ESOPHAGUS Flashcards
(113 cards)
1
Q
What type of hiatal hernia can be managed medically?
A
Type I (II-IV need surgical repair always)
2
Q
Most common benign tumor of esophagus
A
esophageal leiomyoma (smooth muscle cells)
3
Q
Types of achalasia (failed peristalsis)
A
- no pressure of esophagus; 100% failed peristalsis
- panesophageal pressurization
- premature esophageal contractions
4
Q
MC site spontaneous esophageal perf
A
distal esophagus at L-posterior aspect ~2-3cm above GE jxn (natural weak spot)
5
Q
Imaging to stage esophageal CA
A
endoscopic US -> depth of tumor penetration, can also identify LN mets
6
Q
Which sxs of GERD do not improve after Nissen?
A
atypical sxs: cough, laryngitis, aspiration
7
Q
Ideal results for paraesophageal hernia repair?
A
GE jxn AND 2+ cm distal esophagus must lie in abdomen wo tension
8
Q
esophageal SCC more prev in …? esophageal adeno more prev in..?
A
SCC = blacks adeno = whites
9
Q
MCC gastric outlet obstruction
A
gastric adenocarcinoma
10
Q
Dx gastrinoma
A
- Gastrin >1000pg/mL, or
- Secretin stim test (baseline gastrin, give 2u/kg secretin as bolus, then measure gastrin q5min for 30 min – if increase gastrin >200pg/ml above baseline, then dx)
11
Q
Steps to repair esophageal perf
A
- Extension of myotomy - to expose full length of mucosal injury
- Debridement of nonviable tissue
- +/- creation of intercostal flap to reinforce repair
- Repair mucosa and muscle in separate layers
12
Q
Primary location esophageal SCC
A
middle third esophagus
13
Q
Primary location esophageal adenocarcinoma
A
lower third esophagus
14
Q
Mgmt of >24hrs esophageal perf
A
divide cardia -> resect disease esophagus -> esophagostomy + gastrostomy + feeding-J + mediastinal drainage -> delayed reconstruction
15
Q
For superficial esophageal neoplasm lesions <2cm, prefer…? for staging.
A
endoscopic mucosal resection > EUS
16
Q
Tx scleroderma esophagus
A
PPI (bc major sxs reflux)
17
Q
Endoscopic surveillance recommendation after severe alkalotic caustic injury
A
15-20 years post-injury (risk esophageal SCC 2%)
18
Q
Most important pathophysiologic explanation for esophageal perf?
A
absence of serosal layer
19
Q
Blood supply to esophagus
A
cervical -> inferior thyroid
thoracic -> aorta
abdominal -> left gastric + inferior phrenic arteries
20
Q
What muscle comprises upper esophageal sphincter? Innervated by?
A
cricopharyngeus muscle; superior laryngeal nerve
21
Q
Borders of Killian’s triangle
A
superior to cricopharyngeus + inferior to inferior constrictor muscles
22
Q
Abx coverage for esophageal perf
A
GNR, oral flora, anaerobes, fungus* = ampicillin, ceftriaxone, flagyl, fluconazole
23
Q
If repairing esophageal perf after EGD dilation for achalasia, must also do what…?
A
contralateral myotomy to relieve achalasia
24
Q
Manometry: achalasia
A
high/normal LES basal pressure + incomplete LES relaxation + hypotonic/atonic peristalsis
25
Extent of Heller myotomy
6cm up esophagus + 2cm onto stomach
26
Manometry: isolated hypertensive LES
high basal LES pressure + complete LES relaxation + normal peristalsis
27
Mgmt Zenker's diverticulum
>3cm -> endoscopic division of UES
| <3cm -> open myotomy of cricopharyngeus muscle via left neck incision +/- division of sphincter
28
Thoracic diverticulum... think?
association with inflammatory process (TB, malignancy) -> traction diverticulum (true)
29
If low-grade dysplasia of Barrett's... surveillance?
repeat EGD w/ biopsy 6-mo + high-dose PPI (40-80 daily)
30
Dx esophageal CA (3)
1. EGD w/ biopsy
2. staging with PET/CT
3. endoscopic US vs. EMR for T-stage and nodes
+/- FNA of suspicious nodes
31
T-stage esophageal CA
```
T1A = lamina propria or muscularis mucosa (inner)
T1B = submucosa (risk lymphatic spread!)
