Benign Esophageal Disease Flashcards Preview

Sabiston Spencer > Benign Esophageal Disease > Flashcards

Flashcards in Benign Esophageal Disease Deck (21)
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1
Q

Pathophysiology of achalasia

A

Achalasia results from damage to the myenteric plexus with selective destruction of inhibitory neurons in the myenteric plexus by cytotoxic T lymphocytes.

2
Q

Mesenteric nervous system effects in achalasia

A

inflammatory neurodegenerative insult:

causes an imbalance between excitatory and inhibitory neurons,

cumulating in aperistalsis of the esophageal body and failure of LES relaxation.

3
Q

sine Quo non of achalasia

A
  1. aperistalsis of the esophageal body
  2. failure of LES relaxation
4
Q

Typical first diagnostic tests for Achalasia

A
  1. Barium esophagram
  2. esophagoscopy

(usually the first diagnostic tests performed because the usual symptoms are dysphagia and regurgitation. )

5
Q

Achalasia:

Classic findings on Esophogram?

A

Classic findings on esophagram:

esophageal dilation

aperistalsis

impaired esophageal emptying symmetrical tapering at the EGJ (bird’s beak or ace of spades appearance)

6
Q

Esophagoscopy findings of Achalasia.

A

Esophagoscopy:

  1. usually shows some degree of food or fluid retention (occasionally only saliva)
  2. chronic stasis changes, and a tight, spastic or puckered EGJ,
  3. not restricting endoscope passage.
7
Q

Role of EGD in the diagnosis of achalasia

A

When achalasia is suspected:

endoscopy is essential to exclude benign or malignant strictures, particularly pseudoachalasia (esophageal obstruction secondary to malignancy), which may be clinically and manometrically indistinguishable from primary achalasia.

8
Q

Manometric findings of achalasia

A

Manometrically, achalasia is defined:

incomplete or failed relaxation of the LES and aperistalsis of the esophageal body

9
Q

LES manometry

A

Resting LES pressure can be normal in up to 50% of patients;

elevated LES pressure is not required for diagnosis

10
Q

How many types of achalsia on manometry

A

Three

11
Q

Type 1 Achalasia

A

Type I (classic):

has minimal or no esophageal pressurization or peristaltic activity

12
Q

Type II achalasia

A

Type II:

panesophageal pressurization, greater than 30 mm Hg, throughout the entire esophagus in at least 20% of sequences;

13
Q

Type III Achalasia

A

type III (spastic, vigorous):

is associated with 20% or more swallows associated with premature contractions.

14
Q

Prognosis for type II achalasia:

A

Type II achalasia has been reported to be a predictor of an excellent outcome after all available treatment modalities.

15
Q

Type I Achalasia prognosis

A

Type I patients do significantly better with Heller myotomy than with pneumatic dilation.

16
Q

What type of achalasia have the worst prognosis

A

Type III and pretreatment esophageal dilation were predictive of poorer outcomes.

17
Q

Two most effective treatment modalities for achalasia?

A
  1. Pneumatic dilation
  2. surgical myotomy
18
Q

Pneumatic dilation achalasia:

method and effectiveness.

A
  1. Rigiflex balloon dilator
    • (balloon diameters of 3.0, 3.5, and 4.0 cm)
    • successful in controlling symptoms in 50% to 93% of patients.
  2. Graded dilator
    • 3.0 cm, 3.5 cm, and 4.0 cm
    • results in good-to-excellent response rates of 74%, 86%, and 90%,
19
Q

Perforation rate with the rigiflex balloon dialation:

A

Rigiflex balloon dilation:

reported a 2.0% perforation rate

20
Q

Rigifix balloon dilation of achasia:

% Good results at follow up ?

Recurance rate ?

A
  • 78% good or excellent results at 3-year follow-up.
  • >1/3 of patients will have symptom recurrence during a 4-year period,but they may respond to repeat dilation.
21
Q

Achlasia: long term outcomes

A

After 4.8 years of follow-up, laparotomy and myotomy provided symptom control in 95% of patients, whereas pneumatic dilation with the Mosher system provided symptom control in 65%.