The Oesophagus:

The oesophagus (pronounced e-sof-fa-gus) is also known as the gullet. It is a hollow muscular tube that connects the throat to the stomach. In an adult it is about 12inches long. When food and liquids are swallowed they are pushed down the oesophagus to the stomach by contraction of the muscles.

The upper part of the oesophagus runs behind the trachea (windpipe) but is separate from it. The trachea connects the mouth and nose to the lungs and allows breathing to take place. The trachea joins the top part of the oesophagus. There, a valve prevents food content of the oesophagus from coming back up and entering the trachea.

There are lymph nodes (which filter fluid and can trap bacteria, viruses and cancer cells) near the oesophagus; in the neck, the middle of the chest and near the area where the oesophagus joins the stomach.

Cancer:

Cells are tiny blocks which form the organs and tissues of the body. Cell growth can go wrong and uncontrolled division and growth of abnormal cells can cause a tumour. Tumours can be benign or malignant. A benign tumour is not cancer, does not spread to other parts of the body and can be surgically removed. A malignant tumour is cancer. A cancer is characterised by the ability of the cells to invade into other tissues. This invasion can be by direct spread into adjacent organs or through the bloodstream or lymph system to distant organs. The cancer in the oesophagus is referred to as the primary tumour and any speard to the more distant organs is referred to as secondary cancer, or secondaries.

Cancer of the Oesophagus

Cancer of the oesophagus affects the cells in the inner layer of the oesophagus. It is divided into two types:

1. Squamous cell cancer
2. Adenocarcinoma.

The type of cancer depends on the type of cells that are malignant. The normal liniing of the oesophagus is made up of squamous or flat cells much like the cells that make up your skin. When a cancer starts up in one of these cells the cancer is called a squamous cell cancer and it can affect any part of the length of the oesophagus. In some people with acid reflux disease the lining of the gullet chages to resemble the lining lower in the intestines – a condition call Barrett’s oesophagus. A cancer arising in Barrett’s oesophagus has a different cell type and is called an adenocarcinoma.

Risk Factors:

• Age: The risk of getting oesophageal cancer increases with age. Most people who develop it are over the age of 60. It can however occur in younger people and  occasionally is seen in people as young as 20’s or 30’s.
  
• Gender: Men have a higher rate of oesophageal cancer than women.
  
• Tobacco Use: Cigarettes and other tobacco products are major risk factors.
  
• Alcohol: Long-term heavy drinkers of alcohol have an increased risk.
  
• Food: Diets lacking in fruit and vegetables, vitamin A, C and riboflavin may increase the risk of developing this cancer. Frequent drinking of very hot liquids may also increase the risk.
  
• Obesity: Obesity is also a risk factor for some types of oesophageal cancer.

Barretts Oesophagus:

This is a condition whereby long-term acid regurgitation from the stomach to the oesophagus causes irritation of the tissue. Over time cells in the irritated part of the oesophagus may change and resemble the cells that line the stomach. Barretts oesophagus increases the risk of oesophageal cancer.

Reflux Disease:

In Reflux disease there is backflow of stomach acid into the oesophagus. Heartburn is one of the main symptoms. Reflux disease can also occur without symptoms. Long-term reflux increases the risk of oesophageal cancer even if Barretts Oesophagus has not been diagnosed.

Symptoms and Signs:

• Ongoing difficulty swallowing which typically starts off for solid foods such as meeats and progresses steadily through difficulty with softer foods and then liquids.
  
• Weight Loss
  
• Prolonged Coughing
  
• Frequent hiccoughs/Belching
  
• Unexplained Tiredness
  
• Acid Indigestion/Heartburn that doesn’t go away
  
• Vomiting
  
• Discomfort in the throat or back
  
• Discomfort between the breast bone or Shoulder.
  
• Oesophageal cancer does not usually have any physical signs apart from weight loss to see. Sometimes a lump may develop in your neck or your voice can become hoarse.

These symptoms do not always mean cancer. If you have any symptoms get your doctor to check them to put your mind at rest or refer you for investigation.

Diagnosis

Most people begin with a visit to their general practitioner. Your GP may refer you to hospital for further tests. Special tests carried out in hospital may be as follows;

Blood tests and Chest Xray to check general health.

Barium Swallow; A special X-ray where the patient drinks a white substance “barium” which outlines the oesophagus. X-rays are taken while the barium flows down the oesophagus. The test takes about 15 minutes.

Endoscopy;
Endoscopy, also known as gastroscopy, is the investigation of choice for a patient who has developed difficulty with swallowing. This enables doctors to look directly at the oesophagus through a thin flexible fibreoptic tube called an endoscope. A sedative may be given to ensure comfort through the procedure. Local anaesthetic throat spray can also be used. The inside of the oesophagus can be examined and if necessary a sample of some cells can be removed for examination (biopsy).

