Oesophagus - Short Answer Questions

1. Achalasia Cardia ⭐⭐⭐⭐⭐

• Degeneration/loss of ganglion cells in Auerbach's (myenteric) plexus
• Idiopathic in most cases; secondary causes include Chagas disease (Trypanosoma cruzi), malignancy (pseudoachalasia)

• Loss of inhibitory neurons (VIP and NO-producing) in the myenteric plexus
• Failure of LOS relaxation + absence of peristaltic waves in the oesophageal body
• Progressive dilatation and elongation ("sigmoid") of oesophagus

• Dysphagia - initially to solids, later to liquids (both solids and liquids equally is characteristic)
• Regurgitation of undigested food (especially at night - risk of aspiration pneumonia)
• Retrosternal chest pain
• Weight loss
• Halitosis (bad breath) from food stasis
• Respiratory symptoms (cough, recurrent chest infections)

• Barium swallow: Dilated, baggy oesophagus with classic "bird's beak" / "rat-tail" tapering at the LOS
• Oesophageal manometry (gold standard): Elevated LOS resting pressure, failure to relax (incomplete LOS relaxation), absent peristalsis; Chicago Classification Type I, II, or III achalasia
• Endoscopy (OGD): Dilated oesophagus with food residue; "popping" through LOS on gentle pressure; excludes pseudoachalasia
• HRM (High Resolution Manometry): IRP (integrated relaxation pressure) elevated >15 mmHg

• Calcium channel blockers (nifedipine), nitrates - reduce LOS pressure temporarily
• Botulinum toxin injection (endoscopic) - blocks ACh release; effective especially in elderly/unfit patients but effect wanes within 6-12 months

• Pneumatic balloon dilatation - effective in ~60-85%; may require repeat sessions; risk of perforation (~2%)
• Heller's cardiomyotomy - surgical longitudinal myotomy of LOS extended onto stomach, combined with partial fundoplication (Dor or Toupet) to prevent reflux; can be done laparoscopically
• POEM (Per-Oral Endoscopic Myotomy) - newer endoscopic approach; comparable results to laparoscopic Heller with faster recovery; higher post-procedure GORD rate
• Bailey & Love's Short Practice of Surgery, 28th Ed.
• Scott-Brown's Otorhinolaryngology Head & Neck Surgery - Vol 2

2. Barrett's Oesophagus ⭐⭐⭐⭐

• Chronic GORD symptoms (>5 years)
• Age >50 years, male sex
• Obesity (especially central), white ethnicity
• Smoking, family history of Barrett's or oesophageal adenocarcinoma

• C = circumferential extent above OGJ (in cm)
• M = maximum extent above OGJ (in cm)
• Long-segment Barrett's: ≥3 cm; Short-segment: <3 cm
• Length is a risk factor for neoplastic progression

• Often asymptomatic - discovered incidentally
• May present with GORD symptoms: heartburn, regurgitation, dysphagia
• Barrett's ulcer (deep penetrating ulcer within the metaplastic segment)

• Endoscopy (OGD): salmon-pink/velvety columnar mucosa above OGJ; Prague criteria used
• Biopsies (4-quadrant every 2 cm + targeted) - must show intestinal metaplasia with goblet cells
• Dysplasia graded: no dysplasia / indefinite / low-grade dysplasia (LGD) / high-grade dysplasia (HGD)
• Dysplasia confirmation requires two experienced pathologists

• No dysplasia: PPI therapy + endoscopic surveillance (every 3-5 years)
• Low-grade dysplasia (LGD): PPI + surveillance or ablative therapy; surveillance or endoscopic ablation
• High-grade dysplasia (HGD): Endoscopic mucosal resection (EMR) / endoscopic submucosal dissection (ESD), or radiofrequency ablation (RFA), or oesophagectomy
• Adenocarcinoma arising in Barrett's: Staging + definitive treatment (endoscopic if T1, surgical if deeper)
• Bailey & Love's Short Practice of Surgery, 28th Ed.

