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ABSITE > Fiser Chaper 29. ESOPHAGUS > Flashcards

Fiser Chaper 29. ESOPHAGUS Flashcards

1
Q

Esophagus wall layers

A

Mucosa: squamous epithelium

Submucosa

Muscularis propria: longitudinal muscle layer

(no serosa)

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2
Q

Upper 1/3 and lower 2/3 esophagus

A

Upper 1/3: striated muscle

Lower 2/3: smooth muscle

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3
Q

Esophagus blood supply

A

Cervical: inferior thyroid artery

Thoracic esophagus: directly off aorta

Abdominal: left gastric and inferior phrenic arteries

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4
Q

Esophagus venous drainage

A

Hemi-azygous and azygous veins

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5
Q

Esophagus lymphatic drainage

A

Upper 2/3 drains cephalad

Lower 1/3 caudad

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6
Q

Right and left vagus nerve

A

Right travels on posterior portion of stomach as it exits chest; becomes celiac plexus; has criminal nerve of Grassi which can cause persistently high acid levels postop if left undivided after vagotomy

Left vagus travels on anterior portion of stomach; goes to liver and biliary tree

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7
Q

Thoracic duct

A

Travels from R to L at T4-5 as it ascends mediastinum; inserts into L subclavian vein

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8
Q

Where does thoracic duct enter into?

A

L subclavian vein

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9
Q

UES and LEs

A

UES: Cricopharyngeus (circular muscle which prevents air swallowing), 15cm from incisors, gets RLN innervation, most common site of esophageal perf (usually occurs with EGD); aspiration with brainstem stroke is due to failure of cricopharyngeus to relax

LES: anatomic zone of high pressure, NOT an anatomis sphincter; 40cm from incisors, relaxation mediated by inhibitory neurons, normal contracted at resting state (prevents reflux)

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10
Q

Normal UES and LES pressure

A

UES: 60mmHg at rest, 15mmHg with food bolus

LES: 15mmHgb at rest, 0mmHg with food bolus

Both are normally contracted between meals

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11
Q

Anatomic areas of esophageal narrowing (and perf)

A
  • Cricopharyngeus muscle
  • Compression by left mainstem bronchus and aortic arch
  • Diaphragm
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12
Q

Swallowing stages

A

CNS initates swallow

  1. Primary peristalsis: food boluw and wallow initiation
  2. Secondary peristalsis: incomplete emptying and esophageal distension, propagating waes
  3. tertiary peristalsis: non-propagating, non-peristalsis (dysfunction)
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13
Q

Swallowing mechanism

A

Soft palate occludes nasopharynx

Larynx rises and airway opening is blocked by epiglottis

Cricopharyngeus relaxes

Pharyngeal contraction moves food into esophagus

LES relaxes soon after initiation of swallow (vagus mediated)

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14
Q

Surgical approach for different regions of esophagus

A

Cervical: Left

Upper 2/3 thoracic: Right (avoids aorta)

Lower 1/3 thoracic: Left

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15
Q

Hiccoughs causes

A

Gastric distension, temperature changes, EtOH, tobacco

Reflex arc: vagus, phrenic, sympathetic chain T6-12

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16
Q

Esophageal dysfunction primary/secondary

A

Primary: achalasia, DES, nutracker

Secondary: GERD (most common), scleroderma

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17
Q

Best test for heartburn

A

Endoscopy

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18
Q

Best test for dysphagia or odynophagia

A

Barium swallow (better at picking up masses)

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19
Q

Meat impaction dx and tx

A

EGD

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20
Q

Pharyngoesophageal disorders

A

trouble in transferring food from mouth to esophagus

Most commonly neuromuscular disease (MG, muscular dystrophy, stroke)

