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Flashcards in Esophagus Deck (62):
1

Clinical manifestations of GERD

(UpToDate)

  • heartburn, regurgitation
  • dysphagia, chest pain, water brash
  • globus sensation, odynophagia 
  • extraesophageal: cough, hoarseness, wheezing
  • infrequent: nausea 

2

Diagnosis of GERD

  • clinical sx alone if they are classic →  start PPI
  • nonclassical sx → exclude other dx
  • alarm sx → EGD w/ biopsies
    • dyspepsia and >60
    • GI bleed, iron def anemia
    • sx of ca: anorexia, wt loss, dysphagia, odynophagia
    • fhx of GI ca
  • persistent sx or failed PPI trial → ambulatory pH
  • chest pn w/ nl EGD and EKG → esophageal manometry

3

Approach to refractory GERD 

(UpToDate)

  • causes: insufficient acid suppression, reflux, functional heartburn
  • reassess: compliance, alarm sx
  • alarm sx: EGD
  • no alarm sx: pt is compliant (lifestyle, meds) - inc PPI
  • if cont sx: esophageal ambulatory pH testing

4

Given a patient with a foreign body ingestion or caustic injury to the esophagus, understand the different populations/etiologies between adult and child ingestions.

  • peak incidence between 6 mo and 6 yrs of age; coins are the majority of swallowed objects
  • In adults, FB ingestions occur more commonly in those with psychiatric disorders, developmental delay, and intoxication; edentulous adults are at risk for ingestion of obstructing food boluses or dental prostheses.
  • In children, caustic ingestions are typically accidental small-volume drinking of household products; in adults, they are commonly suicide attempts by large volumes creating more extensive injuries.

5

Given an adult or pediatric patient, describe the anatomic locations of the esophagus in which a foreign body is most likely to become lodged.

  • The three sites of physiologic narrowing include the upper esophageal sphincter, the level of the aortic arch, and the diaphragmatic hiatus.
  • Areas of congenital malformation (eg, tracheoesophageal fistula), or prior surgery, represent sites with increased risk of obstruction.
  • The site of symptoms or discomfort does not correspond to the site of obstruction.

6

Given a patient with a foreign body ingestion, describe structural or functional esophageal pathology in adults with an increased risk of foreign body/food impaction in the esophagus.

  • Structural: carcinoma (intrinsic or extrinsic), strictures, diverticula, hiatal hernia
  • Functional: achalasia
  • Eosinophilic esophagitis: can present as food impaction. 

7

Given a patient with a caustic injury to the esophagus, recognize the importance of the characteristics of the ingested substance (alkali vs. acid, solid vs. liquid), amount, and concentration.

  • Alkali (ammonia, sodium hydroxide, lye) - liquefactive necrosis that extends rapidly through the esophageal mucosa.
  • Acid - superficial coagulation necrosis with thrombosis of mucosal blood vessels and formation of a protective eschar.
  • Alkali ingestions tend to be more damaging to the esophagus than acidic ingestions as they are more viscous and less painful to the oropharynx thus decreasing expectoration. 

8

Given a patient with an esophageal caustic injury or foreign body impaction, recognize the signs and symptoms of perforation.

  • Oropharyngeal or proximal esophageal perforation can cause neck swelling, erythema, tenderness, or crepitus.
  • Intrathoracic esophageal perforation may present with severe retrosternal chest pain, back pain, chest wall crepitus, or mediastinal crackling on cardiac auscultation (Hamman sign).
  • Intra-abdominal esophageal perforation may present with epigastric or back pain, and/or peritonitis on examination. 
  • Maintain a high suspicion for perforation in patients with signs of severe sepsis after esophageal injury.

9

Recognize the appropriate use and the limitations of radiographic studies in the workup of an esophageal foreign body.

  • Two-view radiographs of the neck, chest, and entire abdomen remain the initial diagnostic test of choice and can reliably elucidate metallic objects, steak bones, as well as mediastinal and/or peritoneal air.
  • Radiolucent objects, such as fish and chicken bones, wood, plastic, glass, and thin metal are not seen on radiography.
  • Patients with persistent esophageal symptoms with a negative radiographic examination should undergo endoscopy.
  • Oral contrast examinations should NOT be performed due to the risk of aspiration and interference with subsequent endoscopy (unless attempting to diagnose perforation).

10

Given a patient with a caustic injury to the esophagus, determine how and when to evaluate the presence and severity of injury.

  • Endoscopy should be performed promptly, within 24 hours, to evaluate the extent of injury.
    • Grade 1: superficial edema/erythema
    • Grade 2: mucosal/submucosal ulceration
    • Grade 2A: focal ulceration, erosions, exudates
    • Grade 2B: deep or circumferential ulcerations
    • Grade 3: transmural ulcerations with necrosis
    • Grade 3A: focal necrosis
    • Grade 3B: extensive necrosis
  • Of note, endoscopy is contraindicated in the setting of perforation and/or hemodynamic instability.