T2 = muscularis propria
T3 = adventitia (outer)
T4 = surrounding structures (A = resectable; B = not)
```
32
N-stage esophageal CA
```
N1 = 1-2
N2 = 3-6
N3 = 7+
```
33
Mgmt >T1 esophageal CA
neoadjuvant CRT + surgery
34
Mgmt cervical vs. thoracic esophageal CA
cervical (<5cm from cricopharyngeus) -> definitive CRT (unresectable bc surgery has too high morbidity)
thoracic (>5cm) -> esophagectomy if resectable
35
Mgmt high-grade + T1A
endoscopic mucosal resection +/- ablation
36
Mgmt high-grade + T1B
neoadjuvant CRT + esophagectomy
37
Low-grade + T1B
esophagectomy (no neoadjuvant)
38
What is definitive CRT for esophageal CA?
5-FU + taxane
39
Iver-Lewis esophagectomy
transthoracic approach = lap + R-thoracotomy (better for distal tumors); anastamosis in thorax
40
Transhiatal esophagectomy
lap + L-cervical incision; anastamosis in neck; long-term survival equal to transthoracic
41
Areas of esophageal narrowing (aka. most vulnerable areas for injury)
1. cricopharyngeus muscle
2. aortic arch
3. L-mainstem bronchus
4. LES
42
Primary blood supply to gastric conduit after esophagectomy
R-gastroepiploic artery
43
Dysphagia + palmoplantar keratoderma... think?
Tylosis (AD chr 17q25)
44
SCC head/neck/esophagus + pancytopenia... think?
Fanconi's anemia
45
Screening for tylosis; risk?
annual EGD starting at age 20 (40-90% risk esophageal SCC by age 70)
46
If advance esophageal CA, but need feeding tube access...?
J-tube (avoid G-tube bc want to preserve gastric conduit)
47
Tx esophageal leiomyoma
If >5cm or symptomatic -> thoracotomy + enucleate; otherwise endoscopic
48
hx GERD, dysphagia, narrow ring above GE jxn... think?
Schatzki ring
49
Course of thoracic duct
lymphatic duct originates in abdomen -> cisterna chyli path that passes up through aortic hiatus and diaphragm -> runs btwn thoracic aorta + azygous vein -> crosses over T5 (R->L) -> drains into confluence of IJ and L-subclav
50
MC location of Mallory Weiss tear
lesser curvature of stomach (at point of GE jxn) - NOT esophagus
51
Do you biopsy esophageal leiomyoma?
NO - dx via imaging. biopsy would complicate excision.
52
Right vagus travels where in relation to esophagus... supplies...?
posterior esophagus -> celiac plexus
53
Left vagus travels where in relation to esophagus... supplies...?
