Fiser ABSITE Ch. 29 Esophagus Flashcards Preview

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Flashcards in Fiser ABSITE Ch. 29 Esophagus Deck (67):
1

What are the layers of the esophagus?

stratified squamous epithelium (mucosa), circular inner muscle layer, outer longitudinal muscle layer; no serosa

2

What is the blood supply of the cervical esophagus? and abdominal esophagus?

Cervical esophagus - supplied by the inferior thyroid artery

3

Which direction does the lymphatics of the esophagus drain?

upper 2/3 drains cephalad, lower 1/3 caudad

4

What kind of muscle is in the upper esophagus? lower esophagus?

striated muscle, smooth muscle

5

Right vagus nerve - travels on ____ portion of stomach as it exits chest; becomes ____ plexus; also has the criminal nerve of ___ > can cause persistently high acid levels postoperatively if left undivided

posterior, celiac, Grassi

6

Left vagus nerve - travels on ____ portion of stomach; goes to liver and biliary tree

anterior

7

The upper esophageal sphincter is how far from the incisors? and lower?

15 cm, 40 cm

8

What is the most common site of esophageal perforation (usually occurs with EGD)?

cricopharyngeus muscle

9

What muscle comprises the upper esophageal sphincter and prevents air swallowing?

cricopharyngeus muscle

10

What are the 3 anatomic areas of narrowing of the esophagus?

cricopharyngeus muscle, compression by the left mainstem bronchus and aortic arch, diaphragm

11

What is the surgical approach to the cervical esophagus? upper 2/3 thoracic? Lower 1/3 thoracic?

Cervical esophagus - left, Upper _ thoracic - right (avoids the aorta), Lower _ thoracic - left (left-sided course in this region)

12

What is the cause in primary esophageal dysfunction? secondary?

unknown in primary; secondary includes systemic disease, gastroesophageal reflux disease (GERD; most common), scleroderma, polymyositis

13

What is the diagnostic procedure of choice for dysphagia and odynophagia?

barium swallow (better at picking up masses)

14

What is the usual cause of cervical esophageal dysphagia?

plummer-vinson syndrome

15

What is the 3 parts of tx for plummer-vinson syndrome?

dilation, Fe, screen for oral CA

16

What can occur between the cripharyngeus and pharyngeal constrictors?

Zenker's diverticulum

17

What is the tx for Zenker's diverticulum?

cricopharyngeal myotomy; Zenker's itself can either be resected or suspended

18

What do you get on POD #1 after a cricopharyngeal myotomy for Zenker's?

esophagogram

19

How is a traction diverticulum different from Zenker's?

Zenker's is a false diverticulum and lies posterior; traction is a true diverticulum is usually lateral in the mid esophagus

20

What is the tx for a traction diverticulum of the esophagus?

excision and primary closure; may need palliative therapy if due to invasive CA

21

What is caused by failure of peristalsis and lack of LES relaxation after food bolus, and is secondary to neuronal degeneration in muscle wall?

Achalasia

22

What is the medical tx for achalasia (2)? what is next step?

CCB, nitrates; LES dilation (effective in 60%)

23

What is the next step in tx of achalasia if CCB, nitrates and LES dilation fail?

Heller myotomy

24

What infection can produce similar sx to achalasia?

T. cruzi

25

Chest pain; other sx similar to achalasia. May have psych history, normal LES tone, strong unorganized contractions.

Diffuse esophageal spasm

26

What are 4 types of tx for diffuse esophageal spasm?

CCB, nitrates, antispasmotics, Heller myotomy

27

Causes dysphagia, loss of LES tone; most have strictures, fibrous replacement of smooth muscle _ Tx: esophagectomy; Nissen may be effective in some

Scleroderma

28

GERD sx with bloating suggests what?

aerophagia and delayed gastric emptying

29

What is the best test for GERD?

pH probe

30

What is the surgical tx for GERD?

