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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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