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Surgery M4 part 2 > Esophagus 2 > Flashcards

Esophagus 2 Flashcards

1
Q

What is the commonest cause of esophageal perforation?

A

IATROGENIC

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2
Q

What is Boerhave’s syndrome?

A

uncoordinated esophageal motility in drunks or head trauma leading to increase in intra-esophageal pressure without relaxation during vomiting -> perforation

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3
Q

How does a patient with esophageal perforation present?

A
  • severe chest pain
  • severe dysphagia
  • surgical emphysema at neck & chest
  • fever & toxemia
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4
Q

What investigations should be used in perforation?

A

XRAY -> pneumomediastinum

       - > pleural effusion 
       - > surgical emphysema

GASTROGRAFIN SWALLOW
THORACOCENTESIS -> purulent aspirate

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5
Q

How should a perforation in the cervical portion of the esophagus be treated?

A
  • could heal spontaneously
  • NPO
  • IV fluids
  • antibiotics
  • drainage
  • surgical repair is (early or conservative fails for 2 weeks)
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6
Q

How should a perforation in the thoracic portion of the esophagus be treated?

A
  • never heals spontaneously
  • primary repair
  • stenting
  • esophagectomy & gastric pull-up in case of bad general condition or extensive tear)
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7
Q

acidic injury leads to?

A

coagulative necrosis -> prevents deeper injury

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8
Q

Alkaline injury leads to?

A

liquefactive necrosis -> deeper penetration -> perforation

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9
Q

What complications could corrosive esophageal injury lead to?

A

EARLY -> laryngeal edema, shock, dehydration, perforation, & sepsis
LATE -> stricture & malignant transformation

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10
Q

How should corrosive injury be managed?

A

AT SITE -> ensure patent airway (cricothyroidotomy if needed)
-> swallow water

AT HOSPITAL -> NPO

                     - > IV Fluids 
                     - > parenteral antibiotics 
                     - > steroids to decrease edema & prevent stricture

2 DAYS LATER -> GASTROGRAFIN SWALLOW shows leakage or double level stricture

ESPHAGOSCOPE -> after 24 hrs

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11
Q

What minimally invasive management should be done in case of corrosive injury?

A

DILATATION

- needs long term follow up to detect recurrent strictures or malignant transformation

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12
Q

What management is done in corrosive injury when dilatation fails & malignant transformation needs to be eliminated?

A

ESOPHAGECTOMY

- ends by gastric pull up

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13
Q

What is done for corrosive injury when the esophagus is extensively fibrosed & is irresectable?

A

BYPASS

- through gastric pull up, colonic bypass, or jejunal bypass

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14
Q

What is the commonest benign esophageal neoplasm? What does it originate from?

A

leiomyoma

  • smooth muscles of musculosa
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15
Q

How does a patient with leiomyoma present & what investigations should be performed?

A
  • dysphagia to SOLIDS

BARIUM SWALLOW -> smooth filling defect
ENDOSCOPIC US -> confirmation + biopsy (exclude GIST)

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16
Q

How should esophageal leiomyoma be treated?

A

small (<5cm) & asymptomatic -> follow up

large (>5cm) OR symptomatic -> excision

17
Q

old male presents with recent onset of dysphagia progressing rapidly, what is the first thing to suspect?

A

cancer esophagus

18
Q

What are the predisposing factors to cancer esophagus?

A
  • chronic irritation
  • achalasia of cardia
  • Barret’s esophagus
  • post-corrosives
  • benign tumors: papilloma
  • food preservatives
19
Q

What is the macroscopic picture of cancer esophagus?

A
  • proliferative mass
  • infiltrating mass
  • malignant ulcer
20
Q

What is the microscopic picture of cancer esophagus?

A
  • squamous cell carcinoma
  • adenocarcinoma from cardia, Barret’s, upward spread of gastric carcinoma
  • anaplastic
21
Q

How does cancer esophagus spread directly?

A
  • circumferentially then beyond wall
  • cervical -> trachea & RLN
  • thoracic -> trachea, aorta, lung & vertebrae
  • abdominal -> liver, stomach & diaphragm
22
Q

What lymph nodes does cancer esophagus spread to?

A
  • CERVICAL -> deep cervical LNs
  • THORACIC -> mediastinal LNs
  • ABDOMINAL -> left gastric & celiac LNs
23
Q

Which part in cancer esophagus can spread transcelomically?

A

ABDOMINAL PART

- causes Krukenberg’s tumor, malignant ascites & peritoneal nodules

24
Q

What is the clinical picture of cancer esophagus?

A
  • old males
  • dysphagia: insidious, progressive in short period, more to solids, excessive salivation with dribbling
  • regurgitation
  • rapid weight loss
  • hematemesis
  • recurrent chest infections
25
Q

What signs are considered as late manifestations of cancer esophagus?

A
  • cachexia
  • chest infection
  • palpable cervical LN
  • malignant ascites
26
Q

What investigations should be done for diagnosis of cancer esophagus?

A

BARIUM SWALLOW -> RAT TAIL

ESOPHAGOSCOPY -> BEST

27
Q

What investigation should be used to stage cancer esophagus?

A

endoluminal US

28
Q

How is cancer esophagus treated?

A

CURATIVE TREATMENT IF OPERABLE

  • patient has good general condition
  • tumor is not advanced

PALLIATIVE IF INOPERABLE

  • patient has bad general condition
  • tumor is advanced of fixed to vital organs
29
Q

How is the curative treatment performed in case of operable cancer esophagus?

A

BUILD UP PERIOD for 1-2 weeks

  • jejunostomy to correct nutritional deficiency
  • IV Fluids
  • hypokalemia & hyponatremia
  • respiratory tract infections

ESOPHAGECTOMY

  • Ivor Lewis -> resect abdominal & part of thoracic -> anastomose at chest (if it leaks its fatal)
  • McKeown -> resect the whole esophagus & anastomose at neck using cervical, thoracic, abdominal, & neck incisions
  • Tranhiatal dissection (most common) -> resect whole esophagus without thoracic incision & anastomose at neck
30
Q

What is done is palliative treatment?

A

relieving dysphagia to improve the quality of life

  • bypass -> only if medically fit
  • stenting -> in surgically fit
  • radiotherapy -> in upper esophagus
  • laser photocoagulation -> vaporization of tumor
  • feeding gastrostomy
  • chemotherapy
31
Q

What is the cause for post-cricoid carcinoma? How does it present?

A

occurs on top of Plummer Vinson syndrome

  • pain instead of dysphagia
  • pain referred to the ear
32
Q

how is post-cricoid carcinoma treated?

A
  • operable -> total pharyngeolaryngectomy with block neck dissection
  • inoperable -> radiotherapy

Surgery M4 part 2 (36 decks)

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