11

Given a patient with a caustic injury to the esophagus, describe initial nonoperative management and contraindicated modalities.

  • Airway protection is paramount to the initial evaluation and management.
  • The induction of vomiting is contraindicated as vomiting may lead to additional esophageal injury.
  • Bedside placement of nasogastric and orogastric tubes should be avoided.
  • Antibiotics are recommended for those with esophageal perforation or grade 3 esophageal caustic injury.
  • Patients with severe injury require ICU: monitor for decompensation indicating further necrosis and perforation.
  • There are conflicting data regarding glucocorticoids and the prevention of future esophageal stricture.

12

In patients with either caustic ingestion or esophageal foreign body, evaluate airway and breathing as the first priority.

  • Upper airway compromise (including dyspnea, drooling, stridor, and hoarseness) likely will require ETT.
  • Signs of severe oropharyngeal or glottic edema and/or necrosis on EGD - consider intubation before continuing.
  • Bronchoscopic guidance for intubation is recommended with preparation for cricothyroidotomy if unsuccessful. 

13

Given a patient with the diagnosis of esophageal foreign body, determine which patients require emergent versus urgent, versus nonurgent endoscopy.

  • Emergent endoscopy is required in patients with complete esophageal obstruction and in patients with disk batteries or sharp objects in the esophagus.
  • Urgent endoscopy (within 24 hours) is recommended for patients with nonsharp esophageal foreign objects, sharp objects in the stomach or duodenum, nonobstructing esophageal food impaction, or magnets within endoscopic reach.
  • Nonurgent endoscopy can be considered for asymptomatic patients with coins in the esophagus (after up to 24 hours of observation).

14

Given a patient with a caustic injury to the esophagus, understand the indications for emergency surgery and what procedures this entails.

  • Acute surgical intervention may be indicated for a full-thickness injury that results in esophageal perforation or diffuse necrosis resulting in uncontrolled sepsis.
  • Critically ill patients with significant necrosis preclude immediate reconstruction and often are managed by cervical esophagostomy, debridement, and possible esophagogastrectomy.
  • Damage to the stomach can necessitate use of colon or jejunum for future reconstruction. 

15

Given a patient with a caustic injury to the esophagus, generate appropriate follow-up short-term for strictures and long-term for increased risk of esophageal cancer.

  • All patients with esophageal burns grade 2A or higher should be evaluated by contrast esophagogram 2 weeks after ingestion to evaluate for stricture.
  • Approximately 2% of individuals with a history of severe caustic injury will develop squamous cell carcinoma of the esophagus.
  • The American Society for Gastrointestinal Endoscopy recommends beginning endoscopic surveillance 15 to 20 years after caustic ingestion.
  • Worsening dysphagia in patients with remote caustic ingestions should be evaluated promptly to exclude malignancy.

16

A 45-year-old woman fell asleep with her partial removable dentures in place. Later she awoke with severe throat pain and could not locate her dentures. How would you evaluate this patient?

  • Recognize that airway compromise must be evaluated first.
  • Recognize and assess for signs/symptoms of esophageal perforation.
  • Understand the need for diagnostic studies to locate the object and rule out perforation.
    • XRs AP and later throughout the GI tract until they are located.
    • Endoscopy if symptomatic.

17

A 30-year-old man is brought into the emergency department after a suicide attempt via caustic ingestion. What is your initial approach to this patient?

  • Identify the ingested agent, alkali versus acid, liquid versus solid.
    • Determine the amount and concentration if possible.
  • Rule out airway compromise.
  • Assess clinical status.

18

A patient recovers from a caustic ingestion without perforation. What would you discuss with the patient regarding long-term sequelae and care?

  • Discuss possible stricture formation, need for dilation, and esophageal replacement.
  • Discuss the role of corticosteroids in stricture prevention (controversial).
  • Discuss long-term risk of cancer if esophagus is left in place or partially resected.

19

Where does the esophagus begin?

at the upper esophageal sphincter - the cricopharyngeus muscle, base of the pharynx, 6th cervical vertebra

20

What is the narrowest point in the GI tract?

cricopharyngeus muscle - 14 mm

highest pressure

most common point of perforation in endoscopy

where Zenker diverticula occur 

21

How long is the esophagus?

25-30cm

22

What is the blood supply to the cervical esophagus?

inferior thyroid arteries

23

What is the blood supply to the thoracic esophagus?

aorta and esophageal branches from the right and left bronchial arteries 

24

Where does the abdominal esophagus get its blood supply?

left gastric and inferior phrenic 

25

How does lymphatic flow differ in the upper and lower parts of the esophagus?

the upper 2/3 flows upward

the lower 1/3 flows downward

26

Are esophageal masses usually benign or malignant? What are some examples of benign masses?

