Abdominal Surgery: Esophagus Flashcards
primarily caused by an inappropriate, transient relaxation of the lower esophageal sphincter (LES)
Reflux/ Gastroesophageal reflux disease (GERD)
What kind of epithelium is changed in barrets esophagus?
columnar epithelium instead of the normal squamous epithelium
intestinal metaplasia of the esophageal mucosa induced by chronic reflux
barrett esophagus
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)
Zenker
What is the general pathophys behind esophageal diverticula?
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
Inflammation of the mediastinum with scarring and retraction (e.g., secondary to tuberculosis or fungal infection) →
traction diverticulum
How do we evaluate esophageal diverticula? What inital study is most useful
Barium swallow with videofluoroscopy (best initial test)
What imaging/modality/testing do we use to dx achalasia?
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.
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
Achalasia
How might you be able to dilineate esophageal obstruction from achalasia?
Achalasia typically manifests with progressive dysphagia to solids and liquids while esophageal obstruction manifests with dysphagia to solids only.
Achalasia, bird beak sign
Achalasia is the best described (hypomotile or hypermobile) esophageal disorder.
hypomotile
An esophageal motility disorder that is characterized by repetitive, uncoordinated, nonprogressive contraction waves of the distal esophagus
Distal esophageal spasm
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.
Hypercontractile esophagus (jackhammer esophagus)
Corkscrew esophagus (pseudodiverticulosis) as seen in diffuse esophageal spasm
What would we expect to see on esophageal manometry for achalasia?
High LES resting pressure, recall that nromal is 40-100 mmhg
What therapies can we consider for achalasia pts?
Botulinum toxin injection in the LES
nitrates or calcium channel blockers
Predisposing conditions for mellory-weiss syndrome
Alcohol use disorder
Bulimia nervosa
Hiatal hernia (higher pressure gradient)
Gastroesophageal reflux disease (GERD)
Often a single longitudinal tear (but multiple tears are possible) in the mucosa at the gastroesophageal junction; limited to the mucosa and submucosa
Mallory Weiss
How do booerhave and mallory weiss tears differ?
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
Most common cause of esophageal perforation
iatrogenic like in an endoscopy
Mackler triad
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)
What inital studies are you going to want in a pt with suspected esophageal perforation?
Chest x-ray, look for….
Widened mediastinum
Pneumomediastinum, pneumothorax, pneumoperitoneum, subcutaneous emphysema
Pleural effusion
What is a major complication of a perforated esophagus?
Mediastinitis
Retrosternal and/or back pain
Subcutaneous emphysema
Fever, tachycardia
Sternal wound drainage
Superior vena cava syndrome
The two main forms of esophageal cancer
The two main forms are esophageal adenocarcinoma and squamous cell carcinoma.
Adenocarcinoma usually affects the _________________________of the esophagus
Adenocarcinoma usually affects the lower third of the esophagus
__________________, which usually affects the lower third of the esophagus, may be preceded by gastroesophageal reflux disease and Barrett esophagus.
Adenocarcinoma
________________________ is the most common type of esophageal cancer in the US while _________________________ is the most common type of esophageal cancer worldwide
Adenocarcinoma: most common type of esophageal cancer in the US
Squamous cell carcinoma (SCC): most common type of esophageal cancer worldwide
The most important risk factors for esophageal adenocarcinoma are ___________________________- and -_______________________________.
The most important risk factors for esophageal adenocarcinoma are gastroesophageal reflux and associated Barrett esophagus.
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.
Plummer-Vinson syndrome
Plummer-Vinson syndrome is a risk factor for what esophageal cancer?
SCC
The primary risk factors for ______________________esophageal cancer are alcohol consumption, smoking, and dietary factors (e.g., diet low in fruits and vegetables).
squamous cell
What test do we use to confirm booherave?
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
pneumomediastinum, esophageal wall thickening, pneumothorax, pneumoperitoneum, subcutaneous emphysema, and pleural effusion.
Booerhave
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?
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).
Zenker diverticulum is commonly complicated by _______________________, caused by swallowed saliva, liquid, or food entering the airway
recurrent aspiration pneumonia
What test do we do to confirm esophageal perforation?
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.
Why might someone not be able to undergo a contrast esophagography?
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!
Dilated submucosal veins in the lower esophagus
esophageal varices
normally presents with severe hemmorhage
What do we do for barret esophagus
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.
What is conservative tx for booerhave?
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.
contrast esophagogram with gastrografin showing esophageal perforation
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).
Simultaneous multi-peak contractions on esophageal manometry are the characteristic finding of
Simultaneous multi-peak contractions on esophageal manometry
High lower esophageal sphincter pressure on esophageal manometry is diagnostic of
achalasia
confirmatory test for zenker
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.
Zenker
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__________________________
zenker diverticulum
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.
Oropharyngeal dysphagia
What do we use in oropharyngeal dysphagia and what do we use in esophageal dysphagia to characterize/confirm?
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.
Patients typically present with dysphagia early in the swallowing process, coughing, choking, and nasal regurgitation.
Oropharyngeal dysphagia
Drug induced esophagitis is often attributed to…..
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.
What do we often find on endoscopy with medication-induced eophagitis?
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).
Narrowing or restriction of the lumen of the esophagus that leads to swallowing difficulties. They are common sequelae of untreated GERD and/or esophagitis.
Esophageal stricture
