QuestionSBA
QuestionChoice
The fluid moving coming out of the chest drain is lymph. The patient has a chylothorax which needs to drain from the chest cavity. Drainage may reduce pressure on the lungs and improve the patient's breathing. Nutritional support is important to remember in these patients, although they may require additional IV fluids
32884
b
Clamp the chest drain and prescribe IV fluids
QuestionChoice
The fluid moving coming out of the chest drain is lymph. The patient has a chylothorax which needs to drain from the chest cavity. Drainage may reduce pressure on the lungs and improve the patient's breathing. It may be necessary to call the intensive care unit depending on the vital signs of the patient
32885
c
Clamp the chest drain and call the intensive care unit
QuestionChoice
Readmission to ITU is the most appropriate initial management. This patient has developed a chyle leak and needs to be managed in ITU given the serious nature of the complication. The chylothorax will need to be drained from the chest cavity. Drainage may reduce pressure on the lungs and improve the patient's breathing.
32887
e
Readmit to ITU as soon as possible
QuestionChoice
The fluid moving coming out of the chest drain is lymph. The patient has a chylothorax which needs to drain from the chest cavity. Drainage may reduce pressure on the lungs and improve the patient's breathing. IV furosemide is not require
32886
d
Clamp the chest drain and prescribe IV furosemide
QuestionChoice
This is a difficult question. This patient has developed chylothorax, which is leaking through his chest drain. Traumatic chylothoraces are the most common type, and they can occur in up to 4% of oesophagectomies. Lymph leaks from the thoracic duct into the chest cavity. In large leaks, the most effective initial management is to allow the lymph to drain and to support the patient with adequate nutritional support
32883
a
Allow the fluid to drain and prescribe total parenteral nutrition
QuestionComment
they've developed a what now 
8000
User
subscriber
Serotonin Relapse
QuestionComment
icu team come quick pls 
22653
User
subscriber
Raphael de la Ghetto
QuestionComment
Got it right for the wrong reasons. I assumed they put an NG in the lung…..
25699
User
subscriber
Anterior Gallbladder
QuestionComment
confused why readmit isn't the right answer then?
28525
User
subscriber
Kinase Embolism
QuestionComment
It says "readmit to UTI is the most appropriate initial management" so why is that answer wrong ??? 
28949
User
subscriber
Poisoned Lyme 
Concept
Chapter
# Summary

Oesophageal carcinoma, primarily categorised as adenocarcinoma or squamous cell carcinoma, is a malignancy impacting the oesophagus. Adenocarcinoma is most prevalent in the Western world, typically located in the lower third of the oesophagus and linked to gastro-oesophageal reflux disease. Squamous cell carcinoma is prevalent globally and typically seen in the upper two-thirds of the oesophagus. Smoking is a significant risk factor for both types. Key signs and symptoms include progressive dysphagia, weight loss, and possible hoarseness. The primary investigation method is upper GI endoscopy, with further assessments for staging including CT scans, MRI, endoscopic ultrasound, FDG-PET scan, and occasionally laparoscopy. Management approaches depend on the staging of the disease, but include surgical, endoscopic, and non-surgical options such as radiotherapy and chemotherapy.

# Definition

Oesophageal carcinoma is a type of cancer that originates from the epithelial cells lining the oesophagus, primarily categorised into adenocarcinoma or squamous cell carcinoma.

# Epidemiology

Squamous cell carcinoma of the oesophagus is the most prevalent type globally, often seen in the upper two-thirds of the oesophagus. Conversely, adenocarcinoma has become the most common cause of oesophageal carcinoma in the Western world, owing to the increasing prevalence of GORD, and is often seen in the lower one-third of the oeseophagus.