Liquids worse than solids

Plummer-Vinson syndrome

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21
Q

Upper esophageal web; IDA

A

Plummer-Vinson syndrome

Tx: dilation, Fe, need to screen for oral Ca

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22
Q

Upper esophageal dysphagia, choking hallitosis

A

Zenker’s diverticulum: caused by increased pressure during swallowing

Is a false diverticulum located posteriorly, located between pharyngeal constrictors and cricopharyngeus

Caused by failure of cricopharyngeus to relax

Dx: barium swallow, manometry, risk for perforation with EGD

Tx: Cricopharyngeal myotomy; can also resect or suspend (removal not necessary); via L cervical incision, leave drains, POD1 esophagogram

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23
Q

Regurgitation of undigested food, dysphagia, in some with recent inflammation/granulomatous disease/tumor

A

Traction diverticulum

True diverticulum, usually lies lateral and in mid-esophagus

Tx: Excision and primary closure if symptomatic, may need palliative therapy (XRT) if due to invasive ca; leave alone if symptomatic

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24
Q

Asymptomatic or dysphagia and regurgitation, found to have diverticulum and achalasia

A

Epiphrenic diverticulum

Rare, associated with esophageal motility disorders like achalasia

Most commonly in distal 10cm of esophagus

D: Esophagram and manomery

Tx: Diverticulectomy and esophageal myotomy on side OPPOSITE the diverticulectomy if symptomatic

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25
Q

Dysphagia, regurgitation, weight loss, respiratory symptoms

A

Achalasia

Caused by lack of peristalsis and failure of LES to relax after food bolus

Secondary to neuronal degeneration in muscle wall

Dx: Manometry shows increased LES pressure and incomplete LES relaxation, with NO peristalsis

Can get tortuous dilated esophagus and epiphrenic diverticula; bird’s beak appearance

Tx: Balloon dilatation of LES is effective in 80%; nitrates and CCBs; If medical tx and dilation fail, Heller myotomty (L thoracotomy, myotomy of lower esophagus ONLY, also partial Nissen)

T cruzi can produce similar symptoms

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26
Q

Chest pain, dysphagia, psychiatric history, manometry shows frequent strong non-peristaltic unorganized contractions and LES relaxes normally

A

DES

Tx: CCB, nitrates; Heller myotomy ifthose fail (myotomy of UPPER AND LOWER esophagus); surgery usually less effective than for achalasia

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27
Q

Chest pain and dysphagia, manometry shows high-amplitude PERISTALTIC contractions and LES relaxes normally

A

Nutcracker esophagus

Tx: CCB, nitrates; Heller myotomy if those fail (myotomy of UPPE AND LOWER esophagus); surgery usually less effective than for achalasia

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28
Q

Dysphagia and loss of LES tone with massive reflux and strictures

A

Scleroderma: fibrous replacement of smooth muscle

Tx: Esophagectomy usual if severe

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29
Q

Normal anatomic protection from GERD

A

Competent LES, normal esophageal body, and normal gastric reservoir

30
Q

Causes of GERD

A

Increased acid exposure to esophagus from loss of gastroesophageal barrier

31
Q

GERD symptoms

A

Heartburn 30-60 minutes after meals, worse with lying down

Can also have asthma symptoms (cough), choking, aspiration

32
Q

GERD workup

A

Make sure patient does not have another cause for pain (check for unusual symptoms)

Unusual symptoms: dysphagia/odynophagia (tumors), bloating (aerophagia and delayed gastric emptying, dx GES), epigastric pain (PUD or tumor)

33
Q

GERD tx

A

Empirically with PPI, 99% effective

Failure of PPI despite 3-4 weeks of escalating doses: need diagnostic studies

34
Q

GERD dx studies

A

pH probe (best test), manometry (resting LES < 6 mmHg), endoscopy, histology

35
Q

GERD surgical indications

A

Failure of medical tx, avoidance of lifetime meds, young patients

36
Q

Surgical tx of GERD

A

Nissen fundoplication: divide short gastrics, pull esophagus into abdomen, approximate crura, 270 (partial) or 360 degree gastric fundus wrap

37
Q

What is the phrenoesophageal membrane made of?

