Esophageal Disorders

Question 1

Hiatal Hernia

Answer 1

Diaphragmatic hernia, esophageal hernia
Herniation of portion of stomach into esophagus through an opening in diaphragm
Most common abnormality found on upper GI x-ray

Question 2

Sliding Hiatal Hernia

Answer 2

Stomach slides through opening with pt is supine, goes back into abdominal cavity when pt is standing upright
Most common type

Question 3

Paraesophageal Hiatal Hernia

Answer 3

Esophogastric junction remains in place but fundus and greater curvature of stomach roll up through diaphragm
Acute parasophageal hernia is a medical emergency

Question 4

Causes of hiatal hernia

Answer 4

Many factors
Structural changes, weaken diaphragm muscles
Increased intraabdominal pressure (obesity, pregnancy, heavy lifting)

Question 5

Hiatal hernia clinical manifestations

Answer 5

May be asymptomatic
Heartburn
Dysphagia

Question 6

Hiatal hernia complications

Answer 6

GERD
Esophagitis
Hemorrhage from erosion
Stenosis
Ulcerations of herniated portion
Strangulation of hernia
Regurgitation with tracheal aspiration
Increased risk of respriatory problems

Question 7

Hiatal hernia lifestyle modifications

Answer 7

Eliminate alcohol
Elevate HOB
Stop smoking
Avoid lifting/straining
Reduce weight, if appropriate
Use antisecretory agents and antacids

Question 8

Hiatal Hernia Surgical Therapy

Answer 8

Reduction of herniated stomach
Herniotomy (excision of hernia sac)
Herniorrhaphy (closure of hiatal defect)
Gastropexy (antireflux procedure)
*Laparoscopically: Nissen or Toupet techniques used
*Thoracic or open abdominal used depending on individual pt

Question 9

Gastropexy

Answer 9

Attachment of the stomach supdiaphragmatically to prevent reherniation

Question 10

Nissen Fundoplication

Answer 10

Fundus of stomach is wrapped around distal esophagus, fundus is then stuffed into itself

Question 11

Esophageal Cancer

Answer 11

Malignant neoplasm of esophagus
Comes from structural changes
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Question 12

Squamous Cell

Answer 12

Changes due to damage that leads to cancer

Question 13

Adenocarcinomas

Answer 13

Arise from glands lining esophagus

Resemble cancers of stomach and small intestine

Question 14

Risk factors for esophageal cancer

Answer 14

Smoking
Excessive alcohol intake
Barrett's metaplasia
Central obesity
History of achalasia

Question 15

Barrett’s metaplasia

Answer 15

Seen in long term bulimics and long term GERD

Question 16

Etiology and Patho

Esophageal Cancer

Answer 16

Majority of tumors located in middle/lower portions of esophagus
Malignant tumors

Question 17

Malignant tumors

Answer 17

Usually appear as ulcerated lesion
May penetrate muscular layer and outside wall of esophagus
Obstruction in later stages

Question 18

Esophageal Cancer Clinical Manifestations

Answer 18

Symptom onset is late
Progressive dysphagia is most common (initially w/ meat then w/ soft foods and liquids)
Pain develops late (substernal, epigastric, or back area)
Weight loss
Regurgitation of blood-flecked esophageal contents

Question 19

If the tumor is in the upper third of the esophagus…

Answer 19

Sore throat
Choking
Hoarseness

Question 20

Esophageal Cancer Complications

Answer 20

Hemorrhage (if it erodes into aorta)
Esophageal perforation w/ fistula formation
Esophageal obstruction
Metastasis via lymph system (liver and lung metastases most common)

Question 21

Esophageal Cancer Diagnostic Studies

Answer 21

Endoscopy w/ biopsy (necessary for definitive diagnosis)
Endoscopic ultrasonography (EUS) *Important tool to stage
Esophagogram (barium swallow)

Question 22

Esophageal Cancer Collaborative Care

Answer 22

Treatment depends on location and spread
Poor prognosis (usually not diagnosed until advanced)
*Get best results with combination therapy

Question 23

Surgical Procedures for Esophageal Cancer

Answer 23

Esophagectomy
-removal of part or all of esophagus
-Use Dacron graft to replace resected part
Esophagogastrostomy
-Resection of portion of esophagus and anastomosis of remaining portion to stomach

Question 24

Concurrent radiation and chemotherapy (esophageal cancer)

Answer 24

Slows progression
Sometimes started before surgery
No standard single or combination drug therapy

Question 25

Palliative Care (esophageal cancer)

Answer 25

Restoration of swallowing function (dilation, stent placement) Maintenance of nutrition and hydration

Question 26

Nutritional Therapy (esophageal cancer)

Answer 26

After surgery, parenteral fluids given Jejunostomy feeding tube may be used Swallowing study may be done before patient can have oral fluids

Question 27

Preoperative Care (esophageal cancer, acute interventions)

Answer 27

``` Explain surgical procedure High-calorie, high-protein diet I/O record for patient/family Teach patient/family how to assess for fluid and electrolyte disturbances Oral care ```

Question 28

What to teach the patient and caregiver about with preoperative care (esophageal cancer)

Answer 28

``` Chest tubes (if open thoracic approach used) IV lines NG Tubes Pain management Gastrostomy feeding (if appropriate) Turning, coughing, deep breathing ```

Question 29

Postoperative care (esophageal cancer, acute intervention)

Answer 29

NG tube w/ bloody drainage for 8-12 hrs Changes gradually to greenish/yellow NG tube should not be repositioned or reinserted w/o surgeon's approval!!! Turning and deep breathing q 2 hrs Incentive spirometer use Position in semi-Fowler's or Fowler's (should be maintained at least 2 hrs after eating) Monitor for complications