1% are benign - most often leiomyomas, but can also be cysts and polyps

27

What are the two most common malignant esophageal cancers? What are their etiologies?

adenocarcinoma 2/2 GERD - lower esophagus

SCC 2/2 alcohol/smoking - upper esophagus

28

What is the presentation of a patient with an esophageal neoplasm?

dysphagia, weight loss, cough, hemoptysis 

29

What is the diagnostic algorithm for dysphagia?

30

Given a patient with biopsy-proven esophageal adenocarcinoma, identify lesions that are appropriate for surgical resection.

  • < 50% of any subtype are surgical candidates
  • stage I (T1 N0) - surgical resection only; if path reveals advanced dz - consider adjuvant chemo
  • stage II (T2 NX, T3 N0) - surgery +/- neoadjuvant chemo
  • stage III (T3 N1, T4 N0) - surgery +/- neo/adj chemo/radx (debatable)
  • stage IV - no surgical cure, palliative procedures

31

Describe the operative plan for an esophageal tumor that doesn't invade the trachea, spine, larynx, or vessels. 

primary resection

32

Describe the management of an esophageal tumor that is adjacent to the cricopharyngeus or larynx

two to three cycles of chemotherapy w/ up to 3500 cGy of radiation, then surgical resection

33

Describe the management of a malignant esophageal tumor that extends into the thoracic inlet

near total esophageal resection through either transhiatal or transthoracic approach

34

Describe the management of a malignant esophageal tumor of the distal esophagus or gastric cardia

esophagectomy - transhiatal, transthoracic (Ivor-Lewis), or minimally invasive (three-hole)

35

Describe the three most common surgical approaches to esophageal resection and advantages/disadvantages of each: 

transhiatal esophagectomy

Transhiatal Esophagectomy involves incisions at the left neck and abdomen without the need for a thoracotomy which reduces respiratory complications and leak rates from the cervical neck anastomosis. However extensive lymphadenectomy is not possible, there is a higher rate of postoperative anastomotic strictures, and there are more injuries to the great vessels due to blind transhiatal dissection.

36

Describe the three most common surgical approaches to esophageal resection and advantages/disadvantages of each: 

Transthoracic Esophagectomy (Ivor-Lewis)

Transthoracic Esophagectomy (Ivor-Lewis) involves a laparotomy and right thoracotomy which facilitates an intrathoracic esophagogastric anastomosis. This results in an optimal perfusion of the gastric conduit and low rate of anastomotic leak (3-4%), however leaks are difficult to control and have higher risk of sepsis and death. Significant gastric reflux may occur.

37

Describe the three most common surgical approaches to esophageal resection and advantages/disadvantages of each: 

Minimally-invasive (three-hole)

Minimally-invasive (three-hole) esophagectomy involves thoracoscopy or transcervical mediastinoscopy and laparoscopy which results in less pain and a shorter hospital stay compared to other techniques. This technique is limited by the inability to achieve a radical resection.

38

Given a patient with unresectable advanced esophageal cancer, be able to describe the available and appropriate palliative therapies.

Palliative measures include chemotherapy, radiation therapy, photodynamic therapy, laser therapy, esophageal stenting, feeding gastrostomy or jejunostomy, and esophagectomy.

Endoscopy with dilation and stent placement maintains enough patency of the lumen to handle swallowed saliva but average survival after placement of a palliative stent is less than 6 months.

39

What layer does the esophagus lack (in contrast to the rest of the GI tract)? 

serosal 

this makes it more susceptible to perforation

40

What is the pathophysiology of necrotizing mediastinitis?

  • perforation
  • bile and gastric contents leak into mediastinum
  • inflammation/infection
  • necrosis

41

In esophageal perforation, what microbes invade?

Staph, Pseudomonas, Strep, Bacteroides

Invasion can occur within 12 hrs leading to sepsis and eventually death if uncontrolled.

42

Most frequent cause of esophageal perforation?

endoscopy

43

Most common site of esophageal perforation?

cricopharyngeus

44

Other than iatrogenic/procedural, what are some causes for esophageal perforation?

  • vomiting
  • trauma
  • pharmacy
  • tumor
  • infection
  • FB

45

Most common location of esophageal perforation if 2/2 vomiting/increased intraluminal pressure?

left side, distal third

46

Most common etiology of blunt trauma causing esophageal perforation?

steering wheel to the chest MVC

47

Presentation of esophageal perforation?

epigastric or chest pain, dysphagia, throat pain

crepitus in face, neck, chest

neck swelling

epigastric tenderness

48

What diagnostic imaging can be used in the workup of esophageal perforation?

