How long is the esophagus?
25 cm/ 10 inches
Esophagus joins the larynx (cricoid cartilage) at the pharynx at what vertebral level?
C6
Esophagus passes the diaphragm to join the stomach at what vertebral level?
T10
Surgery: Cardia is at T11
Esophageal constrictions are important to notes because
- Site of carcinomas
- Development of strictures
- Difficult to pass esophagoscope
- Foreign bodies commonly lodge
3 esophageal constrictions
- Upper/pharyngoesophageal - cricopharyngeus (1.5 cm)
- Middle/thoracic - left mainstem bronchus (1.6 cm)
- Inferior/diaphragmatic - diaphragmatic hiatus (1.6 -1.9 cm)
Anatomic divisions of the esophagus
- Cervical
- Thoracic
- Abdominal
What nerve accompanies the esophagus through the diaphragm?
Vagus n.
L and R vagi lie where in relation to esophagus?
LARP
L vagus anterior
R vagus posterior
Blood supply of esophagus
Cervical - inferior thyroid a. from subclavian a.
Thoraxic - esophageal a. from descending thoracic aorta
Abdominal - left gastric from celiac trunk of abdominal aorta and inferior phrenic a.
Venous drainage of esophagus
Cervical - inferior thyroid v.
Thoracic - bronchial, azygous and hemiazygous v.
Abdominal - coronary v. (distal esophagus is left gastric v.)
Lymphatic drainage of esophagus
Cervical/upper: deep cervical
Thoracic/middle: mediastinal (usual site of nodal mets)
Abdominal/lower: celiac
What structure also passes through esophageal hiatus that may also be compressed by a sliding hiatal hernia?
Vagal trunks
Incompetent LES (loss of high pressure zone at the esophagogastric junction), substernal burning that is worse when lying down
GERD/heartburn
*LES is not a true anatomic sphincter
Failure of relaxation of the inferior/lower esophageal sphincter
Achalasia
Abdominal part of esophagus and part of the stomach herniate into the mediastinum causing hearthburn
Sliding hiatal hernia
average distance between external orifices of the nose and stomach
44 cm/17.2 inches
Important for Sengstaken-Blakemore Balloon insertion
Test to detect structural abnormalities in esophagus
Barium swallow
Endoscopy
Test to detect functional abnormalities of esophagus
Manometry
Tests to detect increased exposure to gastric juice in esophagus
24 hour ambulatory pH monitoring - gold standard for GERD diagnosis
Radiographic exposure of GER (barium regurgitates when upright)
Complications of GERD
esophagitis stricture repetitive aspiration progressive pulmonary fibrosis barrett esophagus (30 to 125x increased risk for developing adenoCA) esophageal adenoCA
Barrett esophagus hallmark of intestinal metaplasia
presence of intestinal goblet cells (intestinalization of esophagus)
GERD diagnosis
(+) symptoms - start empiric antacids for 12 weeks
persistent symptoms: endoscopy, 24 hr ambulatory pH monitoring, esophageal manometry
Anti-reflux procedures
Nissen fundoplication Toupet fundoplication Dor fundoplication Belsey Mark IV Hill posterior gastropexy
*T,D,B - partial fundoplication, for patients presenting with dysphagia
Types of diaphragmatic/hiatal hernias and description
Type I (sliding hiatal hernia) - cardia, GERD symptoms - medical tx Type II (rolling/paraesophageal) - fundus, obstruction, dysphagia, ulcers, strangulation, bleeding, volvulus, infarct - surgical tx Type III (combined) Type IV (additional organ herniates aside from stomach)
Borchardt triad (hiatal hernias) SSx indicative of incarcerated intrathoracic stomach
chest pain
retching with inability to vomit
inability to pass NGT
Esophageal diverticula based on location
Pharyngoesophageal (Zenker)
Mid thoracic (para-bronchial)
Epiphrenic
Most common esophageal diverticula with SSx
Zenker diverticulum
Dysphagia Regurgitation of undigested food Halitosis Choking Aspiration
Types of mid thoracic diverticula
Traction - TB, histoplasmosis, pulmo diseases
Pulsion - more common, motility disorders
Esophageal diverticula associated with hiatal hernia
Epiphrenic (distal end of esophagus)
Triad of achalasia
Hypertensive LES
Aperistalsis of esophageal body
Failure of LES to relax
Esophagogram findings in achalasia
Bird’s beak esophagus/pencil tip deformity
Air fluid level
Sigmoid esophagus
Esophageal dilatation
Medical management of achalasia
botulinum toxin
nitrates
CCBs
Corkscrew deformity on esophagogram
Diffuse and segmental esophageal spasm
Most common primary esophageal motility disorder
Nutcracker esophagus
Severe neck pain due to spontaneous rupture of esophagus (true surgical emergency)
Boerhaave syndrome
Caustic substance injury scale
Zargar’s grading classification of mucosal injury caused by ingestion of caustic substances
0 - normal
1 and 2a - good prognosis
2b, 3a, 3b - stricture formation, observe for signs of perforation
Usual location of esophageal carcinoma
SquaCA - middle third of thoracic esophagus
AdenoCA - distal esophagus
Risk factors for squaCA of esophagus
tobacco use alcohol use history of head and neck cancer history of breast cancer with radiotherapy Plummer-Vinson syndrome caustic injury to esophagus achalasia
Risk factors for adenoCA of esophagus
barrett esophagus - not in squaCA weekly GERD symptoms - not in squaCA history of breast cancer with radiotherapy obesity - not in squaCA tobacco
Functional grade of dysphagia
1 - eating normally 2 - liquid with meals 3 - semisolids 4 - liquids only 5 - saliva 6 - cannot swallow saliva
Exclusion criteria for curative surgery or resection for esophageal CA
Age > 75years old
FEV1 < 1.25 and EF <40%
>20% weight loss
locally advance tumor
Best way to palliate malignant dysphagia in esophageal CA
Surgical
EHJ carcinoma classification
I - esophageal
II - cardiac
III - sub-cardiac
Dysphagia, atrophic oral mucosa, spoon-shaped fingers with brittle nails, chronic anemia, middle-aged edentulous women, esophageal web (FeSO4-induced), pre-malignant lesions
Plummer-Vinson syndrome
Thin submucosal ring in lower esophagus
Schatzki ring
UGIB after repeated vomiting, mucosal tears along GEJ
Mallory-Weiss tear
85% of esophageal atresia is what type?