anterior esophagus -> hepatic branches to liver and biliary tree
54
Findings scleroderma on manometry
low amplitude, simultaneous contractions with normal/low LES pressure (+reflux)
55
Indications for emergent endoscopy 2/2 foreign body (3)
- esophageal obstruction (aka. unable to handle oral secretions)
- disk battery in esophagus
- sharp-pointed object in esophagus
56
Indications urgent (within 24 hr) endoscopy 2/2 foreign body (5)
- not-sharp objects in esophagus
- esophageal food impaction wo complete obstruction
- sharp objects in stomach/duodenum
- objects >6cm at/above prox duodenum
- magnets within endoscopic reach
57
Indications non-urgent endoscopy (5)
- coins in esophagus may be observed for 12-24hrs if asymptomatic
- blunt objects >2.5cm in stomach
- disk or cylindrical batteries in stomach wo signs GI injury may be observed up to 48hrs (unless >2cm)
- blunt objects that fail to pass stomach 3-4wks
- blunt objects distal to duodenum that remain in same location >1wk
58
Mgmt Barrett esophagus w/ high-grade dysplasia
radiofrequency ablation* vs. endoscopic mucosal resection
59
Mgmt proximal vs. distal esophageal adenoCA with complete clinical response after chemorad
proximal -> observation
| distal (high recurrence) -> surveillance -> obs + salvage esophagectomy vs. neoadjuvant + radial esophagectomy
60
If progressive disease despite neoadjuvant for esophageal adenoCA?
palliative chemoRx or surgery
61
What should you do after neoadjuvant for esophageal or rectal CA?
restaging for consideration of surgical intervention vs. surveillance
62
normal LES pressure
10-15 mmHg
63
Acidic substances cause what kind of necrosis?
coagulative
64
Alkaline agents cause what kind of necrosis?
liquefactive - can produce injury outside of esophagus, to mediastinum
65
When endoscopy for caustic agent ingestion?
within 24 hours once pt stable
66
Grade of caustic ingestion injury (Zargar): endoscopic vs. pathologic findings
1: edema, erythema, exudate // little or no loss of mucosa
2: ulcer and/or hemorrhage // injury to submucosa or muscle layer
3: transmural ulceration with focal vs. extensive necrosis // injury through entire wall
4: penetration and/or perf
67
What grade of caustic ingestion injury requires IV Abx?
grade 3
68
Adult with esophageal food impaction... concern for?
underlying pathology (MC eosinophilic esophagitis, tumor, Schatzski rings, peptic stricture)
69
Mgmt esophageal food impaction
flexible endoscopy + biopsy
70
When consider esophageal stenting for iatrogenic perf?
consider in all pts with perf from upper endo - particularly useful in presence of maligancy
71
C/I esophageal stenting for iatrogenic perf
- tear >6cm
- delayed presentation (>24hr) bc tissue necrosis
relative: difficult to place stent in proximal esophagus + at distal/GE junction
72
Compared with pts Tx surgery alone for esophageal CA, those Tx with neoadjuvant CRT are more likely to have increased...
chylothroax
73
Most likely cause of food bolus impaction in otherwise healthy adult
Eosinophilic esophagitis
74
EGD finding: eosinophilic esophagitis
multiple concentric rings or white exudate
75
Compared to total fundiplication, partial has lower rates of...?
- dysphagia
| - gas-related symptoms
76
Compared to partial fundiplication, total is more effective at...?
controlling post-operative reflux symptoms
77
POEM divides what muscle fibers of lower esophagus and stomach vs. Heller myotomy? Results?
POEM: only circular muscles (lowers incidence of GERD vs. Heller myotomy wo fundiplication)
Heller: circular and longitudinal muscle layers
78
Pt after alkali ingestion, with circumferential ulceration at proximal esophagus... next step for evaluation?
CT C/P - as effective as endoscopy in assessment of depth of injury (do NOT do endoscopy past point of circumferential injury) - also alkali tend to have low risk stomach perf
79
Pt with failed Nissen (recurrent GERD) + shortened esophagus 2/2 transmural esophagitis + obese... best procedure to repair?
Belsey Mark IV - thoracic approach + can free up the esophagus for tension-free return of terminal esophagus to abdomen
80
Ligation of thoracic duct performed in what type of esophagectomy?