3. Tracheo-Oesophageal Fistula (TOF) ⭐⭐⭐

• Type A/C (with atresia): Maternal polyhydramnios (amniotic fluid not swallowed); postnatal drooling, frothy secretions, cyanosis on first feed, aspiration pneumonia, inability to pass nasogastric tube
• Type E (H-type, without atresia): Recurrent chest infections, coughing/choking after feeds, may present later in childhood

• Failure to pass an NG tube (curls in upper pouch) - confirmed on X-ray showing tube coiled in mediastinum
• Contrast swallow (H-type): fistula seen in the neck
• CXR: air in stomach (confirms distal fistula in Type C); gasless abdomen in Type A

• Pre-operative: Replogle suction catheter in upper pouch, nurse 30° head-up, IV access, TPN/gastrostomy
• Surgical: Right thoracotomy or thoracoscopy - division and ligation of fistula; primary end-to-end oesophageal anastomosis over a trans-anastomotic feeding tube
• Long gap atresia: delayed anastomosis (with traction sutures or elongation procedures) or oesophageal replacement
• H-type fistula: Usually repaired via neck approach

• Bailey & Love's Short Practice of Surgery, 28th Ed.

4. Oesophageal Atresia ⭐⭐

• Polyhydramnios (amniotic fluid not swallowed)
• Small or absent stomach bubble on USS

• Excessive frothy saliva, drooling from birth
• Cyanosis and choking on first feed
• Inability to pass nasogastric tube (coils in upper pouch)
• Abdominal distension if distal fistula (air enters stomach)
• Gasless abdomen on AXR if pure atresia (Type A)

• Immediate: Replogle tube suction in upper pouch, IV fluids, TPN, nurse head-up (30°)
• Echocardiogram (check for cardiac anomalies + side of aortic arch for surgical approach planning)
• Surgical repair: Right posterolateral thoracotomy or thoracoscopy - division of TOF + end-to-end anastomosis
• Long-gap atresia: Foker technique (traction sutures for elongation), or later oesophageal replacement with stomach/colon/jejunum

• Bailey & Love's Short Practice of Surgery, 28th Ed.

5. Barrett's Ulcer / Barrett's Oesophagus ⭐⭐

• Occurs within the metaplastic columnar segment (not in normal squamous mucosa)
• Deeper and more penetrating than typical peptic ulcers
• Can penetrate adjacent structures (aorta, pleura) - risk of torrential haemorrhage
• Presents with dysphagia, odynophagia, haematemesis, or chest/back pain
• Associated with stricture formation

• High-dose PPI therapy
• Endoscopic management for active bleeding
• Underlying Barrett's oesophagus surveillance and ablation as per guidelines

6. Dysphagia Lusoria ⭐⭐

• Normally the right subclavian artery arises from the right brachiocephalic trunk
• In ARSA, the 4th right aortic arch involutes abnormally; the right subclavian arises as the last branch of the aortic arch, from the left side
• The artery crosses the midline behind the oesophagus in an oblique course, compressing it posteriorly
• Occurs in ~0.7% of the population; only ~10% are symptomatic
• The base of the aberrant artery may have a dilation = Kommerell's diverticulum

• Dysphagia - often to solids, may be intermittent
• Symptoms can begin with introduction of semisolids in infancy, or in adulthood
• Pulsatile compression seen at endoscopy in the proximal oesophagus

• Barium swallow: Oblique filling defect just above the aortic arch (posterior impression)
• CT/MRI angiography: Confirms the vascular anomaly and its relationship to oesophagus - has largely replaced angiography
• Endoscopy: Posterolateral pulsatile extrinsic compression

• In children: Division and ligation of the aberrant artery
• In adults: Reanastomosis to the ascending aorta (to prevent subclavian steal syndrome - retrograde flow in vertebral artery causing brainstem ischaemia)
• Many adult patients with mild symptoms can manage with dietary modification
• Yamada's Textbook of Gastroenterology, 7th Ed.