Type C
Segments of the large intestines and their measurements
cecum - 6 cm appendix - 6 to 10 cm ascending colon - 13 cm transverse colon - 38 cm descending colon - 25 cm sigmoid colon - 25 to 38 cm rectum - 13 cm rectosigmoid junction 17 to 18 cm anal colon - 4 cm
Blood supply and venous drainage of cecum
ant. and post. cecal a. from ileocolic a. from SMA
ant. and post. cecal v. from ileocolic v. to SMV
McBurney point
in relation to the ant. abdominal wall, its base is situated 1/3 of the way up to the line joining the R ASIS to the umbilicus
Most common position of appendix (trace the ileocolic a.!)
Retrocecal
Pelvic
Ileocecal
Subcecal
Causes weakening of anterior abdominal wall when injured during appendectomy
iliohypogastric n.
Common causes of appendicitis
adults - fecalith
children - lymphatic tissue
Blood supply and venous drainage of the ascending colon
Ileocolic and R colic a. from SMA
Drained by ileocolic and R colic v. to SMV
Location of ascending colon
Retroperitoneal
Longest, largest and most mobile portion of large intestine
transverse colon
contains a transverse mesocolon
Blood supply and venous drainage of transverse colon
middle colic a. and R colic a. from SMA and L colic from IMA
Drained by superior and inferior mesenteric v.
Retroperitoneal in location, supplied by L colic and sigmoid a. from IMA and drained by IMV
Descending colon
Fan-shaped mesocolon, extends from iliac fossa to 3rd sacral vertebra
sigmoid colon
Structures ant. and post. to sigmoid colon
Posterior - rectum and sacrum
Anterior
M - urinary bladder
F - uterus and vagina
Blood supply and venous drainage of sigmoid colon
sigmoid a. from IMA
drained by IMV
Left-sided (R-sided is intussusception) colicky pain, abdominal distention and hematochezia
sigmoid volvulus
diverticulosis vs. diverticulitis
no inflammation vs. with inflammation
End of rectum, inside pelvic cavity, has valves of Houston
tip of coccyx/ anal canal
Surgical anal canal includes
internal rectal v.
Rectum relations: lateral, ant. and post.
lateral: ischiorectal fossa and ischial spines
posterior: sacrum, coccyx, piriformis, coccygeus, levator ani
anterior:
M - sigmoid, ileum, urinary bladder, vas deferens, seminal vesicles, prostate, perineal body, urogenital diaphragm, bulb of penis
F - sigmoid, ileum, rectouterine pouch, vagina, cervix, urogenital diaphragm, perineal body
Blood supply and venous drainage of rectum
Supplied by:
superior rectal a. from IMA
middle rectal a. from internal iliac
inferior rectal a. from internal pudendal
Drained by:
superior rectal v. - IMV to portal side
middle rectal v. - internal iliac to caval side
inferior rectal v. from internal pudendal to internal iliac to caval side
Located in the perineum, begins where rectal ampula narrows at the level of the U-shaped sling of puborectalis muscle, ends at anus
Anal canal
Separates the anal canal into 2 segments with different embryonic origin, blood supply and innervation
dentate/pectinate/anorectal line
Upper/Superior anal canal: embryonic origin cell lining other characteristics blood supply and drainage lymphatic drainage
Upper/Superior anal canal:
embryonic origin - hindgut endoderm
cell lining - columnar
other characteristics - anal colums of morgagni, stretch
blood supply and drainage - superior rectal a. and n.
lymphatic drainage - inferior mesenteric LN
Lower/Inferior anal canal embryonic origin cell lining other characteristics blood supply and drainage lymphatic drainage
Lower/Inferior anal canal
embryonic origin - ectoderm
cell lining - strat. squamous
other characteristics - no anal columns, pain, temperature, touch, pressure
blood supply and drainage - inferior rectal a. and n.
