Esophagus

Question 1

Strongest layer

Answer 1

Mucosa (in small bowel, submucosa is strongest)

Question 2

Normal LES tone

Answer 2

15-25 mm Hg

Question 3

Swallowing order of events

Answer 3

soft palate closes nasopharynx, larynx up, larynx closes, UES relaxes, pharyngeal contraction

Question 4

Zencker’s diverticulum definition

Answer 4

Dysfunction of upper esophageal sphincter muscles

Question 5

Zenker’s tx

Answer 5

division of upper esophageal sphincter muscles
 >3 cm diverticulum: endoscopic division of UES sphincter
 <3 cm diverticulum: open division

Question 6

Mid-esophageal diverticulum

Answer 6

o Traction diverticulum (all three layers of esophageal wall being pulled)

Tx: VATS diverticulotomy and dissection

Question 7

Barrett’s surveillance

Answer 7

• Surveillance: EGD with bx annually, 4 quadrant biopsy every 1-2 cm of affected segments
  o Low grade dysplasia: repeat EGD in 6 months
  o High grade dysplasia: repeat and confirm  endoscopic mucosal resection

Question 8

Achalasia manometry findings

Answer 8

High LES/normal basal pressure with incomplete LES relaxation

Absent/incomplete peristalsis

Question 9

Paraesophageal hernia tx

Answer 9

Operate -> risk of incarceration, strangulation

Question 10

Diffuse esophageal spasm manometry findings

Answer 10

o Normal LES pressure and relaxation

o High amplitude, uncoordinated esophageal contractions

Question 11

Achalasia tx

Answer 11

Tx: Hellery myotomy with fundoplication

 Myotomy: 6 cm onto the esophagus, 2 cm onto stomach

Question 12

DES tx

Answer 12

CCB, nitrates -> long segment myotomy

Question 13

Nutcracker esophagus manometry findings

Answer 13

o Normal LES pressure and relaxation

o High amplitude, coordinated contractions

Question 14

Nutcracker esophagus tx

Answer 14

CCB, nitrates -> long segment myotomy

Question 15

Cause of achalasia

Answer 15

o Degenerative loss of inhibitory neurons of LES
o Chagas disease, autoimmune, idiopathic
o Pseudoachalasia: secondary to tumor/malignancy

Question 16

Barrett’s esophagus definition

Answer 16

metaplasia from squamous to columnar cells. 1-2% get adenocarcinoma (30-100 x risk) P53 associated (tumor suppresor gene)

Question 17

main supply to stomach when used to replace esophagus?

Answer 17

R gastroepiploic artery

Question 18

Leiomyoma tx

Answer 18

if symptomatic or > 5cm excise by enucleation via thoracotomy (R if middle, L if lower esophagus). Do not biopsy on EGD.

Question 19

Narrowest point of diaphragm

Answer 19

Cricopharyngeus

Question 20

Contained esophageal perforations treatment

Answer 20

observation and abx ok

Question 21

Barrett’s histologic change

Answer 21

squamous to columnar cells with Goblet cells

Question 22

LES resting pressure

Answer 22

10-20 mm Hg

Question 23

UES resting pressure

Answer 23

50-70 mm Hg

Question 24

Surgical esophagomyotomy steps

Answer 24

Incise 6.5 cm of longitudinal then circular muscle fibers of distal esophagus and 2.5 cm of proximal gastric muscle fibers

Question 25

Mallory Weiss syndrome

Answer 25

linear tear of gastroesophageal mucosa

Question 26

Blood supply to the gastric conduit after esophagectomy

Answer 26

R gastroepiploic artery

Question 27

Principles of partial fundoplication (Dor - anterior, Toupet - posterior)

Answer 27

Restore an intra-abdominal segment of distal esophagus Accentuate the angle of His Create a long anterior mucosal valve at GEJ

Question 28

Esophageal cancer T stages

Answer 28

``` o T1:  1A: invades lamina propria or muscularis mucosa  1B: invades submucosa o T2: invades muscularis propria o T3: invades adventitia o T4: invades surrounding structures  T4a: resectable (invades pleura/pericardium, etc)  T4b: unresectable ```

Question 29

Tx of esophageal CA >5 cm from cricopharyngeus + resectable

Answer 29

esophagectomy

Question 30

Tx of esophageal CA <5 cm from cricopharyngeus

Answer 30

definitive chemoradiation

Question 31

T1a tumors tx

Answer 31

endoscopic mucosal resection +/- ablation

Question 32

T1b (no nodes) tx

Answer 32

upfront esophagectomy

Question 33

T2 or greater OR any positive LN tx

Answer 33

neoadjuvant + esophagectomy

Question 34

Unresectable disease or distant mets tx

Answer 34

chemoradiation only

Question 35

Layers of the esophagus

Answer 35

Mucosa Submucosa Muscularis propria NO SEROSA

Question 36

Blood supply of the esophagus

Answer 36

Cervical portion: inferior thyroid artery Thoracic portion: straight from aorta Abdominal portion: L gastric and inferior phrenic arteries

Question 37

UES is made of? Innervated by?

Answer 37

Cricopharyngeus muscle | Superior laryngeal nerve

Question 38

Tx of Barretts with high grade dysplasia?

Answer 38

Endoscopic treatment: radiofrequency ablation vs endoscopic mucosal resection Radiofrequency ablation preferred for long segment Barretts EMR best for lesions < 2 cm - resect down to submucosa

Question 39

Esophageal varices treatment

Answer 39

Prophylactic antibiotics for 7 days Started on octreotide and/or vaso - reduces portal blood flow and thus reduces portal pressure Endoscopic therapy: sclerotherapy or variceal banding

Question 40

Techniques of transthoracic heller myotomy

Answer 40

Patient positioned in right lateral decubitus position Enter the pleural space in the 7th intercostal space Incise the inferior pulmonary ligament Retract the lung medially and cephalad Incise the mediastinal pleura Encircle the esophagus with a penrose drain Identify both vagus nerves Perform esophagomyotomy

Question 41

Manometry findings of scleroderma

Answer 41

Low amplitude | Simultaneous contractions with normal or low LES pressures

Question 42

Most common complication following fundoplication

Answer 42

Dysphagia MC cause is post-op edema - self limiting and resolves within 6-8 weeks If dysphagia persists beyond this time frame, further investigation is indicated

Question 43

Hormones that increase LES pressure

Answer 43

Gastrin | Motilin

Question 44

Hormones that decrease LES pressure

Answer 44

``` CCK Estrogen/progesterone Glucagon Somatostatin Secretin ```

Question 45

Manometry findings of achalasia

Answer 45

Hypertonic LES, failure of LES to relax with a food bolus | Aperistalsis