# Aetiology

Risk factors for oesophageal carcinoma include:

-   **Smoking**: The most significant risk factor for both adenocarcinoma and squamous cell carcinoma.
-   High alcohol intake
-   Obesity and gastro-oesophageal reflux disease: Linked specifically to adenocarcinoma, as recurrent reflux leads to metaplastic formations of mucin-producing glandular tissue known as Barrett's oesophagus, which can further develop into neoplasia.
-   Achalasia
-   Zenker diverticulum
-   Oesophageal web
-   High intake of hot beverages
-   Dietary intake of:
    -   Increased dietary nitrosamines
    -   Areca or betel nuts

# Signs and Symptoms

Patients with oesophageal carcinoma often present with the following symptoms:

-   Progressive dysphagia: Initially for solids, and later for liquids. Dysphagia typically occurs when there is obstruction of more than two-thirds of the lumen.
-   Weight loss: This symptom, the second most common, results from a combination of anorexia and dysphagia.
-   Odynophagia: Pain on swallowing can occur.
-   Hoarseness: Can develop if there is local invasion of the recurrent laryngeal nerve.

# Differential Diagnosis

-   Gastro-oesophageal reflux disease (GORD): GORD also presents with dysphagia and odynophagia, but is often associated with heartburn, regurgitation, and chest pain.
-   Achalasia: Achalasia is characterised by dysphagia for solids and liquids from the start, regurgitation of undigested food, and chest pain.
-   Peptic stricture: Presents with intermittent dysphagia for solid foods, heartburn, and acid regurgitation.
-   Zenker diverticulum: Presents with dysphagia, regurgitation of undigested food, halitosis, and possible aspiration pneumonia.
-   Neurological causes of dysphagia such as motor neuron disease, mysaesthenia gravis
-   Oesophagitis - often due to candidiasis and presents with odynophagia more than dysphagia. May be underlying immunosuppression e.g. HIV.

# Investigations

### NICE 2-week-wait criteria:

- Offer urgent direct access upper gastrointestinal endoscopy (to be performed within 2 weeks) to assess for oesophageal cancer in people with **dysphagia** or those aged 55 years and over with weight loss and any of the following: upper abdominal pain, reflux, or dyspepsia.
- Consider non-urgent direct access upper gastrointestinal endoscopy to assess for oesophageal cancer in people with haematemesis.

Investigations for oesophageal carcinoma encompass:



-   Initial investigation: Upper GI endoscopy is performed to visualise and grade the tumour via biopsy.
-   Staging:
    -   CT chest, abdomen and pelvis: Assesses the size of the tumour, local and lymph node spread, and any visceral metastases.
    -   MRI: Identifies metastatic spread to the liver and advanced local disease.
    -   Endoscopic ultrasound: Assesses whether a tumour is amenable for resection.
    -   FDG-PET scan: Identifies distant and nodal metastases.
    -   Laparoscopy: Used to identify intra-abdominal metastases if all other imaging has been negative.

# Management

Management of oesophageal carcinoma is based on the stage of the disease and may include:

-   Surgical resection: The primary choice for localised disease.
-   Endoscopic therapies: Such as endoscopic mucosal resection or endoscopic submucosal dissection for early-stage disease.
-   Non-surgical options: Such as radiotherapy, chemotherapy or chemoradiotherapy for advanced disease, or as neoadjuvant or adjuvant therapy with surgery.

# NICE Guidelines

[Click here to see the NICE guidelines on oesophageal cancer](https://www.nice.org.uk/guidance/conditions-and-diseases/cancer/oesophageal-cancer)
773
2665
Oesophageal carcinoma
Topic
23
Gastroenterology
6577
A chylothorax is a condition where lymph leaks from the thoracic duct into the chest cavity, often occurring after trauma like oesophagectomy, and is typically managed by draining the lymph and ensuring adequate nutritional support.
A 78-year-old male patient is on the surgical wards after an oesophagectomy. Several hours postoperatively, he develops shortness of breath. He has a chest drain in-situ, which has started to leak large amounts of milky fluid.

Which of these would be the most appropriate initial management?
a