A

Its an extension of the transversalis fascia

38
Q

Key maneuver for Nissen wrap

A

identification of the L crura

39
Q

Complications of Nissen wrap

A

Injury to spleen, diaphragm, esophagus, or pneumothoraz

40
Q

Belsey anti-reflux

A

Approach through chest

41
Q

Collis gastroplasty

A

When not enough esophagus exists to pull down into abdomen, can staple along stomach cardia and create a neo-esophagus

42
Q

MCC dysphagia after Nissen

A

Wrap too tight

43
Q

Hiatal hernia types

A

I: Sliding hernia from dilation of hiatus (most common); often associated with GERD

II: Paraesophageal; hole in diaphragm alongside esophagus, normal GEJ, symptoms of chest pain, dysphagia, early satiety. Usually need repair due to high risk of incarceration; may want to avoid repair in the elderly and frail. In repair STILL NEED NISSEN as diaphragm repair can affect LES and also helps anchor stomach

III: combined

IV: entire stomach in chest plus another organ (colon, spleen)

44
Q

Schatzki’s ring

A

Almost all have an associaed sliding hiatal hernia

Symptoms of dysphagia

Tx: dilatation of ring and PPI usually sufficent; do NOT resect

45
Q

Barrett’s esophagus

A

Squamous metaplasia to columnar epithelium

Occurs with long-standing exposure to gastric reflux

Cancer risk is 50x higher (adenocarcinoma)

Ucomplicated Barrett’s can be treated like GERD (PPI or Nissen): surgery will decrease esophagitis and further metaplasia but will NOT prevent malignancy or cause regression of columnar lining. Need careful follow up with EGD for lifetime, even after Nissen

Severe Barrett’s dysplasia is an indication for esophagectomy

46
Q

Esophageal cancer characteristics

A

Almost always malignant with early invasion of nodes

Spreads quickly along submucosal lymphatic channels

Symptoms are dysphagia especially to solids, and weight loss

Risk factors are EtOH, tobacco, caustic injury, nitrosamines

Dx: esophagram (best test for dysphagia)

47
Q

Signs of unresectable esophageal cancer

A

CT chest and abdomen is the best single test for resectability

Hoarseness (RLN invasion)

Horner’s syndrome (brachial plexus invasion)

Phrenic nerve invasion

Malignant pleural effusion

Malignant fistula

Airway invasion

Vertebral invasion

Supravlavicular or celiac nodes (M1 disease; nodal disease outside area of resection)

48
Q

Types of esophageal cancer

A

Adenocarcinoma: #1, usually in lower 1/3, liver mets most common

Squamous cell carcinoma: usually upper 2/3, lung mets most common

49
Q

Chemo for esophageal cancer

A

Neoadjuvent CRT may downstage tumorsand make them resectable

Chemotx: 5Fu and cisplatin (for node-positive disease or preop to shrink tumors)

50
Q

Esophagectomy mortality rate and cure rate

A

5% mortality, 20% cure rate

51
Q

Primary blood supply to stomach after replacing esophagus

A

R gastroepiploic artery (have to divide L gastric and short gastrics)

52
Q

Transhiatal approach esophagectomy

A

Abdominal and neck incisions; bluntly dissect intrathoracic esophagus; may hae decreased mortality from esophageal leaks with cervical anastomosis

53
Q

Ivor Lewis esophagectmoy

A

Abdominal incision and R thoracotomy

Exposes all of the intrathoracic esophagus

Intrathoracic anastomosis

54
Q

3-hole esophagectomy

A

Abdominal, thoracic, and cervical incisions

55
Q

Esophagectomy types

A

Transhiatal approach

Ivor Lewis

3-Hole

Colonic interposition

Need pyloromyotomy with these procedures

56
Q

Colonic interposition esophagectomy

A

May be choice in young patients when you want to preserve gastric function; 3 anastomosis required; blood supply depends on colon marginal vessels

