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Flashcards in Esophagus Deck (49)
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1

Where does the esophagus begin?

lower border of C6 (pharynx)

2

Muscle types in esophagus

Superior third = striated

Middle third = Both striated and smooth

Lower third = smooth

3

What are the 3 areas of narrowing?

1) At beginning - from the cricopharyngeus muscle

2) Where left mainstem bronchus and aortic arch cross

3) At hiatus of diaphragm

4

Where is the LES?

T11

5

What is the distance of the GEJ from incisor teeth?

40cm - important for endoscopy

6

T8 vs T10 vs T12

T8 = IVC

T10 = Esophagus

T12 = Aorta

7

Achalasia definition

LES cannot relax

Resulting dysphasia due to 3 mechanisms:
- Complete absence of peristalsis in esophageal body
- Incomplete/impaired relaxation of LES after swallowing
- Increased resting tone of LES

This all increases pressure within esophagus, causes dilation, and causes progressive loss of normal swallowing

8

Signs/symptoms of achalasia

Triad = Dysphagia, regurgitation, weight loss

Dysphagia for solids and liquids

Severe halitosis

May feel knot or ball of food getting stuck

9

Achalasia dx

Lat upright CXR may show dilated esophagus and presence of air-fluid levels in posterior mediastinum

Barium swallow reveals Bird's beak sign

#1 = manometry: increased LES tone

Esophagoscopy is indicated to r/o mass lesions or strictures and to get a bx

10

Achalasia tx

Medical = drugs that relax LES - nitrates, ca blockers, antispasmodics

***Surg = Esophagomyotomy (heller's myotomy) with or without fundoplication - incise tunica muscularis. Divide LES (if all the way add Nissen 360 fundop or partial fundop).

Endoscopic dilation - lower success, more complications (perf)

Botox

11

Complications of achalasia

Risk of SCC up to 10% over 15-25 years

Patients may get pulmonary complications like aspiration, pneumonia, bronchiectasis, asthma due to reflux and aspiration

12

Diffuse esophageal spasm definition

Unknown etiology. Primarily a disease of the esophageal body. Can be primary issue of the muscle or may occur in association with reflux esophagitis, esophageal obstruction, collagen vascular disease, or diabetic neuropathy

Spasm is in distal 2/3 and is caused by uncontrolled large-amplitude rapid contractions of smooth muscle

LES tone is Normal

13

Signs/symptoms of DES

Dysphagia for solids and liquids

Substernal CP, similar to MI. Acute onset may radiate to arms, jaw, back. May happen at rest or may follow swallowing

No regurgitation (unlike achalasia); no water brash (unlike GERD)

14

DES dx

Barium swallow can reveal "corkscrew" appearance of esophagus due to ripples and sacculations from uncoordinated contraction. Barium may be totally normal though. LES appears normal though always.

Manometry shows large, uncoordinated repetitive contractions in lower esophagus. May be normal when asymptomatic though. LES manometry will show normal resting pressure with LES relaxation upon swallowing

Esophagoscopy should be done to r/o mass, stricture, esophagitis

Bc of the cardiac-like complaints, dx is often delayed for cardio workup.

Patients with DES often have other functional intestinal disorders like IBS and spastic colon

15

Tx for DES

Nitrates or Ca blockers to relax smooth muscle

Surg via esophageal myotomy is NOT as succesful in relieving symptoms as it is in achalasia so it's not recommended unless dysphagia is severe and incapacitating.

16

Nutcracker esophagus

Another hypermotility disorder that is more focal in nature within the esophagus

17

Esophageal diverticula definition

Outpouching of esophageal mucosa that protrudes through a defect in the muscle layer (remember esophagus has no serosa). Often co-existing motility issue.

Can be true, which involves all 3 layers of esophagus (midesophageal diverticulum) or false involving mucosa and submucosa only (Zenker)

Characterized by location - Pharyngoesophageal (Zenker), midesophageal, or epiphrenic (terminal third of esophagus)

Pharyngoesophageal and epiphrenic are "pulsion" diverticula bc they are caused by increased esophageal pressure - both are FALSE ones

18

Zenker's diverticulum

Pharyngoesophageal (Zenker) is the most likely kind of diverticulum to be symptomatic

Dysphagia with spontaneous regurgitation of undigested food, halitosis, choking, aspiration, repetitive respiratory infections, and eventual debilitation and weight loss

Diagnosis with Barium swallow for all types of diverticula. Endoscopy is dangerous due to risk of perf through diverticulum

Tx is to relieve symptoms and prevent complications.