Iver-Lewis esophagectomy bc possible chyle leak after extensive thoracic lymphadenectomy
81
What part of transhiatal esophagectomy is done under direct visualization? what is done blind?
distal third - good for distal tumors. but limited and blind thoracic lymphadenopathy
82
UGI finding for diffuse esophageal spasm
corkscrew appearance
83
Epiphrenic diverticula due to ...?
motility disorder (pulsion diverticula)
84
Sensory nerve to gag reflex
glossopharyngeal nerve - supplies upper epiglottis
85
Sensory nerve to cough reflex
internal branch of superior laryngeal nerve of superior laryngeal nerve - supplies lower epiglottis and larynx above vocal cords
86
Sensory nerve to larynx below vocal cords
recurrent laryngeal nerve
87
Motor nerve to intrinsic muscles of larynx (except cricothyroid)
recurrent laryngeal nerve
88
Esophageal perf 2/2 cancer... mgmt?
if <24hrs - esophagectomy with primary anastomosis
| if >24hrs (too much inflam) or unstable - resection and diversion
89
Primary repair can be done for EARLY esophageal perf except...?
- cancer
- severe peptic strictures
- caustic injury
- refractory achalasia
90
If early esophageal free perf + unstable then...?
resection and diversion
91
If stable esophageal perf and no cancer... mgmt?
eval extent of perf with swallow study - if contained, non-op mgmt (if free, then OR)
92
If free early esophageal perf, no cancer, stable... mgmt?
primary repair of perf +/- drain placement +/- flap
93
Esophageal pH monitoring done by two methods...
1. wireless pH monitoring - single probe placed 5cm above LES
2. intraluminal lube via nasopharyngeal catheter - multiple pH probes along catheter
94
Abnormal DeMeester score
>14.72
95
How does esophageal impedance study work?
low voltage current applied to multiple electrodes within probe to determine direction of bolus transport (ie. bile reflux)
96
Steps of transthoracic heller myotomy (ie. for refractory diffuse esophageal spasm)
- right lateral decub position
- enter pleural space in 7th intercostal space
- incise inferior pulm ligament
- retract lung medially + cephalad
- incise mediastinal pleura
- encircle esophagus with penrose drain
- identify both vagus nerves
- perform esophagectomy
97
Surveillance and mgmt Barrett's + no dysplasia
serial endoscopies q3-5 years with 4-quad biopsy q2cm + daily PPI (if persists, may do BID)
98
Alcohol associated with esophageal SCC vs. adenoCA?
SCC
99
What GI hormones increase LES pressure?
gastrin and motilin
100
GERD + stricture... mgmt?
Nissen fundoplication +/- Collis gastroplasty for tension-free anastomosis (bc shortened esophagus)
101
How much tension-free anastomosis should be mobilized in abdomen for fundoplication?
>2.5-3 cm
102
Mgmt Zenker's diverticulum <2cm
cricopharyngeal myotomy alone via left neck incision
103
Mgmt Zenker's diverticulum 2-5cm
Dohlman procedure (obliterate sac w/ endoscopic division of distal cricopharyngeus muscle) -- requires max neck extension (not for elderly)
104
Mgmt Zenker's diverticulum >5cm
myotomy + resection
105
Mgmt Zenker's in frail elderly w/ large diverticula
diverticulopexy (via incision left neck)
106
For what size Zenker's diverticulum is surgical vs. endoscopic repair the same result?
>3cm
107
For what size Zenker's diverticulum is surgical repair superior to endoscopic?
<3cm
108
Swallowing center located where in brain?
medulla
109
Indications for Toupet fundoplication
- poor esophageal body motility
- following Heller’s myotomy
- severe aerophagia (swallow air)
- inadequate gastric fundus for full wrap (ie. Tubular stomach, previous gastric surgery or splenorrhaphy)
110
Gold standard dx esophageal motility disorders
Manometry
111
Tx and surveillance of Barrett’s + high-grade dysplasia
Ablation + repeat biopsy q3m
112
Surveillance for Barrett’s + low-grade dysplasia
q6-12m
113
When should esophagostomy + feeding tube be placed for esophageal injury?
For injuries >24-hrs (if less than, should try to repair primarily)
