Abdominal Surgery: Esophagus

Question 1

primarily caused by an inappropriate, transient relaxation of the lower esophageal sphincter (LES)

Answer 1

Reflux/ Gastroesophageal reflux disease (GERD)

Question 2

What kind of epithelium is changed in barrets esophagus?

Answer 2

columnar epithelium instead of the normal squamous epithelium

Question 3

intestinal metaplasia of the esophageal mucosa induced by chronic reflux

Answer 3

barrett esophagus

Question 4

Most common type of esophageal diverticulum at the Killian triangle (a triangular weak point in the dorsal muscular wall of the hypopharynx, between the thyropharyngeal and cricopharyngeal parts of the inferior pharyngeal constrictor muscle)

Answer 4

Zenker

Question 5

What is the general pathophys behind esophageal diverticula?

Answer 5

Inadequate relaxation of the esophageal sphincter (e.g., caused by achalasia or spastic motility) and increased intraluminal pressure → outpouching of the esophageal wall → pulsion diverticulum like a zenker

Question 6

Inflammation of the mediastinum with scarring and retraction (e.g., secondary to tuberculosis or fungal infection) →

Answer 6

traction diverticulum

Question 7

How do we evaluate esophageal diverticula? What inital study is most useful

Answer 7

Barium swallow with videofluoroscopy (best initial test)

Question 8

What imaging/modality/testing do we use to dx achalasia?

Answer 8

While upper endoscopy and/or esophageal barium swallow are often obtained initially, manometry usually confirms the diagnosis, and upper endoscopy is indicated to rule out a malignant underlying cause. Barium swallow is where you will see the bird beak sign.

Question 9

Atrophy of inhibitory neurons in the Auerbach plexus → lack of inhibitory neurotransmitters (e.g., NO, VIP) → inability to relax and increased resting pressure of the LES, as well as dysfunctional peristalsis → esophageal dilation proximal to LES

Answer 9

Achalasia

Question 10

How might you be able to dilineate esophageal obstruction from achalasia?

Answer 10

Achalasia typically manifests with progressive dysphagia to solids and liquids while esophageal obstruction manifests with dysphagia to solids only.

Question 11

Answer 11

Achalasia, bird beak sign

Question 12

Achalasia is the best described (hypomotile or hypermobile) esophageal disorder.

Answer 12

hypomotile

Question 13

An esophageal motility disorder that is characterized by repetitive, uncoordinated, nonprogressive contraction waves of the distal esophagus

Answer 13

Distal esophageal spasm

Question 14

An esophageal hypermobility disorder characterized by hypertensive propagative esophageal contractions in which at least 20% of swallows have a distal contractile integral > 8,000 mm Hg/sec/cm.

Answer 14

Hypercontractile esophagus (jackhammer esophagus)

Question 15

Answer 15

Corkscrew esophagus (pseudodiverticulosis) as seen in diffuse esophageal spasm

Question 16

What would we expect to see on esophageal manometry for achalasia?

Answer 16

High LES resting pressure, recall that nromal is 40-100 mmhg

Question 17

What therapies can we consider for achalasia pts?

Answer 17

Botulinum toxin injection in the LES
nitrates or calcium channel blockers

Question 18

Predisposing conditions for mellory-weiss syndrome

Answer 18

Alcohol use disorder
Bulimia nervosa
Hiatal hernia (higher pressure gradient)
Gastroesophageal reflux disease (GERD)

Question 19

Often a single longitudinal tear (but multiple tears are possible) in the mucosa at the gastroesophageal junction; limited to the mucosa and submucosa

Answer 19

Mallory Weiss

Question 20

How do booerhave and mallory weiss tears differ?

Answer 20

Their depth

Boerhaave syndrome: A transmural rupture of the distal esophagus as a result of a sudden increase in intraesophageal pressure.

Mallory Weiss: a sudden and severe rise in the esophageal intraluminal pressure results in tearing of the esophageal mucous membrane, as well as the submucosal arteries and veins. Limited to mucosa and submucosa

Question 21

Most common cause of esophageal perforation

Answer 21

iatrogenic like in an endoscopy

Question 22

Mackler triad

Answer 22

Seen especially in boerhaave

Vomiting and/or retching

Severe retrosternal pain that often radiates to the back

Subcutaneous or mediastinal emphysema: crepitus in the suprasternal notch and neck region or crunching/crackling sound on chest auscultation (Hamman sign)

Question 23

What inital studies are you going to want in a pt with suspected esophageal perforation?

