Chapter 29: Esophagus Flashcards Preview

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Flashcards in Chapter 29: Esophagus Deck (158):
1

Layers of the esophagus

Mucosa (squamous epithelium), submucosa, and muscular propria (longitudinal muscle layer); no serosa

2

Does the esophagus have serosa?

No

3

Muscle: upper 1/3 esophagus

Striated muscle

4

Muscle: middle 1/3 and lower 1/3 esophagus

Smooth muscle

5

Major blood supply to the thoracic esophaugs

Vessels directly off the aorta are the major blood supply to the thoracic esophagus

6

Artery: cervical esophagus

Supplied by the inferior thyroid artery

7

Artery: abdominal esophagus

Supplied by left gastric and inferior phrenic arteries

8

Venous drainage of the esophagus

Hema-Azygous and azygous veins in chest

9

Lymphatics of esophagus

Upper 2/3 drains cephalad, lower 1/3 caudad

10

Travels on posterior portion of stomach as it exits chest; becomes celiac plexus

Right vagus nerve

11

Right vagus nerve: can cause persistently high acid levels postoperatively if left undivided after vagotomy

Criminal nerve of Grassi

12

Travels on the anterior portion of stomach; goes to liver and biliary tree

Left vagus nerve

13

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

Thoracic duct

14

Where is the upper esophageal sphincter in relation to the incisors?

UES is 15cm from incisors

15

Is the cricopharyngeus muscle (circular muscle, prevents air swallowing); recurrent laryngeal nerve innervation

Upper esophageal sphincter (UES)

16

Normal UES pressure at rest

60 mmHg

17

Normal UES pressure with food bolus

15 mmHg

18

Most common site of esophageal perforation (usually occurs with EGD)

Cricopharyngeus muscle

19

What causes aspiration with brainstem stroke?

Failure of cricopharyngeus to relax

20

Where is lower esophageal sphincter in relation to incisors?

LES is 40 cm from incisors

21

Relaxation mediated by inhibitory neurons; normally contracted at resting state (prevents reflux); is an anatomic zone of high pressure, not an anatomic sphincter

Lower esophageal sphincter (LES)

22

Normal LES pressure at rest

15 mmHg

23

Normal LES pressure with food bolus

0 mmHg

24

Anatomic areas of esophageal narrowing

- Cricopharyngeus muscle
- Compression by the left mainstem bronchus and aortic arch
- Diaphragm

25

Swallowing stages

- Primary peristalsis: occurs with food bolus and swallow initiation
- Secondary peristalsis: occurs with incomplete emptying and esophageal distention; propagating waves
- Tertiary peristalsis: non-propagating, non-peristalsing (dysfunctional)

26

What initiates swallowing stages?

CNS initiates swallow

27

Normally contracted between meals

UES and LES

28

Swallowing mechanism

Soft palate occludes nasopharynx.
Larynx rises and airway opening is blocked by epiglottis.
Cricopharyngeus relaxes.
Pharyngeal contraction moves food into esophagus.

29

What relaxes soon after initiation of swallow?

LES - vagus mediated.

30

Surgical approach:
- Cervical esophagus
- Upper 2/3 thoracic
- Lower 1/3 thoracic

- Cervical: left
- Upper 2/3: right (avoids the aorta)
- Lower 1/3 thoracic: left (left-sided course in this region)

31

Causes hiccoughs

Gastric distention, temperature changes, ETOH, tobacco

32

Hiccough reflex arc

Vagus, phrenic, sympathetic chain T6-T12

33

Primary esophageal dysfunction

Achalasia, diffuse esophageal spasm, nutcracker esophagus

34

Secondary esophageal dysfunction

GERD (most common), scleroderma

35

Best test for heartburn (can visualize esophagitis)

Endoscopy

36

Best test for dysphagia or odynophagia (better at picking up masses)

Barium swallow

37

Dx / Tx: meat impaction

Endoscopy

38

- Trouble in transferring food from mouth to esophagus
- Liquids worse than solids

Pharyngoesophageal disorders

39

What are pharyngoesophageal disorders most likely secondary to?