If a tumour is found further tests may be needed to check its size and whether it has spread to other parts of the body. These may include:

Liver Ultrasound; Carried out in the Xray department. A painless procedure where sound waves are passed over the area of the liver to give a picture of it.

Endoscopic Ultrasound: Similar to an endoscopy, only on this occasion the endoscope has a built in ultrasound probe so that it can be placed very close to the tumour. Sound waves are used to get a picture of the tumour and nearby lymph nodes from inside the oesophagus. The ultrasound can guide a biopsy from these lymph nodes during the endoscopic ultrasound procedure.

CT Scan: A special type of X-ray giving a detailed picture of the inside of the body. Sometimes a drink or an injection may be given to highlight a particular part of your body. This scan takes about 30 minutes during which you lie as still as possible on the X-ray table and your body passes trough the scanner.

MRI Scan: This scan uses magnetic fields. It is painless but very noisy. Some may find it claustrophobic. It is important to tell the person doing the scan if you have  a pacemaker or any metal device in your body.

PET scanning: PET stands for Positron Emmission Tomography and this type of scan uses a radioactive tracer drug to help show how the tissues in the body are working as well as what they look like. Increasingly PET scanning is used in combination with the images from CT or MRI scans.

Coping with diagnosis:

When a cancer is diagnosed the natural reactions are disbelief, shock, and anxiety. Sometimes it is almost impossible to take in any information. After a while many questions may arise and it is a good idea to write these down when they do. When meeting your doctor again bring along the list of questions. It is advisable to bring along a friend or relative. You can make notes while with the doctor so that you leave with as much information as possible.

Treatment:

Cancer of the oesophagus can be treated using surgery, chemotherapy or radiotherapy. They can be used on their own or in combination. The type of treatment depends on the size of the tumour, the position of the tumour and whether it has spread to other parts of the body. Your doctor or nurse should explain how the different treatments work, any side effects they may have and their duration. Often, radiotherapy and chemotherapy are given before surgery to shrink the tumour and make surgery more effective. Usually a number of cancer specialists work together as a team to decide the most suitable treatment for an individual. Even so you may decide you would like a second opinion. Most doctors will be happy to refer you to another specialist for a second opinion if you feel this would be helpful. If you go for a second opinion it is a good idea to bring a relative or friend and to have a list of questions ready so that all your concerns can be dealt with. Keep in mind that waiting for a second opinion may delay the start of your treatment so you would need to be confident that it would provide useful information.

Surgery:

Surgery is the main form of treatment for cancer of the oesophagus. The type of surgery will depend on:

• The type of tumour
  
• The size of the tumour
  
• The location of the tumour
  
• Whether it has spread to other organs.
  
• If the tumour is small it can be removed along with part of the oesophagus and the remaining part of the oesophagus is joined to the stomach. Sometimes, depending on the location of the tumour surgery may be needed on the abdomen and chest and neck, so the affected part of the oesophagus can be removed.

Chemotherapy:

Chemotherapy involves the use of drugs to kill cancer cells. It can be given after surgery to prevent the cancer coming back. Usually it is given cycles for about 6 months. Chemotherapy may also be used to treat oesophageal cancer when the cancer has spread and surgery is not possible.

Radiotherapy:

Radiotherapy is the use of powerful X-rays to treat cancer. It can be used to ease the difficult and painful swallowing caused by the tumour.

Dietary Advice for people with Oesophageal Cancer:

At the time of diagnosis you may be able to get some professional advice from a dietician or nutritionist regarding your diet. If you are unable to swallow at all let the hospital know immediately. While you are waiting for treatment it is important to eat well.

During surgery the top part of the stomach is usually removed and the remaining part of the stomach now joined to the oesophagus is higher up than before. After surgery you will start eating a soft diet for a few weeks. This will exercise the surgical join and keep the passage open as it heals. You will find that you need to eat small amounts but more often. You may feel sick or very full if you eat too quickly.

Gradually you may be able to eat solid foods again. Food should be very well chewed and any food which is lumpy avoided. It is natural to feel nervous at first about eating solid food but this will lessen in time. Your doctor or nurse can advise on this. Bouts of diarrhoea are fairly common after any surgery for cancer of the oesophagus. From time to time you may need to cut out some foods, such as fruit, vegetables, cereals, and reduce the amount of milk you drink (or eat in food) to help deal with this. If you had radiotherapy or a tube fitted in the oesophagus you will need a softer diet. Eat slowly and drink plenty during and after meals. Some foods may block the tube or be particularly difficult to swallow so should be avoided. Examples are, raw fruit and vegetables tough meat and crusty bread. Powdered food supplements like Complan must be very thoroughly mixed. Eating well means getting enough calories and protein to prevent weight loss and build up strength.