophagus = progressive dilatation, tortuosity, inco-ordination of peristalsis and often hypertrophy of the oesophagus above
due to loss of inhibitory VIP and nitric oxide releasing inhib neurones in the lower oesophagus = leaving unopposed excitatory cholinergic neurones
thought cause of neurone loss may relate to a viral infection or autoimmune response to infection in susceptible individuals
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CLINICAL FEATURES
may occur at any age, particularly 30s
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progressive dysphagia - particularly to fluids over months to yrs sometimes assoc with spasm-like chest pain
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SPECIAL IX
CXR may reveal dilated oesophagus as a mediastinal mass with an air fluid level and pneumonitis from aspiration of oesophageal contents
barium swallow shows gross dilatation and torturosity of the oesophagus leading to an unrelaxing narrowed segment at the lower end said to resemble a birds beak
oesophagoscopy demonstrates an enormous sac of oesophagus containing a pond of stagnant food and fluid
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TREATMENT
Heller's operation - a cardiomyotomy dividing the muscle of the lower end of the oesophagus and the upper stomach doen to the mucosa in a similar manner to Ramstedt's operation for congenital pyloric hypertrophy
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same effect may be achieved by forcible dilation of the oesophagogastric junction by means of an endoscopic balloon that is inflated under fluoroscopic (X-ray) control
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newer alternative involves endoscopic injection of botulinum toxin (botox) to paralyse LOS = relief in pts may last a yr
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REFLUX OESOPHAGITIS
reflux of peptic juice through the incompetent cardiac sphincter into the lower oesophagus = ulceration and inflam => stricture
may occur in assoc with
repeated vomiting, esp in presence of a duodenal ulcer with high acid content of gastric juice
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SPECIAL IX
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oesophagoscopy - demonstrates presence of oesophagitis and hiatus hernia and facilitates biopsy to exclude carcinoma or the presence of gastric type epithelium
DDX
pain of oesophagitis may be confused with cholecystitis, peptic ulcer or angina pectoris
obstructive symptoms of an associated stricture must be differentiated from carcinoma of the oesophagus or of the cardia
TREATMENT
weight loss, stop smoking, dietary manipulation
avoid stooping or lying, sleeep propped up in bed
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advanced , where frequent dilatation is required or is unsuccessful, resection of stricture may be necessary
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PLUMMER-VINSON SYNDROME
comprises dysphagia and iron deficiency anaemia (with its associated smooth tongue and koilonychia - spoon shaped nails) usaully in middle aged or elderly women
dysphagia is assoc with hyperkeratinisation of the oesophagus and often with the formation of a web in the upper part of the oesophagus.
the condition is premalignant and is assoc with development of a carcinoma in the cricopharyngeal region
TREATMENT
the dysphagia responds to treatment with iron, although the web may requre dilatation through an oesophagoscope
PHARYNGEAL POUCH
mucosal protrusion between the 2 parts of the inf pharyngeal constrictor - the thyropharyngeus and cricopharyngeus
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CLINICAL FEATURES
more often in men, usually elderly
dysphagia, regurgitation of food collected in pouch, often palpable swelling in neck which gurgles
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TREATMENT
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or endoscopic diverticulotomy leavign the pouch in situ and avoid risk of fistula formation and leaks assoc with open op
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