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Flashcards in ESOPHAGUS Deck (42):
1

scleroderma of esophagus

Patients with scleroderma have manifestations in many different organ systems.

Esophageal dysmotility
low amplitude,
simultaneous contractions
NORMAL or LOW lower esophageal sphincter (LES) pressures

Treatment centers around treating scleroderma with secondary improvement of the esophageal symptoms.

Achalasia shows similar findings with the difference being achalasia has a high LES pressure Similar to scleroderma, achalasia shows low amplitude, simultaneous contractions.

2

Leiomyomas treatment

Standard:
Leiomyomas Extramucosal enculeation with subsequent closure of the myotomy

Esophageal resection is used for greater than 8 cm or annular in character.

Non-operative surveillance is used only for asymptomatic patients with a small leiomyoma (<3
cm).

3

Esophageal pH monitoring


two methods:
Wireless pH monitoring
or
by an intraluminal tube with nasopharyngeal catheter.

With wireless monitoring, a single Bravo pH probe is placed 5 cm above the lower esophageal sphincter (LES) and 48 hours of measurements are obtained.

Patients indicate when they experience symptoms as well as their change in position.

Nasopharygeal catheters measure pH for only 24 hours, however, and are considered to be more accurate due to the presence of multiple pH probes along the catheter allowing for larger sampling of pH changes.

Esophageal acid exposure may be physiologic, therefore, measurements include percent total time of pH <4 while upright, supine and overall.

Also the number and duration of each episode are monitored.

A composite score (DeMeester) is calculated based on these parameters. A score greater than 14.72 (95th percentile) is considered abnormal.

Esophageal impedance is an adjunct (does not measure pH). A low voltage current is applied to multiple electrodes within the probe which determine the presence of liquid, food bolus or esophageal tissue via impedance.

With multiple electrodes along a probe, direction of bolus transport may also be determined. This allows for detection of non-acid (bile) reflux and may be used to determine reflux even with the presence of PPIs.


4

Belsey Mark IV

done through left thoracotomy

continued symptoms of GERD post Nissen now with shortened esophagus

Advantages of the Belsey Mark IV include
the ability to free up the esophagus,
all the way to the level of the aortic arch.

tension-free return of the terminal esophagus to the abdomen is especially important when the esophagus has been shortened by transmural esophagitis.

Also, surgery in an obese patient is more easily accomplished through the chest.

direct mediastinal approach when it is filled with fibrous tissue owing to previous esophageal surgery and more than 75% of patients retain the capacity for normal swallowing, belching and vomiting.





Bottom Line: The Belsey Mark IV technique is often used to treat complications of laparoscopic fundoplications. It is a wise choice to use in the patient with a shortened esophagus, the obese patient, and/or the patient with coexisting disease in the left chest wall, lung or upper abdomen.

5

what is the maximum depth of invasion on EUS in esophageal cancer and still go for cure

endoscopic ultrasound indicates that the tumor has not invaded adjacent organs,

and/or

fewer than five enlarged lymph nodes are imaged.

This means that if tumor has invaded outside of the esophagus perforated and there are 4 positive nodes you can still go for cure!!

The main purpose of cross-sectional imaging studies in patients with known esophageal carcinoma is to stage the disease as accurately as possible to determine which patients may be suitable candidates for surgical resection.

Computed tomography (CT) (choice D) is considered complementary to endoscopy and barium

6

Treatment of local esophageal carcinoma

roughly divided into those with a high probability of mucosal confined disease (T1)

and

those with possible regional disease (T2-3).

Disease confined to the mucosa (T1a) is unlikely to have systemic involvement and may be treated by resection alone.


Treatment for extension into the submucosa (T1b) is somewhat controversial as there is a significant chance for nodal disease (15-25%), even with a negative EUS.

Many would give chemotherapy in this scenario.

Invasion of the muscularis propria (T2) indicates a high probability of regional disease.

Chemotherapy is usually given.