Answer 23

Chest x-ray, look for….
Widened mediastinum
Pneumomediastinum, pneumothorax, pneumoperitoneum, subcutaneous emphysema
Pleural effusion

Question 24

What is a major complication of a perforated esophagus?

Answer 24

Mediastinitis

Retrosternal and/or back pain
Subcutaneous emphysema
Fever, tachycardia
Sternal wound drainage
Superior vena cava syndrome

Question 25

The two main forms of esophageal cancer

Answer 25

The two main forms are esophageal adenocarcinoma and squamous cell carcinoma.

Question 26

Adenocarcinoma usually affects the _________________________of the esophagus

Answer 26

Adenocarcinoma usually affects the lower third of the esophagus

Question 27

__________________, which usually affects the lower third of the esophagus, may be preceded by gastroesophageal reflux disease and Barrett esophagus.

Answer 27

Adenocarcinoma

Question 28

________________________ is the most common type of esophageal cancer in the US while _________________________ is the most common type of esophageal cancer worldwide

Answer 28

Adenocarcinoma: most common type of esophageal cancer in the US
Squamous cell carcinoma (SCC): most common type of esophageal cancer worldwide

Question 29

The most important risk factors for esophageal adenocarcinoma are ___________________________- and -_______________________________.

Answer 29

The most important risk factors for esophageal adenocarcinoma are gastroesophageal reflux and associated Barrett esophagus.

Question 30

A condition characterized by the triad of dysphagia, upper esophageal webs, and iron deficiency anemia. Associated with glossitis and increased risk of esophageal squamous cell carcinoma. Most commonly presents in white women 40-70 years of age.

Answer 30

Plummer-Vinson syndrome

Question 31

Plummer-Vinson syndrome is a risk factor for what esophageal cancer?

Answer 31

SCC

Question 32

The primary risk factors for ______________________esophageal cancer are alcohol consumption, smoking, and dietary factors (e.g., diet low in fruits and vegetables).

Answer 32

squamous cell

Question 33

What test do we use to confirm booherave?

Answer 33

In patients who are hemodynamically stable, contrast esophagography with gastrografin is the preferred confirmatory test.

CT scan of the chest is used to confirm the diagnosis of Boerhaave syndrome in patients who are hemodynamically unstable or otherwise not suited to undergo contrast esophagography.

KEY WORD BEING HEMODYNAMICALLY UNSTABLE…If stable, confrim with contrast esophagography

Question 34

pneumomediastinum, esophageal wall thickening, pneumothorax, pneumoperitoneum, subcutaneous emphysema, and pleural effusion.

Answer 34

Booerhave

Question 35

The combination of dysphagia to solids and liquids, bird-beak sign on esophagram, and impaired relaxation of the lower esophageal sphincter on manometry are indicative of achalasia. What is the most appropriate next tests for this pt?

Answer 35

Get an endoscopy to rule out malignancy

Gastroesophageal endoscopy is indicated in this patient to rule out malignancy (e.g., cancer of the esophagus or the gastroesophageal junction) as a cause of secondary achalasia (pseudoachalasia).

Question 36

Zenker diverticulum is commonly complicated by _______________________, caused by swallowed saliva, liquid, or food entering the airway

Answer 36

recurrent aspiration pneumonia

Question 37

What test do we do to confirm esophageal perforation?

Answer 37

Iatrogenic trauma is the most common etiology of esophageal perforation (e.g., following upper endoscopy). While this patient’s x-ray findings and Hamman sign already suggest pneumomediastinum, gastrografin contrast esophagography is indicated as a confirmatory test to visualize the potential defect and assess its size and exact location.

Question 38

Why might someone not be able to undergo a contrast esophagography?

Answer 38

not stable enough

if you have someone who has an esophageal rupture from booerhave and is hemodynamically unstable, then they will likely just get a CT!