7. Plummer-Vinson Syndrome (Paterson-Kelly Syndrome)

• Iron deficiency anaemia (microcytic, hypochromic)
• Dysphagia due to pharyngo-oesophageal webs (upper oesophagus/post-cricoid region) and degeneration of oesophageal muscle
• Glossitis (atrophic, smooth tongue)
• Atrophy of lingual papillae
• Angular stomatitis / cheilosis (fissures at corners of mouth)
• Achlorhydria (absent gastric acid)
• Pharyngitis, esophagitis
• Splenomegaly (in some cases)

• Predominantly affects women in their 4th decade
• Much more common in females than males

• Associated with increased risk of post-cricoid carcinoma and oesophageal/hypopharyngeal squamous cell carcinoma

• CBC: microcytic hypochromic anaemia
• Low serum iron, low ferritin, high TIBC
• Barium swallow / OGD: web in post-cricoid region
• Biopsy to exclude carcinoma

• Iron supplementation (oral or IV) - may cause web regression
• Oesophagoscopy and dilation of the web
• Must rule out postcricoid carcinoma
• K.J. Lee's Essential Otolaryngology

8. Stricture of the Oesophagus

• Progressive dysphagia - initially to solids, later liquids
• Weight loss
• Regurgitation

• Barium swallow: site, length, nature of stricture
• OGD with biopsies (to exclude malignancy)
• CT staging if malignancy suspected

• Treat underlying cause (PPI for peptic stricture)
• Dilation - balloon (TTS - through the scope) or bougie (Savary-Gilliard); may need serial dilations
• Caustic stricture: serial balloon dilations; steroids to limit stricture formation (controversial); surgery (oesophagoplasty/replacement) if severe
• Eosinophilic oesophagitis: topical swallowed corticosteroids (fluticasone/budesonide) + dietary elimination

9. Carcinoma of the Middle Third of the Oesophagus

• Smoking and alcohol (synergistic)
• Hot/thermal beverages
• Nutritional deficiencies (vitamins A, C, riboflavin, zinc)
• Achalasia (stasis)
• Plummer-Vinson syndrome
• Tylosis (palmoplantar keratoderma)
• Caustic stricture
• Human papillomavirus (HPV) in some populations

• Progressive dysphagia - solids first, then liquids
• Weight loss and cachexia
• Retrosternal pain or back pain (mediastinal invasion)
• Hoarseness (recurrent laryngeal nerve involvement)
• Cough after swallowing / aspiration pneumonia (TOF from tumour invasion)
• Haematemesis
• Cervical lymphadenopathy

• Barium swallow: "rat-tail" or "apple-core" filling defect - irregular narrowing; no proximal dilatation (unlike achalasia)
• OGD + biopsy (definitive diagnosis)
• CT chest/abdomen/pelvis (staging - local invasion, nodes, distant mets)
• Endoscopic ultrasound (EUS) - T and N staging
• PET-CT (detect distant metastases)
• Bronchoscopy (to exclude airway invasion if near carina)

• Surgical resection (oesophagectomy) for T1-T3, N0-1, M0:
  • Middle- and lower-third cancers: two-stage transthoracic (Ivor Lewis) oesophagectomy - upper midline laparotomy + right posterolateral thoracotomy (4th/5th ICS)
  • Upper/middle third: Three-stage McKeown oesophagectomy (laparotomy + right thoracotomy + neck anastomosis)
  • Conduit: Stomach (preferred - based on right gastroepiploic artery); colon if stomach unavailable
  • Pyloroplasty/pyloromyotomy to improve gastric emptying
  • En-bloc resection with mediastinal lymphadenectomy (two-field dissection standard; three-field for upper or upper middle-third tumours)
• Neoadjuvant chemotherapy (FLOT, or CROSS regimen - chemoradiotherapy) prior to surgery improves resectability and survival
• Definitive chemoradiotherapy (dCRT) - if surgical resection not feasible; also used for cervical oesophageal SCC

• Oesophageal stenting (self-expanding metal stents) for dysphagia
• Palliative radiotherapy / laser ablation / photodynamic therapy
• Nutritional support (PEG, jejunostomy)

• Scott-Brown's Otorhinolaryngology Head & Neck Surgery
• S Das Manual on Clinical Surgery, 13th Ed.
• Bailey & Love's Short Practice of Surgery, 28th Ed.

Summary Box: All these conditions relate to the oesophagus. The highest-yield points: Achalasia = bird's beak + Heller's myotomy; Barrett's = intestinal metaplasia + adenocarcinoma risk; TOF Type C = most common (distal fistula); Plummer-Vinson = triad of dysphagia + iron deficiency + postcricoid web; Dysphagia lusoria = aberrant right subclavian artery; Middle third oesophageal Ca = SCC + Ivor Lewis operation.