Nissen

31

The key maneuver in Nissen is identifcation of what?

left crura

32

What is name of the approach through the chest in a Nissen?

Belsey

33

During a Nissen, when not enough esophagus exists to pull down into abdomen, can staple along stomach and create a "new" esophagus. What is this called?

Collis gastroplasty

34

Name the type of hiatal hernia: Sliding hernia from dilation of hiatus (most common); often associated with GERD

Type I

35

Name the type of hiatal hernia: Paraesophageal; hole in the diaphragm alongside esophagus, normal GE junction.

Type II

36

What is a Type III hiatal hernia? and type IV?

Type III - combined _ Type IV - entire stomach in the chest plus another organ (i.e., colon, spleen)

37

Almost all pts with Schatzki's ring have an associated ___

sliding hiatal hernia

38

What is the tx for Schatzki's ring?

dilatation of the ring usually sufficient; may need antireflux procedure

39

What is the transformation in pts with Barrett's esophagus?

squamous metaplasia to columnar epithilium

40

Pts with Barrett's esophagus are at 50x increased risk for what?

adenocarcinoma

41

Severe Barrett's dysplasia is an indication for what?

esophagectomy

42

Uncomplicated Barrett's can be treated like GERD with PPI or Nissen and surgery will decrease esphagitis and further metaplasia but it will not prevent what?

malignancy or cause regression of the columnar lining

43

Pts with Barrett's esophagus who get a Nissen still need careful lifetime follow up with what?

EGD

44

Esophageal tumors are almost always malignant. How does it spread?

submucosal lymphatic channels

45

What is the best test for unresctablity in esophageal CA?

Chest/abdominal CT

46

What is the #1 esophageal CA? What type occurs most often in the upper 2/3?

Adenocarcinoma; Squamous cell carcinoma

47

Supraclavicular nodes in esophageal CA indicate what?

unresectability

48

Distant metastases with esophageal CA is a contraindication to what? what is the survival?

esophagectomy,

49

What is the mortality from surgery in esophagectomy for CA? and what percentage is it curative?

5%, 20%

50

What is the primary blood supply to stomach after replacing esophagus in esphagectomy?

right gastroepiploic artery (have to divide left gastric and short gastrics)

51

What is the name of the type of esophagectomy with an abdominal incision and right thoracotomy -> exposes all of the esophagus; intrathoracic anasomsis

Ivor Lewis

52

What type of esophagectomy may be choice in young pts with benign disease when you want to preserve gastric function.

Colonic interposition

53

What do you need after esophagectomy on post op day 7?

contrast study to rule out leak

54

Name two chemo agents that can be used with esophageal CA for node positive disease or use preop to shrink tumors?

5FU and cisplatin

55

In esophageal CA with malignant fistulas, most die within 3 months due to what?

aspiration

56

What is the most common benign tumor of the esophagus?

Leiomyoma

57

Diagnosis of Leiomyoma is esophogram, endoscopy to rule out CA. Why don't you bx?

can form scar and make subsequent resection difficult

58

Tx for Leiomyoma of the esophagus is excision via thoractomy. What are the 2 indications?

>5 cm or sx

59

Management for caustic esophageal injury: NG tube? Induce vomiting? Irrigation?

no, no, no

60

What is first step in dx in caustic esophageal injury? then what?

CXR and AXR to look for free air; endoscopy to assess lesion (but not with suspected perforation)

61

What is the most common cause of esophageal perforation?

EGD

62

What is the most common site of esophageal perforation?

cricopharyngeus muscle

63

How to dx esophageal perforation?

gastrograffin swallow followed by barium swallow

64

What is the tx for esophageal perforation that is contained, self-draining and no systemic effects?

Conservative: IVF, NPO, spit

65

What type of flap can be used with repair of esophageal perforation to help the area heal?

intercostal muscle pedicle flap

66

What is Hartmann's sign?

mediastinal crunching on ascultation

67

How to dx Boerhaave's syndrome?

gastrofrafin swallow