  • AP and lateral CXR w/ upright abdominal XR: pleural effusion, pneumomediastinum, subcutaneous emphysema
  • Esophagogram w/ gastrograffin: straight to OR if positive
    • can do barium if this is negative
  • CT if broad ddx - use with oral contrast 

49

Identify the basic goals of the operative management of esophageal perforation.

  1. treatment of contamination
  2. wide local drainage
  3. source control
  4. feeding access

50

How do you approach an esophageal perforation in OR?

  • high - left side neck at anterior border of SCM 
    • retract carotid sheath laterally, enter plane adj to trach
    • omohyoid m, mid thyroid v, inf thyroid a are ligated
    • NGT can be used as adjunct for occult injury
    • check contralateral side
  • mid - right posterolateral thoracotomy (facilitate buttress - pedicle of intercostal m)
  • low - left posterolateral thoracotomy or laparotomy

  *esophagus is slightly left of midline

51

After the incision is made for an esophageal perforation, how do you proceed?

  • myotomy to expose the injury
  • debride devitalized tissues, ID edges of viable mucosa
  • small injuries with healthy tissue - repair primarily w/ absorbable mono suture in two layers with tissue flap (intercostal, pericardium, pleura, omentum)
  • extensive injuries with devitalization - controlled fistulization by T-tube
  • very large or devitalized defects - esophageal exclusion w/ cervical esophagostomy and gastrostomy, future recon w/ esophagectomy and conduit (6-12 mo later)
  • use bougie to prevent stricture; leave drains
  • gastrostomy/jejunostomy tubes - decompression and nutrition access
  • further evaluation of causes (malignancy, stricture, scar) at initial surgery

52

When can an esophageal perforation be managed nonoperatively?

  • clinical stability
  • no sepsis
  • observe with serial examinations (must be reliable) and continuous monitoring
  • iatrogenic perforations where pt is NPO often do better
  • no crepitus, pneumothorax, or pneumomediastinum on rads

53

What are the management guidelines for nonoperative esophageal perforation?

  • NPO
  • IVF
  • BS ABX w/ antifungal
  • Nutritional assessment - may need TPN

54

 

A few hours after having an upper endoscopy, a 53-year-old man presents to the emergency department complaining of worsening chest pain and dysphagia. How would you initially evaluate this patient?

  • any patient presenting with worsening chest or epigastric pain, dysphagia, or neck pain after an upper endoscopic procedure has an esophageal perforation until proven otherwise
  • first step: upright AP/lat CXRs, esophagram w/ water-soluble contrast
  • management based on clinical severity, location of perforation, size of perforation

55

23-year-old man presents to the emergency department complaining of chest pain after multiple bouts of emesis the previous night. He is otherwise hemodynamically stable and denies any other complaints. A contrast study shows a small esophageal perforation with minimal contrast extravasation. How would you proceed with management?

  • Nonoperative is appropriate in patients who are continuously stable on, who are NPO w/ early dx, and w/ contained perforation w/o contrast extravasation.
  • This pt can be nonop. Make patient NPO w/ IVF and BS ABX w/ antifungal.
  • Recognize that constant reevaluation of the patient is key.
  • If the pt worsens or deteriorates - proceed with operative management.

56

You are called to the recovery room to evaluate a 50-year-old man who just underwent pneumatic dilation for achalasia and is now complaining of chest pain and dyspnea. A chest x-ray shows left-sided pleural effusion and air in the mediastinum. A contrast study reveals esophageal perforation with active contrast extravasation. How would you proceed with the management of this patient?

  • NPO, IVF, BS ABX w/ antifungal
  • uncontained perforations - surgical control is gold standard.
  • likely low perforation - will need either left thoracotomy or laparotomy; further management depends on size/severity of defect

57

What procedure can be used as an adjunct in esophageal injury?

Endoscopy may be used as an adjunct if care is taken to avoid worsening injury.  Flexible endoscopy is widely used, but is less sensitive in detecting cervical esophageal injuries; rigid esophagoscopy is preferred for diagnosis of proximal injuries.

58

Is esophageal injury urgent or emergent?

Delay in management can significantly increase injury; therefore, evaluation must occur as soon as injury is suspected.

59

MC complication of esophageal injury repair?

pneumonia

60

Given a patient with esophageal injury, be able to describe evaluation for durability of repair postop.

At the end of the first postoperative week, repairs of the thoracic esophagus should be evaluated for a leak using contrast esophagram with Gastrografin followed by thin barium.

If no leak, adv diet as tolerated.

61

How do you manage a leak postop esophageal repair?

  • look for SIRS
  • check drains for gastric contents
  • CT finds undrained collections, esophagram confirms leaks
  • sepsis w/ leak - reoperation
  • source control, controlled fistula, wide drainage 
  • optimize nutrition w/ distal feeding

62

In an esophageal perforation patient with concurrent vascular or larynx/tracheal injuries, what must be done to protect repair?

vascularized flap can be used between all repairs