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ABSITE > 29 Esophagus > Flashcards

29 Esophagus Flashcards

1
Q

Layers of the esophagus

A

Mucosa (squamous epithelium)
Submucosa
Muscularis propria (longitudinal muscle layer)
NO serosa

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2
Q

Musculature of the esophagus

A

Upper 1/3 - striated muscle
Lower 1/3 - smooth muscle
Middle 1/3 - mixed

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3
Q

Blood supply of the esophagus

A

Branches off the aorta

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4
Q

Blood supply of the cervical esophagus

A

Inferior thyroid artery

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5
Q

Blood supply of the abdominal esophagus

A

Left gastric and inferior phrenic arteries

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6
Q

Venous drainage of the esophagus

A

Hemi-azygous and azygous veins

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7
Q

Lymphatic drainage of the esophagus

A

Upper 2/3 drains cephalad

Lower 1/3 drains caudad

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8
Q

Path of the right vagus nerve

A

Travels on posterior portion of the stomach as it exits the chest - becomes the celiac plexus

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9
Q

Criminal nerve of Grassi

A

Branch of right vagus nerve

Causes persistent high acid levels if left undivided after vagotomy

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10
Q

Path of left vagus nerve

A

Travels on anterior portion of the stomach, goes to liver and biliary tree

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11
Q

Course of the thoracic duct

A

Travels from right to left at T5-4, ascends to mediastinum

Inserts into left subclavian vein

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12
Q

Upper esophageal sphincter

A

15cm from incisors
Cricopharyngeus muscle - circular muscles, prevents air swallowing
Innervated by the recurrent laryngeal nerve

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13
Q

Normal UES pressure at rest?

A

60mmHg

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14
Q

Normal UES pressure with food bolus?

A

15mmHg

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15
Q

What is the most common site of esophageal perforation?

Cause?

A

Cricopharynegeal muscle

Occurs with EGD

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16
Q

Cause of aspiration after brainstem stroke?

A

Failure of cricopharyngeus to relax

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17
Q

Lower esophageal sphincter

A

40cm from incisors
Relaxation mediated by inhibitory neurons
Normally contracted at resting state (prevents reflux)
Anatomic zone of high pressure (not technically a sphincter)

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18
Q

Normal LES pressure at rest?

A

15mmHg

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19
Q

Normal LES pressure with food bolus?

A

0mmHg

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20
Q

Anatomic areas of eosphageal narrowing?

A

Circopharyngeus muscle
Compression by the left mainstem bronchus and aortic arch
Diaphragm

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21
Q

What initiates swallowing?

A

CNS

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22
Q

Swallowing stages?

A

Primary peristalsis - occurs with food bolus and swallow initiation
Secondary peristalsis - occurs with incomplete emptying and esophageal distention; propagating waves
Tertiary peristalsis - non-propagating, non-peristalsing (dysfunctional)

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23
Q

State of UES/LES between meals?

A

Contracted

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24
Q

Swallowing mechanism

A

Soft palate occludes nasopharynx
Larynx rises and airway opening is blocked by epiglottis
Cricopharyngeus relaxes
Pharyngeal contraction moves food into esophagus
LES relaxes soon after initiation of swallow (vagus mediated)

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25
Q

What initiates LES relaxation? When?

A

Vagus mediated

Initiation of swallow

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26
Q

Best surgical approach for the cervical esophagus?

A

Left

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27
Q

Best surgical approach for the upper 2/3 thoracic esophagus?

A

Right (avoids aorta)

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28
Q

Best surgical approach for the lower 1/3 thoracic esophagus?

A

Left (left-sided course in this region)

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29
Q

Causes of hiccups?

A

Gastric distention
Temperature changes
ETOH
Tabacco

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30
Q

Reflex arc for hiccups

A

Vagus, phrenic, sympathetic chain T6-T12

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31
Q

Causes of primary esophageal dysfunction

A

Achalasia
Diffuse esophageal spasm
nutcracker esophagus

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32
Q

Causes of secondary esophageal dysfunction

A

GERD*

Scleroderma

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33
Q

What is the best test for heartburn?

A

Endoscopy

Can visualize the esophagus

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34
Q

What is the best test for dysphagia or odynophagia?

A

Barium swallow

Better at picking up masses

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35
Q

What is the best test for meat impaction?