Question 39

Dilated submucosal veins in the lower esophagus

Answer 39

esophageal varices

normally presents with severe hemmorhage

Question 40

What do we do for barret esophagus

Answer 40

The risk for malignant transformation of BE with high-grade dysplasia to esophageal adenocarcinoma is approx. 7% per year. Therefore, endoscopic eradication of dysplasia via mucosal resection and/or radiofrequency ablation is the treatment of choice in patients with high-grade dysplasia. Concurrent eradication of intestinal metaplasia also reduces the risk of dysplasia recurrence. In BE with low-grade dysplasia, the risk for malignant transformation is approx. 0.7% per year. Endoscopic eradication is also preferred for BE with low-grade dysplasia but surveillance endoscopy every 12 months is an acceptable alternative.

Question 41

What is conservative tx for booerhave?

Answer 41

Components of conservative therapy for Boerhaave syndrome include nothing by mouth with parenteral nutrition if required, IV proton pump inhibitors, analgesia, broad-spectrum antibiotic prophylaxis (e.g., ampicillin/sulbactam), percutaneous drainage of any fluid collections, and cardiopulmonary monitoring. Prior to restarting oral intake, a contrast esophagogram with gastrografin is indicated to confirm healing of the perforation.

Question 42

Answer 42

contrast esophagogram with gastrografin showing esophageal perforation

Question 43

Answer 43

Barium swallow (lateral view): circular narrowing of the esophagus directly at the esophagogastric junction (Schatzki ring or B-ring).
As opposed to A-rings (which are located just proximal to the EG junction), B-rings often can only be seen if there is a concomitant hiatal hernia. with which they are frequently associated (as is the case here).

Question 44

Simultaneous multi-peak contractions on esophageal manometry are the characteristic finding of

Answer 44

Simultaneous multi-peak contractions on esophageal manometry

Question 45

High lower esophageal sphincter pressure on esophageal manometry is diagnostic of

Answer 45

achalasia

Question 46

confirmatory test for zenker

Answer 46

The best confirmatory test in patients with ZD is barium esophagram with dynamic continuous fluoroscopy.The best confirmatory test in patients with ZD is barium esophagram with dynamic continuous fluoroscopy.

Question 47

Answer 47

Zenker

Question 48

The patient’s symptoms of dysphagia, halitosis, regurgitation, and coughing up of undigested food as well as her retrosternal pressure and the gurgling sound while eating are most likely caused by symptomatic__________________________

Answer 48

zenker diverticulum

Question 49

Difficulty propelling a food bolus from the oral cavity into the pharynx, or from the pharynx into the upper esophagus. Common causes include Ludwig angina, cranial nerve IX and/or X palsy, oropharyngeal carcinoma, congenital webs, and Zenker diverticulum. Patients typically present with dysphagia early in the swallowing process, coughing, choking, and nasal regurgitation.

Answer 49

Oropharyngeal dysphagia

Question 50

What do we use in oropharyngeal dysphagia and what do we use in esophageal dysphagia to characterize/confirm?

Answer 50

Oropharyngeal dysphagia: videofluoroscopic modified barium swallow

Esophageal dysphagia: Esophageal manometry is indicated in patients with esophageal dysphagia who are believed to have an esophageal motility disorder.

Question 51

Patients typically present with dysphagia early in the swallowing process, coughing, choking, and nasal regurgitation.

Answer 51

Oropharyngeal dysphagia

Question 52

Drug induced esophagitis is often attributed to…..

Answer 52

Common causes include antibiotics, anti-inflammatory drugs (e.g., aspirin) and bisphosphonates.

A condition characterized by esophageal mucosal irritation (e.g., from increased acidity, alkalinity, or osmolality) caused by oral medications. Common causes include antibiotics, anti-inflammatory drugs (e.g., aspirin) and bisphosphonates.

Bisphosphonates (e.g., alendronate) can directly injure the esophageal mucosa in case of prolonged contact and cause drug-induced esophagitis.

Question 53

What do we often find on endoscopy with medication-induced eophagitis?

Answer 53

The characteristic finding on upper endoscopy is a punched-out ulcer with normal surrounding mucosa, often located at a site of anatomic narrowing (e.g., the gastroesophageal junction).

Question 54

Narrowing or restriction of the lumen of the esophagus that leads to swallowing difficulties. They are common sequelae of untreated GERD and/or esophagitis.

Answer 54

Esophageal stricture