According to CROSS trial, neoadjuvant chemotherapy with paclitaxel and carboplatin improves five year survival vs surgery alone (47% vs 34%). While 35%-50% of patients will receive a complete clinical response from chemotherapy alone, many will still have viable tumor obtained after resection. For this reason, surgical resection is still recommended after neoadjuvant treatment.


While both esophagectomy and endoscopic mucosal resection (EMR) are considered acceptable options, most centers now perform EMR followed by radiofrequency ablation due to similar outcomes by case-control studies with few complications.

is appropriate for lesions confined to the mucosa (T1a).



Bottom Line: Esophageal adenocarcinoma is treated by EMR for lesions limited to mucosa.

Resectable lesions which invade the muscularis propria require neoadjuvant chemoradiation followed by esophagectomy.
ABS Qualifying Exam Insight: Many questions about malignancy are about chemotherapy indication and options for a more limited resection. Know the stages that dictate changes in treatment.


7

Barrett's esophagus occurs where

distal esophagus proximal to the GE junction

8

Barrett's esophagus conformational change

secondary to chronic reflux

from squamous to columnar

9

cells seen with Barrett's esophagus

On EGD, it has the appearance of

Goblet cells - evil goblins in this case

salmon colored mucosa

inflammation and erosions - of mucosal inflammatio (not full thickness)

10

Barrett's esophagus increases the risk of developing

adenocarcinoma;

however the overall risk remains quite low at less than 1% per year.


11

Schatzki’s ring

narrowing of the esophagus

occurs at the GE junction

comprised of mucosa, submucosa, and connective tissue. NO muscular component to these rings.

Patients often present with symptoms of obstruction following meals and are diagnosed with a barium esophagram performed in the prone position for better visualization.

Treatment is only warranted for symptomatic patients (choice B), and usually consists of serial dilations.

Persistent symptoms are treated with a Nissen fundoplication. Surgical resection is contraindicated (choice D) as this will result in severe strictures.

Bottom Line: Symptomatic Schatzki’s rings that fail to improve with dilations are treated with a Nissen fundoplication.

For more information, see: Sabiston’s Textbook of Surgery, 18th Edition, Chapter 41, Electronic Publication.

12

mid-esophageal diverticulum

The patient is presenting with a mid-esophageal diverticulum. These are traction diverticulum that involve all layers of the esophageal wall and can be due to inflammation, granulomatous disease, or even cancer. The treatment is with a diverticulectomy and primary closure.

Answer E: Manometry testing is not required for the diagnosis of esophageal diverticulum.

BUT - ruling out cancer is

13

Zenker's diverticulum

occur near the cricopharyngeus muscle in an area known as Killian's triangle. Only the mucosa herniates with a Zenker's or a distal esophageal diverticulum and these are due to pulsion forces. Pulsion diverticulum will require a myotomy for surgical treatment.
Answer A: Zenker's diverticulum are found in Killian's triangle. Answer B: Mid-esophageal diverticulum are due to traction or inflammation.


14

what distance is considered mid esophagus

20 cm

15

sophageal adenocarcinoma is known to spread aggressively through the
The correct answer is: A lymphatic channels (choice A).

The likelihood of nodal invasion increases with the depth of the tumor (choice E). For this reason, most tumors that are T2-T4 are treated with neoadjuvant therapy to decrease this disease burden.
T1 tumors extend into the submucosa (choice D) and are treated with surgical resection alone (choice B).
If N1 disease is present, then an en bloc resection is indicated (choice C). Bottom Line: Esophageal adenocarcinoma spreads via submucosal lymphatic
channels.

16

A zenker's diverticulum is defined as

blowout of the mucosa on the posterior wall at the transition zone between the hypopharynx and the esophagus (Kilian triangle).

The mucosal herniation occurs through an anatomical weakness near the cricopharyngeus muscle

(most likely due to failure of relaxation of the UPPER esophageal sphincter during swallowing)

It is a false diverticulum.

Normally, at rest, the upper esophageal sphincter (UES) is closed due to tonic contraction.

After swallowing, within milliseconds, the UES relaxes as a result of a transient interruption of the muscle contraction, allowing the passage of the bolus into the upper esophagus.