A

Dx and tx - endoscopy

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36
Q

Characteristics of pharyngeosophageal disorders?

A

Trouble transferring food from mouth to esophagus
Commonly neruomuscular disease (myasthenia gravis, muscular dystrophy, storke)
Liquids worse than solids

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37
Q

Plummer-Vinson syndrome

A

Upper esophageal web
Iron deficient anemia
Tx: dilation, iron
Need to screen for Oral cancer

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38
Q

Zenker’s diverticulum

A

Caused by increased pressure during swallowing
- False diverticulum, located posterior
- Caused by failure of the cricopharyngeus to relax
Symptoms - upper esophageal dysphagia, choking, halitosis

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39
Q

Where does Zenker’s diverticulum occur?

A

Posterior - between the pharyngeal constrictors and cricopharyngeus (Killian’s triangle)

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40
Q

Diagnosis of Zenker’s diverticulum?

A

Barium swallow studies
Manometry
(Avoid EGD - risk for perforation)

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41
Q

Treatment of Zenker’s diverticulum?

A 
Cricopharyngeal myotomy
Can be resected or suspended - doesn't need to be resected
Left cervical incision
Leave drain in
Esophagogram POD1
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42
Q

Traction diverticulum

A

True diverticulum - lies lateral
Due to inflammation, granulomatous disease, tumor
Found in mid-esophagus
Sx: regurgitation of undigested food, dysphagia
Tx: excision and primary closure if symptomatic; palliative therapy (i.e. XRT) if due to invasive CA
Asymptomatic - leave alone

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43
Q

Epiphrenic diverticulum

A

Associated with esophageal motility disorders (i.e. alchalasia)
Distal 10cm
Most are asymptomatic - can have dysphagia and regurgitation
Dx: Esophagram, esophageal manometry
Tx: Diverticulectomy and esophageal myotomy on side opposite the diverticulotomy if symptomatic

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44
Q

Symptoms of achalasia

A

Dysphagia, regurgitation, weight loss, respiratory symptoms

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45
Q

Causes of achalasia

A

Caused by lack of peristalsis and failure of LES to relax after food bolus
Secondary to neuronal degeneration in muscle wall
(Also seen with T. cruzi)

46
Q

Manometry findings in achalasia

A

Increased LES pressure
Incomplete LES relaxation
No peristalsis

47
Q

Complications of alchalasia - seen on CXR

A

Tortuous, dilated esophagus
Epiphrenic diverticula
Bird’s beak apperance

48
Q

Treatment of achalasia

A

Balloon dilation of LES
Nitrates, CCB
Failed –> heller myotomy (left thoracotomy, myotomy of lower esophagus only; may need partial nissen fundoplication)

49
Q

Diffuse esophageal spasm

A

Chest pain, dysphagia, psych history
Manometry - frequent, strong, non-peristaltic unorganized contractions; LES relaxes normally
Tx: CCB, nitrates, if fails –> Heller myotomy (upper and lower esophagus)

50
Q

Nutcracker esophagus

A

Chest pain and dysphagia
Manometry - high-amplitude peristaltic contractions; LES relaxes normally
Tx: CCB, nitrates; Heller myotomy (upper and lower esophagus)

51
Q

Scleroderma

A

Fibrous replacement of esophageal smooth muscle
Causes dysphagia and loss of LES tone with massive reflux and strictures
Tx: esophagectomy, if severe

52
Q

What is the normal anatomic protection from GERD?

A

LES competence
Normal esophageal body
Normal gastric reservoir

53
Q

Requirements of LES competence

A

Resting pressures >6mmHg
Sphincter length >2cm
Intraabdominal section >1cm

54
Q

Concerns if patient has: GERD + dysphagia/odynophagia

A

Check for tumors

55
Q

Concerns if patient has: GERD + bloating

A

Suggests aerophagia and delayed gastric emptying

Dx: gastric emptying study

56
Q

Concerns if patient has: GERD + epigastric pain

A

Peptic ulcer disease

Tumor

57
Q

Diagnosis of GERD

A 
pH probe (best)
Endoscopy
Histology
Manometry (resting LES
58
Q

Surgical indication for GERD

A

Failure of medical treatment

Avoidance of lifetime meds (young patients)

59
Q

Surgical treatment for GERD

A

Nissen fundoplication

- Divide short gastrics, pull esophagus into abdomen, approximate crura, 270 (partial) or 360 gastric fundus wrap

60
Q

What is the phrenoesophageal memebrane?

