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The chief complaint of any oesophageal disease is dysphagia (difficulty in swallowing) or odynophagia (pain on swallowing).
Methods of Examination
The most important examination methods for the diagnosis of diseases of the oesophagus are explained below. In addition, further x-ray examinations can be carried out.
Endoscopy
Illumination and inspection of body cavities with the aid of an endoscope; endoscopy at the same time allows the removal of a tissue sample (biopsy) for further examination, possibly in combination with an ultrasound examination (endosonography), and the carrying out of minor surgical procedures (e.g. electro or laser coagulation, endoscopic removal of polyps).
Gastroscopy, Oesophagogastroduodenoscopy
Following anaesthetisation of the membrane of the pharynx (throat), a flexible endoscope is passed through the mouth, pharynx and oesophagus into the stomach. If patients wish, they can be given a strong sedative so that they have little awareness of the procedure. The advantage of this form of examination is that changes which indicate disease can immediately be seen and biopsied in order to conduct a fine-tissue analysis of the mucous membrane. Minor surgical procedures, such as cauterisation (haemostasis) can also be carried out via the endoscope.
Acidity / Pressure Measurement (pH-/Manometry)
A narrow probe can be inserted into the oesophagus through the nose in order to measure the levels of acidity (pH) and pressure in the oesophagus.
Ingestion of Contrast Medium
A contrast medium (barium or gastrografin) is swallowed while the patient is monitored by x-ray, enabling an examination of the functioning of the oesophagus. This allows various conditions including constriction (cancer) or abnormal muscle contractions to be seen.
Major disorders of the Oesophagus
1. Tumours
a) Benign tumours: e.g. leiomyoma
b) Malignant tumours (cancer): e.g. squamous cell carcinoma
2. Mechanical blockages (foreign bodies, tumours etc.)
3. Muscular disorders (Achalasia, dermatosclerosis etc.)
4. Inflammatory disorders (gastrooesophageal reflux disease, oesophagitis etc.)
5. Injuries (acid-induced trauma or base trauma etc.)
6. Bleeding (mechanical tearing to the mucous membrane, bleeding from oesophageal varicose veins etc.)
7. Rare congenital abnormalities and other conditions
Selected Disorders
1. Tumours
1. Definition
A Tumour is a growth in the tissue. A benign tumour is a growth which is usually restricted to a particular area and which normally has no effect on life expectancy. A malignant tumour does not respect tissue boundaries, and, if untreated, can lead to a reduction in life expectancy.
Cancer of the Oesophagus
- 5x more common in men than in women
- Risk factors: among others, smoking and alcohol
2. Symptoms and Signs
- Difficulty in swallowing
- Weight loss
- Pain on swallowing, pain behind the sternum (breastbone)
- Vomiting, bleeding etc.
3. Complications and Risks
- Fistulisation of oesophagus (coughing while eating!)
- Bleeding
- Hoarseness
4. Diagnosis / Preliminary Investigations
- Endoscopy with removal of tissue samples.
- Ingestion of contrast medium, if necessary
- Supplementary investigations before beginning treatment using e.g. computerised tomography, endoscopy with ultrasound (endosonography) etc.
5. Therapy / Treatment
According to the stage and size of the tumour:
- Surgery - Radiotherapy
- In exceptional cases: chemotherapy
If no treatment is possible due to the spread of the cancer:
- Local measures to ensure the passage of food: bouginage of the oesophagus, laser, possible insertion of a stent (a small pipe of woven metal).
6. After-care
Regular check-ups via endoscopy
2. Achalasia
1. Definition
A neuromuscular disorder of unknown cause in which propulsive (forward moving) peristalsis is absent and the lower oesophageal sphincter only relaxes to an insufficient extent. A rare condition (approx. 1 case per 100'000 population).
2. Symptoms and Signs
- Difficulties in swallowing when eating
- Regurgitation of undigested food, possible aspiration (coughing)
- Cramp-like pain behind the sternum (breastbone)
3. Complications and Risks
- Coughing!
- Malnutrition
- After a number of years: development of a malignant tumour (precancerosis)
4. Diagnosis and Preliminary Investigations
- Ingestion of contrast medium
- Endoscopy (oesophagogastroscopy)
- Measurement of proportional pressures in the oesophagus (manometry)
5. Therapy / Treatment
- Eat slowly, chew well, adequate liquid consumption
- Medication: e.g. nitrate or calcium channel blockers (only successful in mild cases)
- Pneumatic expansion of the lower oesophageal sphincter (3cm) under endoscopic or x-ray monitoring. Normally successful (80%). N.B.: risk of perforation of the oesophagus (around 1%)
- Surgery (Heller's myotomy) if the expansion is not successful. N.B.: risk of reflux disease (around 20%)
6. After-care
Endoscopic check-ups at 1 to 3 year intervals, even in cases where symptoms have cleared up (slight, but perceptible risk of development into a malignant tumour).
3. Reflux Disease
1. Definition
Reflux disease involves an increased back-flow (reflux) of gastric acid or bile into the oesophagus which leads to symptoms such as acidic eructation (belching) or heartburn. Increased exposure of the oesophagus to acid in this way commonly causes inflammation in the lower oesophageal region (oesophagitis or refluxoesophagitis). Reflux disease has number of causes. One of these is related to a hiatus hernia; various types of food and drugs (nicotine) can also have an unfavourable effect, as can increased pressure in the abdominal cavity caused by, for example, obesity or pregnancy.
2. Symptoms and Signs
- Heartburn, acidic eructation, burning sensation behind the sternum etc.
- Often symptoms are influenced by the positioning of the body or by eating.
3. Complications and Risks
- Constriction of the oesophagus (stenosis)
- Changes in the mucous membrane in the oesophagus, which can again lead to tumours (so-called Barret's Oesophagus)
- Bleeding from the mucous membrane or ulceration of the mucous membrane, which in extreme cases can lead to perforation.
4. Diagnosis
Initially the patient history may provide typical or atypical indications. The first diagnostic stage involves carrying out an oesophagogastroscopy. Any inflammation of the oesophagus is classified according to its extent and treated accordingly. In special cases, further tests such as the measurement of acidity and pressure in the oesophagus (pH-manometry) are carried out.
5. Therapy / Treatment
In the first place, so-called conservative measures apply, such as dieting, eating more but smaller meals (no late-night meals), sleeping in a more upright position etc. For most patients, the symptoms can be relieved by medication. Today the first step is to use acid blockers such as Antra, Zurcal or Agopton. Somewhat less effective but widely used in mild cases are histamine blockers such as Zantic, or acid inhibitors such as Alucol.
Surgery is mainly considered in the case of younger patients or those for whom other forms of treatment have proved unsuccessful. However, a thorough investigation is first required before surgery is carried out.
6. After-care
After-care is above all required for patients who suffer from a complication involving a change in the mucous membrane. This complication, known as Barret's Mucous Membrane, can mutate in rare cases (cancer risk). For this reason, check-ups at two year intervals are recommended.
Footnote
Hiatus Hernia A hiatus hernia is often found in patients with reflux disease. A hiatus hernia, however, is not in itself of any significance as a cause of disease.
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