Most commonly neuromuscular disease - myasthenia gravis, muscular dystrophy, stroke

40

Can have upper esophageal web, iron deficiency anemia
- Tx: dilation, iron, need to screen for oral cancer

Plummer-Vinson syndrome

41

Caused by increased pressure during swallowing

Zenker's diverticulum

42

What type of diverticulum is Zenker's?

Is a false diverticulum located posteriorly.

43

Where does Zenker's diverticulum occur?

Occurs between the pharyngeal constrictors and cricopharyngeus

44

What causes Zenker's diverticulum?

Caused by failure of the cricopharyngeus to relax

45

Symptoms: upper esophageal dysphagia, choking, halitosis

Zenker's diverticulum

46

Dx: Zenker's diverticulum

Barium swallow studies, manometry; risk for perforation with EGD and Zenker's

47

Tx: Zenker's diverticulum

Cricopharyngeal myotomy (key point); Zenker's itself can either be resected or suspended (removal of diverticula is not necessary)

48

Post op management of Zenker's diverticulum

Left cervical incision, leave drains in, esophagogram POD#1.

49

- Is a true diverticulum - usually lies lateral
- Due to inflammation, granulomatous disease, tumor.
- Usually found in the mid-esophagus
- Symptoms: regurgitation of undigested food, dysphagia

Traction diverticulum

50

Tx: traction diverticulum

Excision and primary closure if symptomatic, may need palliative therapy (i.e. XRT) if due to invasive CA; if asymptomatic, leave alone

51

- Rare, associated with esophageal motility disorders (e.g., achalasia)
- Most common in the distal 10 cm of the esophagus
- Most are asymptomatic; can have dysphagia and regurgitation

Epiphrenic diverticulum

52

Dx / Tx: epiphrenic diverticulum

Dx: esophagram and esophageal manometry

Tx: diverticulectomy and esophageal myotomy on the side opposite the diverticulectomy if symptomatic

53

Where are epiphrenic diverticulum most common?

Most common in the distal 10 cm of the esophagus

54

- Dysphagia, regurgitation, weight loss, respiratory symptoms
- Caused by lack of peristalsis and failure of LES to relax after food bolus
- Secondary to neuronal degeneration in muscle wall

Achalasia

55

What will manometry show in achalasia?

Increased LES pressure, incomplete LES relaxation, no peristalsis

56

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

Achalasia

57

Initial Medical Treatment: achalasia

Balloon dilatation of LES -> effective in 80%; nitrates, calcium channel blocker

58

Treatment for achalasia when medical treatment and dilation fail

Heller myotomy (left thoractomy, myotome of lower esophagus only; also need partial Nissen fundoplication

59

Organism producing similar symptoms as achalasia

T. cruzi

60

Chest pain, may have dysphagia; may have psychiatric history

Diffuse esophageal spasm

61

Manometry in diffuse esophageal spasm

Frequent strong non-peristaltic unorganized contractions, LES relaxes normally

62

Treatment: diffuse esophageal spasm

Calcium channel blocker, nitrates; Heller myotomy if those fail (myotomy of upper and lower esophagus)

63

What is a Heller myotomy?

procedure in which muscles of the cardia are cut (lower esophageal sphincter)

64

What is surgery more effective for achalasia or diffuse esophageal spasm?

Surgery usually less effective for diffuse esophageal spasm than for achalasia

65

Chest pain and dysphagia

Manometry: high-amplitude peristaltic contractions; LES relaxes normally

Nutcracker esophagus

66

Treatment: nutcracker esophagus

Calcium channel blocker, nitrates; Heller myotomy if those fail (myotomy of upper and lower esophagus)

67

Manometry: nutcracker esophagus

High-amplitude peristaltic contractions; LES relaxes normally

68

Fibrous replacement of esophageal smooth muscle

Causes dysphagia and loss of LES tone with massive reflux and strictures

Scleroderma

69

Tx: scleroderma

Esophagectomy if severe

70

Normal anatomic protection from GERD

Need LES competence, normal esophageal body, normal gastric reservoir

71

What causes GERD?