A

Extension of the transversalis fascia

61
Q

What is the key maneuver for Nissen fundoplication wrap?

A

Identification of the left crura

62
Q

Complications of Nissen fundoplication?

A

Injury to spleen, diaphragm, esophagus

Pneumothorax

63
Q

Belsey fundoplication

A

Approach is through the chest

64
Q

Collis gastroplasty

A

When not enough esophagus exists to pull down into abdomen

Staple the stomach along the cardia and create a neo-esophagus

65
Q

Most common cause of dysphagia following nissen?

A

Wrap is too tight

66
Q

Fixation of the fundoplication

A

Sutured in place with a single U-stitch of 2-0 proline pledgeted on the outside.
A 60-french mercury-weight bougie is passed thorugh the gastroesophageal junction prior to fixation of the wrap to assure a floppy fundoplication.

67
Q

Hiatal hernia - type I

A

Sliding hernia from dilation of hiatus - GE junction above the diaphragm
Associated with GERD

68
Q

Hiatal hernia - type II

A

Paraesophageal hernia
Hole in the diaphragm alongside the esophagus
Normal GE junction
Sx: chest pain, dysphagia, early satiety
Tx: Nissen + diaphragm repair
Always repair - high risk of incarceration

69
Q

Hiatal hernia - type III

A

Combined sliding hernia and paraesophageal hernia

70
Q

HIatal hernia - type IV

A

Entire stomach is in the chest, plus another organ (i.e. spleen, colon)

71
Q

Schatzki’s ring

A

Associated with sliding hiatal hernia
Sx: dysphagia
Tx: dilation of the ring and PPI (do not resect)

72
Q

Barrett’s esophagus

A

Squamous metaplasia to columnar epithelium
50x increased risk of cancer (adenocarcinoma)
Dysplasia –> esophagectomy
Uncomplicated Barrett’s - PPI, Nissen
EGD follow up for lifetime, no matter treatment

73
Q

Effect of surgery on Barrett’s esophagus

A

Decreases esophagitis and further metaplasia

Does not prevent malignancy or cause regression of the columnar lining

74
Q

Esophageal cancer spreads via:

A

Submucosal lymphatic channels

75
Q

Symptoms of esophageal cancer

A

Dysphagia (especially solids)

Weight loss

76
Q

Risk factors for esophageal cancer

A 
ETOH
Tobacco
Achalasia
Caustic injury
Nitrosamines
77
Q

Diagnosis of esophageal cancer

A

Esophagram

78
Q

Indications of unresectability with esophageal cancer

A 
Hoarseness (RLN invasion)
Horner's syndrome (brachial plexus invasion)
Phrenic nerve invasion
Malignant pleural effusion
Malignant fistula
Airway invasion
Vertebral invasion
79
Q

How do you assess resectability in esophageal cancer?

A

Chest and abdominal CT

80
Q

Characteristics of adenocarcinoma of the esophagus

A

Lower 1/3 of esophagus

Liver mets most common

81
Q

Characteristics of SCC of the esophagus

A

Upper 2/3 of esophagus

Lung mets most common

82
Q

Nodal spread that would indicate unresectability

A

Nodal disease outside the area of resection (M1)

Supraclavicular or celiac nodes

83
Q

Reason for pre-op chemo-XRT

A

Downstage tumor and possibly make them resectable

84
Q

Primary blood supply to stomach after replacing the esophagus?

A

Right gastroepiploic artery (have to divide the left gastric and short gastric)

85
Q

Transhiatal approach for esophagectomy

A

Abdominal and neck incision
Bluntly dissect intrathoracic esophagus
Decreased morality from esophageal leaks - easier to access the anastomosis in the cervical area

86
Q

Ivor Lewis approach for esophagectomy

A

Abdominal incision and right thoracotomy
Exposes all of the intrathroacic esophagus - better able to get nodal dissection
However, anastomosis is located intrathoracially - worse prognosis with leak

87
Q

3-hole esophagectomy

A

Abdominal, thoracic and cervical incisions

88
Q

Indication for colonic interposition in esophagectomy

A

May be choice in young patients when you want o preserve gastric function
3 anastomoses required
Blood supply depends on colon marginal vessels

89
Q

Post-op follow up after esophagectomy?