57
Q

Post esophagectomy care

A

POD7 contrast study to rule out leak

Postop strictures: most can be dilated

58
Q

Most common benign esophageal tumor

A

Leiomyoma

Located in muscularis propria

Present as dysphagia, with mass usually in lower 2/3 of esophagus (smooth muscle cells)

Dx: esophagram, EUS, CT scan to r/o cancer, DO NOT BIOPSY (can form scar and make subsequent resection difficult)

Tx: Excise via thoractomy if > 5cm or symptomatic

59
Q

Dysphagia and hematemesis, and found to have esophageal polyps

A

2nd most common benign tumor of esophagus

Usually in cervical esophagus

Small lesions can be resected endoscopically; larger lesions need cervical incision

60
Q

Caustic esophageal injury

A

Alkali or acid

Primary, secondary, or tertiary burns

NO NG TUBE, DO NOT INDUCE VOMITING, NOTHING TO DRINK

61
Q

Alkali and acid burns

A

Alkali: deep liquefaction necrosis, especially liquid (Drano), worse than acid and more likely to cause cancer

Acid: coagulation necrosis; mostly causes gastric injury

62
Q

Caustic injury workup

A

CT chest and abdomen to look for free air and perforation

Endoscopy to assess lesion: do NOT use with suspected perforation and NOT go past a site of sevre injury

Serial exams and plain films required

63
Q

Degrees of esophageal caustic injury

A

Primary burn: hyperemia, observe and IVF, spiting, abx, NPO 3-4 days, may need future serial dilation for strictures (usually cervial), can also get shortening of esophagus with GERD (tx PPI)

Secondary burn: ulcerations, exudates, sloughing, do prolonged observation and IVF, spitting, abx, NPO 3-4 days, future dilation if needed; indication for esophagectomy is sepsis, peritonitis, mediastinitis, free air, mediastinal or stomach wall air, crepitance, contrast extrav, pneumothorax, or large effusion

Tertiary burn: deep ulcers, charring, lumen narrowing; esophagectomy usually necessary; alimentary tract NOT restored until after patient recovers from caustic injury

CAUSTIC ESOPHAGEAL PERFORATIONS REQUIRE ESOPHAGECTOMY AND ARE NOT REPAIRED DUE TO EXTENSIVE DAMAGE

64
Q

Esophageal perforations MCC

A

EGD

65
Q

Esophageal perforations most common site

A

Cervical esophagus near cricopharyngeus muscle (?)

66
Q

Pain, dysphagia, tachycardia

A

Esophageal perforation

Dx: CXR to look for free air, gastrograffin swallow followed by barium swallow

67
Q

Management of esophageal perf

A

Contained perforation by contrast, self draining, NO systemic effects: IVF, NPO, spit, abx

Non-contained:
If <24 hr and minimal contamination: primary repair with drains (also need longitudinal myotomy to see full extent of injury and consider intercostal muscle flaps to cover repair)

If > 48 hr or extensive contamination:

    - Neck: Drainage (no resection) 
    - Chest: Resection (esophagectomy and cervical esophagostomy) or exclusion and diversion (cervical esophagostomy, staple across distal esophagus, washout mediastinum, chest tubes - late esophagectomy at time of gastric replacement)
68
Q

Indications for esophagectomy in perforation

A

Severe intrinsic disease (burned out esophagus from achalasia or cancer) regardless of contained or non contained

69
Q

Forceful vomiting followed by chest pain

A

Boerhaave’s: perforation most likely to occur in L lateral wall of esophagus, 3-5 cm above GEJ

Mediastinal crunching on auscultation: Hartmann’s sign

70
Q

Highest mortality of all perforations

A

Boerhaave’s syndrome: early diagnosis and treatment improve survival

Dx: gastrografin swallow

Tx: same as for other esophageal perforations

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