Caused by increased acid exposure to esophagus from loss of gastroesophageal barrier

72

Get heartburn symptoms 30-60 minutes after meals; worse with lying down

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

GERD

73

What do you worry about with dysphagia / odynophagia?

Need to worry about tumors

74

What do you worry about with bloating?

Suggest aerophagia and delayed gastric emptying

Dx: gastric empything study

75

What do you worry about with epigastric pain?

Suggests peptic ulcer, tumor

76

Failure of PPI in GERD despite escalating doses (give it 3-4 weeks) -> ___?

Need diagnostic studies

77

Dx: GERD

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

78

Surgical indications in GERD

failure of medical treatment, avoidance lifetime meds, young patients

79

Tx: GERD

Nissen fundoplication

80

What is a Nissen fundoplication?

Divide short gastrics, pull esophagus into abdomen, approximate crura, 270- (partial) or 360-degree gastric fundus wrap

81

What is the phrenoesophageal membrane an extension of?

Transversalis fascia

82

Key maneuver for wrap in Nissen fundoplication

Left crura

83

Complications Nissen fundoplication

Injury to spleen, diaphragm, esophagus, or pneumothorax

84

Treatment for GERD with approach going through chest

Belsey approach

85

What is Collis gastroplasty?

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

86

Most common cause of dysphagia following Nissen

Wrap is too tight

87

Hiatal Hernia: sliding hernia from dilation of hiatus (most common); associated with GERD

Type 1 Hiatal hernia

88

Hiatal Hernia: paraesophageal; hole in the diagphragm alongside the esophagus, normal GE junction

Symptoms: chest pain, dysphagia, early satiety

Type 2 Hiatal Hernia

89

Hiatal Hernia: combined Type 1 and type 2

Type 3: sliding hernia from dilation of hiatus; paraesopageal (hole in the diaphragm)

90

Hiatal Hernia: entire stomach in the chest plus another organ (i.e. colon, spleen)

Type 4 hiatal hernia

91

Why do you need Nissen with type 2 hiatal hernia?

Still need Nissen as diaphragm repair can affect LES; also helps anchor stomach

92

Hiatal hernia: usually need repair -> high risk of incarceration; may want to avoid repair in the elderly and frail

Paraesophageal hernia (type 2)

93

- Almost all patients have an associated sliding hiatal hernia
- Symptoms: dysphagia
Tx: dilation of the ring and PPI usually sufficient, do not resect

Schatzki's ring

94

- Squamous metaplasia to columnar epithelium
- Occurs with long-standing exposure to gastric reflux

Barret's esophagus

95

Cancer risk in Barrett's esophagus

Cancer risk increased 50 times (adenocarcinoma)

96

Treatment: severe Barrett's dysplasia

Indication for esophagectomy

97

Treatment uncomplicated Barrett's esophagus

Indication for esophagectomy

98

How does surgery affect cancer risk in Barrett's esophagus?

Surgery will decrease esophagitis and further metaplasia but will not prevent malignancy or cause regression of the columnar lining

99

Follow up for Barrett's esophagus

Need careful follow-up with EGD for lifetime, even after Nissen

100

Malignancy potential of esophageal cancer

Esophageal tumors are almost always malignant; early invasion of nodes

101

How does esophageal cancer spread?

Spreads quickly along submucosal lymphatic channels

102

Symptoms: dysphagia (especially solids), weight loss

Risk factors: ETOH, tobacco, achalasia, caustic injury, nitrosamines

Esophageal cancer

103

Dx: esophageal cancer

Esophagram (best test for dysphagia)

104

When is esophageal cancer considered unresectable?