A

Contrast study on postop day 7 to rule out leak

90
Q

Treatment of post-op strictures after esophagectomy?

A

Dilation

91
Q

Chemotherapy for esophageal cancer

A

5-FU
Cisplatin
(For node-positive disease or use pre-op to shrink tumors)

92
Q

Malignant fistulas (esophageal cancer)

A

Most die within 3 months due to aspiration

Tx: esophageal stent for palliation

93
Q

Leiomyoma of the esophagus

A

Most common benign esophageal tumor
Located in the muscularis propria (lower 2/3 of esophagus)
Sx: dysphagia
Dx: esophagram, EUS, CT (r/o cancer)
DO NOT biopsy - scare can make resection difficult
Tx: >5cm or symptomatic –> excision (enucleation) via thoracotomy

94
Q

Esophageal polyps

A

Sx: dysphagia, hematemesis
2nd most common benign tumor of the esophagus
Located in the cervical esophagus
Tx: endoscopy; larger lesions require cervical incisions

95
Q

What to NOT do with caustic esophageal injury?

A

NO NG tubes
Induce vomiting
Nothing to drink

96
Q

Caustic esophageal injury - Alkali

A

Causes deep liquefaction necrosis - especially with liquid (i.e. drano)
Worse injury than acid - more likely to cause cancer

97
Q

Caustic esophageal injury - Acid

A

Causes coagulation necrosis

Mostly causes gastric injury

98
Q

Diagnosis of Caustic esophageal injury?

A

Chest and abdominal CT - look for signs of perforation (free air)
Endoscopy - to assess lesion (do not go past site of severe injury, do not do if suspect perforation)
Serial exams and plain films

99
Q

Caustic esophageal injury - primary burn

A

Hyperemia
Tx: observation and conservative therapy (IVF, spitting, abx, PO intake after 3-4 days)
May develop cervical strictures (serial dilation)
May develop shortening of esophagus (GERD)

100
Q

Caustic esophageal injury - secondary burn

A

Ulceration, exudate, shoughing
Tx: prolonged observation and conservative therapy
Indications for esophagectomy - sepsis, peritonitis, mediastinits, free air, mediastinal or stomach wall air, crepitance, contrast extravasation, pnaumothroax, large effusion

101
Q

Caustic esophageal injury - tertiary burn

A

Deep ulcers, charring, lumen narrowing
Tx: observation, will likely need esophagectomy
Do not repair the alimentary tract until patient recovers from the caustic injury

102
Q

Most common cause of esophageal perforation?

A

EGD

103
Q

Most common site of esophageal perforation?

A

Cervical esophagus near cricopharyngeus muscle

104
Q

Symptoms of esophageal perforation?

A

Pain
Dysphagia
Tachycardia

105
Q

Diagnosis of esophageal perforation?

A

CXR (look for free air)

Gastrografin swallow, followed by barium swallow

106
Q

Criteria for nonsurgical management in esophageal perforation?

A

Contained perforation as per contrast study
SElf-draining
No systemic effects
Tx: IVF, NPO, spit, broad-spectrum ABx

107
Q

Treatment for non-contained perforations - diagnosed within 24hrs and area has minimal contamination

A

Primary repair with drains
Requires longitudinal myotomy to see full extent of injury
Consider muscle flaps (i.e. intercostal) to cover repair

108
Q

Treatment for non-contained perforations - diagnosed after 48hrs or area has extensive contamination

A

Neck - just place drains (no esophagectomy)
Chest - resection (esophagectomy, cervical esophagostomy) or exclusion and diversion (cervical esophagostomy, staple across distal esophagus, washout mediastinum, place chest tubes - late esophagectomy at time of gastric replacement)
Gastric replacement of esophagus late when patient fully recovers

109
Q

Boerhaave’s syndrome

A 
Forceful vomiting --> chest pain
Full thickness perforation of esophagus
Highest moretality of all perforations
Dx: Gastrografin swallow
Tx: as above for esophageal perforations
110
Q

Most likely location of perforation in Boerhaave’s syndrome

A

Left lateral wall of esophagus

3-5cm above the GE junction

111
Q

Hartmann’s sign

A

Mediastinal crunching on auscultation

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