"When Zenker's causes Zymptoms it requires Zurgery" Asymptomatic only treated if > 2cm in size.

#1 = Cervical pharyngocricoesophageal myotomy (incise the cricopharyngeus) - always done when surg is needed

Diverticulopexy - suture diverticulum in inverted position to prevertebral fascia. Added to myotomy for larger diverticula

Diverticulectomy - endoscopic stapling of diverticulum along with myotomy is done in largest ones

19

Esophageal varices pathophys

From portal HTN, usually a result of alcoholic cirrhosis

As elevated portal system pressure impedes the flow of blood through the liver (increased intrahepatic pressure), various sites of venous anastomosis become dilated secondary to retrograde flow from portal to systemic ciruclation. Varices are portosystemic collaterals

Clinically significant portal-systemic sites are cardio-esophageal junction (dilation = esophageal varices), periumbilical region (dilation = caput medusae), and rectum (dilation = hemorrhoids)

20

Signs/symptoms of esophageal varices

Painless hematemesis

Unprovoked (not postemetic)

Hemodynamic instability common

Risk for rebleeding high

Peripheral stigmata of liver disease

21

Treatment of esophageal varices

1) ID high-risk patients and prevent the first bleeding episode! - screening endoscopy to determine varices in cirrhotic patients. This includes pharm therapy to reduce portal pressure - reduce collateral portal venous flow with vasoconstrictors (somatostatin, vasopressin, octreotide) and reduce intrahepatic resistance with vasodilators (B blockers, esp propranolol and nitrates, reduce portal pressure)

Variceal bleeding stops spontaneously in about 50%

2) Manage the ruptured varices that cause acute bleeds
- stabilize hemodynamics: NS or LR with RBCs, NG suction/lavage
- continuous vasopressin/somatostatin/ octreotide to reduce splanchnic blood flow and portal pressure

3) Endoscopic sclerotherapy (inject bleeding vessel with sclerosing agent via catheter) or band ligation (equivalent with fewer complications) for control of ruptured varices has 90% success rate. Patients are usually intubated first to prevent aspiration of blood

4) Balloon tamponade to apply direct pressure and hemostasis to varix with the balloon

5) For refractory acute bleeding, TIPSS (tansjugular intrahepatic portosystemic shunt)

6) Intraoperative placement of portocaval shunt. Surg is considered when there is continued bleed or recurrent rebleeding with poor control

7) Liver transplant

22

Esophageal stricture definition

Local, stenotic regions within lumen usually a result of inflammatory or neoplastic process

23

Risk factors and causes of esophageal stricture

1) Long-standing GERD
2) Radiation esophagitis
3) Infectious esophagitis
4) Corrosive/caustic esophagitis
5) Sclerotherapy for bleeding varices

24

Signs/symptoms of stricture

While small strictures may be asymptomatic, those that obstruct the lumen will induce progressive dysphagia for solids

Odynophagia may or not be there

25

Dx of stricture

Initial eval via barium swallow

Esophagoscopy is needed always since it should be evaluated for malignancy and to determine the right treatment

26

Tx of stricture

Esophagus visualized endoscopically and bougie dilators are carefully passed through the stricture. Each successful dilation is done with progressively larger dilator

Dysphagia is relieved in most cases following adequate dilation of the lumen

Most feared complication is esophageal rupture

27

Esophageal perf or rupture - general info

Trauma to esophagus may result in leakage of air and esophageal contents into mediastinum

Surgical emergency

50% mortality

28

Causes of esophageal perf/rupture

#1 = iatrogenic following endoscopy, dilation, tamponade tubes. Usually in cervical esophagus near cricopharyngeus muscle

Boerhaave (15% of cases). Spontaneous perf and FULL THICKNESS tear. Usually in L pleural cavity or just above GEJ/ L lateral wall due to transmission of abdominal pressure to the esophagus. Can be from forceful vomiting, retching coughing, labor, lifting, trauma

Mallory-Weiss: Partial thickness mucosal tear. Usually in R posterolateral wall of distal esophagus. Causes bleeding that generally goes away on own. Due to forceful vomiting.

Foreign body ingestions (14% of cases) - objects lodge near anatomic narrowing and then perforate through near UES, aortic arch, LES

29

Signs/symptoms of esophageal perf/rupture

Severe, constant cervical, substernal or back pain

Dysphagia

Dyspnea

SubQ emphysema (requires full thickness)

Mediastinal emphysema heard as "crunching" sounds (Hamman's sign) - also requires full thickness

Sepsis/fever

Pneumothorax

30

How do you treat ANY GI bleed?

NGT, EGD, 2 large bore IVs, type/cross