During this process, the larynx moves forward and upward to facilitate the opening of the relaxed sphincter.

17

management of caustic ingestions with findings of an unstable or perforation

taken immediately to the operating room for an esophagectomy?!

18

management of caustic ingestions if stable

upper endoscopy is performed to determine the severity of disease.

Superficial or partial thickness injuries:
can be observed for 48 hours and if remain stable can initiate a diet.

Any signs of deterioration:
addition of antibiotics and potentially operative intervention

Full thickness tears:
antibiotics immediately
require very close monitoring for signs of perforation.

Surgery is indicated for full thickness necrosis

NOT An esophogram - does not give information regarding the viability of the mucosa and is more useful to rule out a suspected perforation.

19

Esophageal perforations from cancer in patients hemodynamically unstable



cervical esophagostomy,

gastrostomy,

feeding jejunostomy.

esophagectomy with delayed reconstruction

20

Leiomyomas of esophagus general location and appearance.


two thirds of all benign tumors of the esophagus.

80% of leiomyoma are located intramurally and originate in the muscularis propria.

Roughly 90% are located in the middle and lower esophagus, reflecting the relative paucity of smooth muscle in the upper esophagus.

They are usually single lesions that appear as smooth-walled SUBmucosal lesions on barium swallow.

21

Leiomyomas of esophagus work up

Evaluation of a patient with a suspected leiomyoma usually includes a

barium swallow,

endoscopy,

endoscopic ultrasound (EUS),

and a CT scan of the chest

ALL OF THAT !???


22

pedunculated lesion outpouching from the posterior wall of the esophagus on barium swallow is suggestive of


Zenker’s diverticulum.

23

The most common complications after Nissen fundoplication and what are their cuases

bloating and dysphagia.

Bloating can be caused by vagal trauma causing delayed gastric emptying or difficulty belching.

These symptoms usually resolve within 2 months but can occur in up to 30% of patients initially.

Dysphagia can occur in up to 20% of patients and also has multiple causes. Edema from the dissection at the hiatus is the most common cause of dysphagia in the early post-operative period and will usually resolve without intervention.

Hematomas in the wall of the esophagus or stomach can be caused during placement of sutures for the wrap and contribute to postoperative dysphagia.

Symptoms will usually resolve spontaneously and using a graduated diet over 4-6 weeks will limit the symptoms.

If the wrap is created too tight around the esophagus, dysphagia that is persistent is likely to result

Endoscopic dilation is usually necessary for treatment. t

24

Esophageal strictures most commonly due to

chronic acid exposure from GERD.

Other causes include esophagitis, infection (esophageal candidiasis), ulcerations, exposure to caustic materials and esophageal motility disorders.

endoscopic band ligation or sclerosant injections (up to 20%)


Development of stricture is also common after endoscopic treatment for Barrett’s esophagus. Symptomatic strictures occur in 36% of those treated with photodynamic therapy and it is also one of the most common complications after endoscopic mucosal resection. Frequency and severity of stricturing is likely related to depth of resection. It may take months to develop and usually responds to serial dilations. Stricturing after radiofrequency ablation has not been reported.

25

autoimmune disorders, Esophageal strictures

Progressive Systemic Sclerosis (50-90%)

and

CREST
(calcinosis, Raynaud's phenomenon, esophageal dysfunction, sclerodactyly, and telangiectasia). H

25% of patients with SLE will also develop esophageal symptoms.

While the etiology is unclear, it is likely related to dysmotility caused by smooth muscle involvement and ischemic changes in the Auerbach plexus.

Answer B: PSS, CREST and SLE tend to involve

26

The most common complications after EMR are


bleeding and stricture.

27

tx of stricture after EMR

Serial dilations are usually effective in managing symptoms.

28

Iatrogenic esophageal perforations are the most common and occur where

at the cricopharyngeus muscle.

29

Longstanding reflux disease causes

repeated inflammation to the distal esophagus,

lead to a metaplastic change from squamous to columnar cells.

If these cells develop dysplasia, then the patient is at increased risk for adenocarcinoma of the esophagus.