Hoarseness (RLN invasion), Horner's syndrome (Brachial plexus invasion), phrenic nerve invasion, malignant pleural effusion, malignant fistula, airway invasion, vertebral invasion

105

Best single test to evaluate for resectability in esophageal cancer

Chest and abdominal CT is the best single test for resectability

106

#1 esophageal cancer

Adenocarcinoma (not squamous)

107

Esophageal cancer:
- Usually in lower 1/3 of esophagus
- Liver metastases most common

Adenocarcinoma

108

Esophageal cancer:
- Usually in upper 2/3 of esophagus
- Lung metastases most common

Squamous cell carcinoma

109

Esophageal cancer: what if there is nodal disease outside the area of resection (i.e. supraclavicular or celiac nodes - M1 disease)?

Contraindication to esophagectomy

110

Esophageal cancer: may downstage tumors and make them resectable

Pre-op chemo-XRT

111

Rates of mortality and cure in esophagectomy for esophageal cancer

5% mortality from surgery; curative in 20%

112

Primary blood supply to stomach after replacing esophagus (have to divide left gastric and short gastrics)

Right gastroepiploic artery

113

Approaches to esophagectomy

Transhiatal approach
Ivor Lewis
3-hole esophagectomy
- Consider colonic interposition in young patients

114

What is the transhiatal approach to esophagectomy?

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

115

What is the Ivor Lewis approach to esophagectomy?

Abdominal incision and right thoracotomy -> exposes all of the intrathoracic esophagus; intrathoracic anastomosis

116

Incisions for 3-hole esophagectomy

Abdominal, thoracic, and cervical incisions

117

What do you need to do in addition to the transhiatal, Ivor Lewis and 3-hole esophagectomy approaches to esophagectomy?

Need pyloromyotomy with these procedures

118

When would you consider colonic interposition for esophagectomy?

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

119

Follow up of esophagectomy post op

Need contrast study on post day 7 to rule out leak

120

Treatment of postoperative strictures s/p esophagectomy

Most can be dilated

121

Chemotherapy for esophageal cancer

5-FU and cisplatin (for node-positive disease or use pre-op to shrink tumors)

122

May help downstage esophageal tumors

XRT

123

Mortality rate of malignant fistulas in esophageal cancer

Most die within 3 months due to aspiration

124

Tx: malignant fistula in esophageal cancer

Esophageal stent for palliation

125

Most common benign esophageal tumor; located in muscularis propr.

Symptoms: dysphagia; usually in lower 2/3 of esophagus (smooth muscle cells)

Leiomyoma

126

Dx: leiomyoma

Esophagram, endoscopic US (EUS), CT scan (need to rule out CA)

127

Why would you never biopsy a leiomyoma?

Do not biopsy -> can form scar and make subsequent resection difficult

128

Tx: leiomyoma

> 5 cm or symptomatic -> excision (enucleation) via thoractomy

129

Symptoms: dysphagia, hematemesis

2nd most common benign tumor of the esophagus; usually in the cervical esophagus

Esophageal polyps

130

Management: esophageal polyps

Small lesions can be resected with endoscopy; larger lesions require cervical incision

131

Emergent management of caustic esophageal injury.

No NGT.
Do not induce vomiting.
Nothing to drink.

132

How do alkali cause caustic injury to esophagus?

Causes deep liquefaction necrosis, especially liquid (e.g., Drano)
- Worse injury than acid; more likely to cause cancer

133

How do acids cause caustic injury to the esophagus?

Causes coagualtion necrosis; mostly causes gastric injury

134

Imaging studies in suspected caustic esophageal injury

Chest and abdominal CT scan to look for free air and signs of perforation
- Endoscopy to assess lesion (do not use with suspected perforation and do not go past a site of severe injury)

135

What is important to remember during endoscopy for caustic esophageal injury?

Do not use with suspected perforation and do not go past a site of severe injury.

136

What is required in management of caustic esophageal injury?

Serial exams and plain films required.