lymphatic drainage - superficial inguinal LN
Differentiate internal vs. external hemorrhoids
Internal hemorrhoids - painless, covered in mucosa, dilated internal rectal venous plexus
External hemorrhoids - painful, covered in skin, dilated external rectal venous plexus
Hemorrhoidal cushions
Left lat
Right ant
Right post
Differentiate degrees of hemorrhoids
First - bulge into anal canal, prolapse beyond the dentate line on straining
Second - prolapse through anus but reduce spontaneously
Third - prolapse through anal canal and require manual reduction
Fourth - cannot be reduced, at risk for strangulation
In Hirschsprung, the constricted part is
abnormal/aganglionic (a.k.a. congenital megacolon)
Mimics referred pain of inflamed appendix, may contain ectopic gastric or pancreatic cells - true diverticulum
Meckel diverticulum
Pain and where the structures are derived
Epigastric = Foregut Periumbilical = Midgut Hypogastric = Hindgut
Lymphatic structures such as the spleen are derived from
Mesoderm
SMA blood supply and parasympathetic innervation from vagus in the large intestine
Ascending and Transverse colon
IMA and parasympathetic fibers from the pelvic splanchnic nerve from sacral nerves S2-S4
Descending and sigmoid colon
Length of entire colon
1 to 1.5 meters
Epithelium of colon
glandular epithelium with straight crypts, goblet cells and absorptive cells
What is absorbed in the colon?
1 to 2 L of fluid daily
sodium
chloride
urea
GIT forms at what week of gestation?
4th
Special signs of appendicitis on PE:
Referred pain or feeling of distress on epigastrium or precordial region on continued firm pressure over the McBurney point (RLQ)
Aaron sign
Special signs of appendicitis on PE:
Bassler sign
Sharp pain elicited by pinching appendix between thumb of examiner and iliacus muscle (chronic appendicitis)
Special signs of appendicitis on PE:
Transient abdominal wall rebound tenderness
Blumberg sign
Special signs of appendicitis on PE:
Exacerbation of pain when the uterus is shifted to the right side (acute appendicitis in pregnancy, also in acute panc)
Bryan sign
Special signs of appendicitis on PE:
Cutaneous hyperesthesia
In area supplied by spinal nerves on the right (T10, T11, T12)
Special signs of appendicitis on PE:
Increased abdominal pain on coughing
Dunphy sign
Special signs of appendicitis on PE:
Kocher/Kosher sign
Migration of pain from the umbilical region to the right iliac region
Special signs of appendicitis on PE:
RLQ pain on dropping from standing on toes to heels
Markle sign
Special signs of appendicitis on PE:
Massouh sign
Grimace when examiner performs a firm swish with index and middle finger across abdomen from epigastrium to right iliac fossa
Special signs of appendicitis on PE:
Tenderness in RLQ increases when patient moves from supine position to a recumbent posture on left side
Rosenstein sign
Special signs of appendicitis on PE:
Rovsing sign
Pain at RLQ when palpatory pressure exerted at LLQ
Special signs of appendicitis on PE:
Patient lies on left side, examiner then slowly extends R thigh, stretching the iliopsoas muscle (positive if extension produces pain)
Iliopsoas sign
Special signs of appendicitis on PE:
Obturator sign
Performed by passive internal rotation of the flexed right thigh with the patient in supine position (positive if with hypogastric pain on stretching the obturator internus muscle)
Special signs of appendicitis on PE:
Increased abdominal muscle tome on exceedingly gentle palpation of the right iliac fossa (early appendicitis)
Summer sign
Special signs of appendicitis on PE:
Ten Horn sign
Pain caused by gentle traction on the right spermatic cord (caused by cord tension)
Prehn sign
testicular torsion, if testicles are lifted, pain is relieved
Alvarado score has 85% accuracy for appendicitis. What are its components? Score of 7-8 is high likelihood of appendicitis
Migratory RLQ pain Anorexia Nausea or vomiting RLQ (right iliac fossa) tenderness Rebound tenderness of R iliac fossa Elevation in temperature Leukocytosis Shift to the left of neutrophils
Another scoring system: Appendicitis Inflammatory Response score (vomiting, RLQ pain, rebound tenderness, elevated temperature, PMN, WBC, CRP), Score of 9-12: Explore
Normal appendix on ultrasound
Aperistaltic
Blind ending
Compressible
Diametes <5 mm
Appendicitis findings on ultrasound
periappendiceal fluid
wall thickening
Appendicitis CT scan criteria
>6 mm diameter > 2 mm wall thickness (target sign) fat stranding fecalith arrowhead sign
Rupture of appendix is greater in which age groups?
<5 and >65 years old
Most common findings in erroneous diagnosis of appendicitis
Acute mesenteric lymphadenitis No organic pathologic condition Acute PID Twisted ovarian cysts or ruptured Graafian follicle AGE
Most commonly injured part of the ureter during Gyne and Uro surgeries
Distal ureter