The repeated episodes of inflammation and scarring also cause the esophagus to shorten, which can impact surgical intervention for the treatment of reflux.


30

Reflux disease is a risk factor for

ADENOcarcinoma of the esophagus.

Reflux disease has some association with pernicious anemia.

31

Barrett’s esophagus is

metaplastic change of the distal esophageal mucosa seen in patients with chronic reflux with squamous transforming into columnar

32

Barrett’s esophagus initial managment

initially placed on a proton pump inhibitor and followed with serial endoscopies.

If there is a low or moderate grade dysplasia, repeat endoscopies should be scheduled every 3-6 months.

Reflux reducing surgeries, such as a Nissen fundoplication, can stop the progression of the disease, but will not reverse it.

High grade dysplasia, however, is an indication to proceed with an esophagectomy if long segment (greater than 3 cm), lymphovascular invasion. If not endoscopic resection and or ablation is acceptable.

However, the standard of care for treatment of high-grade dysplasia and intramucosal carcinoma outside a specialized esophageal center, particularly in younger patients or those unable to undergo consistent endoscopic surveillance, remains esophagectomy.

33

The term Barrett esophagus should currently be used with what criteria

in the setting of an endoscopically visible segment of intestinal metaplasia of any length or columnar replacement of the esophagus of 3 cm or more.

34

Patients whose biopsies are interpreted as indefinite for dysplasia should be managed how?

treated with a medical regimen consisting of 60 to 80 mg of PPI therapy for 3 months and rebiopsied. Importantly, esophagitis should be healed prior to interpretation of the presence or absence of dysplasia.

35

Mallory-Weiss tear

linear laceration of the gastroesophageal mucosa caused by severe retching and vomiting.

present most commonly with hematemesis

often seen in conjunction with:
hiatal hernias
or
liver disease

occur below the GE junction.

Boerhaave syndrome is a full thickness tear of the distal esophagus at the GE junction (bleeding goes into LEFT chest - not hematemesis..)

36

The swallowing center is located where and what does it do

The swallowing center is located in the medulla (just like respiration is also medulla / brain stem)

coordinates movements of both the striated and smooth esophageal musculature

Esophageal peristalsis occurs with swallowing. It is believed that striated esophageal musculature is stimulated by the vagus nerve.

(careful, Spontaneous contractions of the esophagus usually do not occur as seen in respiration)

37

The initial treatment for motility disorders is with

medical management with the use of calcium channel blockers and nitrates.

These can be very effective in most cases,

EXCEPT for achalasia where the results are poor.

Achalasia is better treated with pneumatic dilations or a Heller myotomy if refractory.

38

tx of DES

The length of myotomy for treatment of is determined preoperatively by manometry and must include the entirety of diseased areas, including the LES and onto the stomach if necessary.

39

tx Nutcracker esophagus

NOT Surgery for a Nutcracker esophagus because the results are very poor.

40

tx of hypertensive LES

Calcium channel blockers and nitrates have shown improved symptoms

Surgery IS effective with:
Heller!

41

First line treatment for achalasia is

#1
calcium channel blockers or nitrates to relax the LES.

Medical therapy, however, has poor long term results and most patients require intervention.

#2
Pneumatic dilations have been shown to be effective in resolving symptoms related to achalasia.

It is a safe and cost effective alternative to surgery.

#3
If symptoms do not improve with dilations, then the patient warrants surgical intervention which involves a distal esophageal myotomy through both the longitudinal and circular muscle layers, followed by a fundoplication.

This procedure can be performed laparoscopically in most instances. Rarely, these patients have such twisted or dilated esophageal changes that an esophagectomy is necessary.

42

Nutcracker esophagus presents with

findings on esophogram, EGD, manometry

chest pain,
dysphagia,
odynophagia - ya, I bet it hurts if your esoph pressure is 180-400!

rarely present with regurgitation or reflux.

normal progressive contraction on esophagram

hyperperistalsis on EGD.

Amplitude pressures of > 180 mmHg to even > 400 mmHg!!
can be seen on manometry

with long duration (> 6 seconds) contraction waves.