137

Caustic esophageal injuries: degree of injury

- Primary burn: hyperemia
- Secondary burn: ulcerations, exudates and sloughing
- Tertiary burn: deep ulcers, charring, and lumen narrowing

138

Treatment: primary burn in caustic esophageal injury

Tx: observation and conservative therapy

Conservative: IVFs, spitting, antibiotics, oral intake after 3-4 days; may need future serial dilation for strictures (usually cervical)

Can also get shortening of esophagus with GERD (tx: PPI)

139

Treatment: secondary burn in caustic esophageal injury

Tx: prolonged observation and conservative therapy.

Conservative: IVFs, spitting, antibiotics, oral intake after 3-4 days; may need future serial dilation for strictures (usually cervical)

140

Indications for esophagectomy in secondary burn caustic esophageal injury

Sepsis, peritonitis, mediastinitis, free air, mediastinal or stomach wall air, crepitant, contrast extravasation, pneumothorax, large effusion

141

Treatment: tertiary burn in caustic esophageal injury

Tx: observation and conservative treatment. Conservative: IVFs, spitting, antibiotics, oral intake after 3-4 days; may need future serial dilation for strictures (usually cervical)

Esophagectomy is usually necessary

142

When is the alimentary tract restored in tertiary burn from caustic esophageal injury?

Alimentary tract not restored until after patient recovers from the caustic injury

143

Treatment: caustic esophageal perforations

Require esophagectomy (are not repaired due to extensive damage)

144

What are the usual cause of esophageal perforations?

Usually the result of EGD

145

Most common site of esophageal perforation

Cervical esophagus near cricopharyngeus muscle

146

Symptoms: pain, dysphagia, tachycardia

Esophageal perforation

147

Dx: esophageal perforation

CXR initially (look for free air); Gastrograffin swallow followed by barium swallow

148

Criteria for nonsurgical management of esophageal perforation

Contained perforation by contrast, self-draining, no systemic effects

Conservative tx: IVFs, NPO, spit, broad-spectrum antibiotics

149

Non-contained esophageal perforations: management if quick to diagnose (

Primary repair with drains.

Need longitudinal myotomy to see the full extent of the injury. Consider muscle flaps (e.g. intercostal) to cover repair

150

Non-contained esophageal perforations: management if late to diagnose (>48hrs) or area has extensive contamination

- Neck: just place drains (no esophagectomy)
- Chest: need 1) resection (esophagectomy, cervical esophagostomy) or 2) exclusion and diversion (cervical esophagostomy, staple across distal esophagus, washout mediastinum, place chest tube - late esophagectomy at time of gastric replacement)
- Gastric replacement of esophagus late when patient fully recovers.

151

May be needed for any esophageal perforation (contained or non-contained) in patients with severe intrinsic disease (e.g. burned out esophagus form achalasia, esophageal CA)

Esophagectomy

152

Forceful vomiting followed by chest pain

Highest mortality of all esophageal perforation - early diagnosis and treatment improve survival

Boerhaave's syndrome

153

Where is perforation in Boerhaave's syndrome most likely to occur?

In the left lateral wall of esophagus, 3-5 cm above the GE junction

154

Mediastinal crunching on auscultation

Hartmann's sign

155

Dx / Tx: boerhaave's syndrome

Dx: gastrograffin swallow

Tx: same for other esophageal perforation

156

Highest mortality of all esophageal perforations

Boerhaave's syndrome: early diagnosis and treatment improves survival

157

Non-contained esophageal perforations: management if late to diagnose (>48hrs) or area has extensive contamination
- Neck

Just place drains (no esophagectomy)

Gastric replacement of esophagus late when patient fully recovers.

158

Non-contained esophageal perforations: management if late to diagnose (>48hrs) or area has extensive contamination
- Chest

1) 1) resection (esophagectomy, cervical esophagostomy)
or
2) exclusion and diversion (cervical esophagostomy, staple across distal esophagus, washout mediastinum, place chest tube - late esophagectomy at time of gastric replacement)

Gastric replacement of esophagus late when patient fully recovers.