| Oesophageal Carcinoma
| Diffuse Oesophageal spasm
| Diffuse Oesophageal Perforation - Rupture
| Gastro-Oesophageal Reflux
| Barrett's oesophagus
- Transient or sustained reduced tone at the Lower Oesophageal sphincter (LOS)
- Structure and function of the vagal supplied LOS is fundamental in GORD.
- Muscular tone at LOS, Acute angle of the junction, Intraabdominal part of the oesophagus.
- Results in an erosive oesophagitis, stricture or Barrett oesophagus, or adenocarcinoma
- Male, Smoking, Alcohol, Pregnancy, Obesity
- Drugs e.g. Nitrates, Tricyclics, Calcium channel blockers
- Relaxation of the LOS may be mediated in part by Nitric Oxide. GTN can theoretically alter Oesophageal symptoms
- Long term reflux oesophagitis and ulceration
- Barrett's oesophagus, Oesophageal adenocarcinoma
- Oesophageal stricture - treat with endoscopic dilatation
- Heartburn and possibly acid reflux into the mouth and water brash, worse after stooping and bending relieved by antacids. Better when lying flat or bending, large meals, alcohol
- Retrosternal discomfort may need differentiation from cardiac pain. Night time regurgitation can produce a nocturnal cough. Aspiration may cause a degree of bronchospasm which may be confused with Asthma
- Chronic reflux can cause an oesophageal stricture and dysphagia. Nitrates and Calcium channel blockers will exacerbate the reflux
- FBC, U&E, LFTs, CXR.
- OGD may show oesophagitis or erythema and erosions. Biopsies of suspicious lesions and Barrett's oesophagus
- 24 hr pH monitoring with a probe placed in lower oesophagus. Bernstein test of infusing diluted acid rarely used nowadays.
- Where ACS considered needs ECG and Troponin
- Cardiac Disease
- Biliary disease
Red flags: consider OGD
- Weight loss
- Protracted vomiting
- Treat cause, lose weight, avoid large meals, reduce alcohol, Stop smoking, review drugs. Not all patients need endoscopy. Consider endoscopy if red flag symptoms or older patients.
- Consider Gaviscon 10 mls PRN and Lansoprazole 30 mg BD for 6 weeks. Then step down to Lansoprazole 10 mg OD.
- Dyspepsia: Consider test for H pylori using a carbon 13 urea breath test or a stool antigen test, or laboratory-based serology where its performance has been locally validated. Eradication is a 7 day, twice-daily course of treatment with: a PPI and Amoxicillin and either clarithromycin or Metronidazole. Penicillin allergy a 7day, twice-daily course of treatment with: a PPI and clarithromycin and Metronidazole.
- Drug causes include calcium antagonists, nitrates, theophylline, bisphosphonates, corticosteroids and non-steroidal anti-inflammatory drugs [NSAIDs].
- Elevate the head of the bed. Antacids and alginates usually Gaviscon like drugs taken for symptom control
- Endoscopic therapy - various techniques now in use to improve LOS function including local injections, sutures, radiofrequency energy to cause fibrosis and scarring.
- Nissen fundoplication may be used in the few severe cases which do not respond and can now be done laparoscopically. The gastric fundus is sutured around the LOS to form a one-way valve
- HP eradication can make matters worse by restoring atrophic gastritis and increasing acidity may be used in view of the possible protection against the development of gastric cancer and peptic ulceration.