Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Surgery Clerkship- Amboss Study Plan > Abdominal Surgery- Esophagus > Flashcards

Abdominal Surgery- Esophagus Flashcards

1
Q

Reflux vs GERD

A

Gastroesophageal reflux: regurgitation of stomach contents into the esophagus

Gastroesophageal reflux disease (GERD): A condition in which reflux causes troublesome symptoms (typically including heartburn or regurgitation) and/or esophageal injury/complications

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

GERD risk factors

A
  • Lifestyle habits such as smoking, caffeine and alcohol consumption
  • Stress
  • Obesity
  • Pregnancy
  • Scleroderma
  • Sliding hiatal hernia: ≥ 90% of patients with severe GERD
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

GERD Clinical Features

A
  • Chief complaint: retrosternal burning pain (heartburn) that worsens while lying down (e.g., at night) and after eating
  • Pressure sensation in the chest
  • Belching, regurgitation
  • Chronic non-productive cough and nocturnal cough
  • Halitosis
  • Triggers:
    • supine position
    • smoking
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

GERD

Diagnostics

A

Empirical therapy:

  • lifestyle modifications
  • short trial with PPIs
  • A GERD diagnosis is assumed in patients who respond to this therapeutic regimen.

Upper endoscopy Indications:

  • Signs of complicated disease
    • (e.g., dysphagia, painful swallowing, weight loss, iron deficiency anemia, and aspiration pneumonia)
  • No response to PPI treatment
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

GERD Tx

A

Lifestyle modifications

  • Normalize body weight
  • Elevate the head of the bed
  • Avoid toxins: nicotine, alcohol, coffee

Medical therapy

  • Standard-dose of PPI for at least 8 weeks

Surgical therapy

  • Fundoplication
    • Nissen fundoplication (= complete fundoplication)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Indications for surgical tx of GERD

A

Barrett esophagus, strictures, recurrent aspiration

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Barett Esophagus

Pathophysiology

A
  • Reflux esophagitis →
  • stomach acid damages squamous epithelium →
  • squamous epithelium becomes replaced by columnar epithelium and goblet cells (intestinal metaplasia, Barrett’s metaplasia)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Barretts Esophagus

Complications

A

precancerous condition for adenocarcinoma

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Barrets Esophagus

Tx

A
  • Medical treatment with PPIs
  • Endoscopy with four-quadrant biopsies at every 2 cm of the suspicious area (salmon colored mucosa)
    • If low-grade dysplasia
      • Endoscopic therapy of mucosal irregularities
    • endoscopic therapy of mucosal irregularities
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Complications of GERD

A
  1. Iron deficiency anemia
  2. Esophageal stricture
  3. Esophageal ring
  4. Aspiration of gastric contents leads to:
    • Aspiration pneumonia
    • Chronic bronchitis
    • Asthma (exacerbation)
  5. Laryngitis and hoarseness
  6. Barrett esophagus
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Esophageal stricture

clinical features / diagnosis

A

Clinical features: solid food dysphagia

Diagnostics

  • Barium esophagram (best initial test): narrowing of the esophagus at the gastroesophageal junction
  • Endoscopy with biopsies: to rule out malignancy
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Esophageal stricture Tx

A

First-line treatment: dilation with bougie dilator/balloon dilator

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Most common type of esophageal ring

A

Schatzki rings at the squamocolumnar junction are the most common type

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Esophafeal diverticula

A

abnormal pouches that arise from the wall of the esophagus.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

True vs False Diverticula

A
  • True diverticula: All layers of the esophageal wall protrude
  • False diverticula: Increased intraluminal pressure causes only the mucosa and submucosa to bulge through weak points in the muscularis propria.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Location of esophageal diverticula

A
  • Upper esophageal diverticulum: Zenker’s diverticulum at Killian’s triangle
  • Middle esophageal diverticulum: diverticulum at the tracheal bifurcation
  • Lower esophageal diverticulum: epiphrenic diverticulum
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Killians Triangle

A

A triangular weak point in the muscular wall between the thyropharyngeal and cricopharyngeal parts of the inferior pharyngeal constrictor muscle.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Esophageal Diverticula Pathophysiology

A
  1. Inadequate relaxation of the esophageal sphincter (e.g., caused by achalasia or spastic motility) and increased intraluminal pressure
  2. results in outpouching of the esophageal wall →
  3. pulsion diverticulum (usually false diverticulum)
  1. Inflammation of the mediastinum
  2. scarring and retraction (e.g., secondary to tuberculosis or fungal infection) →
  3. traction diverticulum (usually true)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Esophageal Diverticula

Clinical Features

A
  • Dysphagia (most common)
  • Regurgitation of undigested food
  • Aspiration
  • Coughing after food intake
  • Retrosternal pressure sensation and pain
  • Halitosis
  • Weight loss
  • Neck mass (Zenker’s)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Esophageal Diverticula

Diagnostics

A
  • Barium swallow (best confirmatory test) with dynamiccontinuous fluoroscopy
    • Visualization of diverticula
    • Lateral projection
  • Endoscopy
    • rule out malignancy
    • diverticula with small opening may be missed
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Esophageal diverticula

Tx

A

Surgical treatment Indications:

  • Symptomatic Zenker’s diverticula
  • In rare cases, epiphrenic diverticula that become symptomatic
  • middle and distal diverticula usually dont require treatment

Procedure:

  • Endoscopy: with diverticulostomy and myotomy
  • Open surgery
    • Zenker’s diverticulum: cricopharyngeal myotomy
    • Epiphrenic diverticula: esophagomyotomy
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Zankers Diverticulum pathopysh

A

caused by an inadequate relaxation of the upper esophageal sphincter (UES) leading to increased intraluminal pressure that results in outpouching of the pharyngeal wall

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Zenker’s Diverticula Complication

A

Aspiration Pneumonia

Rare: perforation and fistula

24
Q

Achalasia

A

Esophageal motility disorder characterized by inadequate relaxation of the lower esophageal sphincter (LES) and nonperistaltic contractions in the distal two-thirds of the esophagus due to the degeneration of inhibitory neurons

25
Q

Achalasia Pathophysiology

A
  1. Atrophy of inhibitory neurons in the Auerbach plexus →
  2. lack of inhibitory neurotransmitters (e.g., NO, VIP) →
  3. inability to relax and increased resting pressure of the LES, as well as dysfunctional peristalsis →
  4. esophageal dilation proximal to LES
26
Q

Achalasia Clinical Findings

A
  • Dysphagia to solids and liquids; can be progressive or paradoxical
  • Regurgitation
  • Retrosternal pain
  • Weight loss
27
Q

Achalasia vs Esophageal obstruction

A

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

28
Q

Achalasia Diagnostics

A
  • Esophageal barium swallow: supportive and/or confirmatory test
    • Bird-beak sign
    • Delayed barium emptying
  • Upper endoscopy: to rule out pseudoachalasia
    • Usually normal
    • If malignancy is suspected, biopsy and endoscopic ultrasound are indicated
  • Esophageal manometry: confirmatory test of choice
    • Peristalsis is absent
    • Incomplete or absent LES relaxation
    • High LES resting pressure
  • Chest x-ray
    • Widened mediastinum
29
Q

Bird Beak sign

A

dilation of the proximal esophagus with stenosis of the gastroesophageal junction

30
Q

Achalasia Tx

A

If a low surgical risk

  • Pneumatic dilation
    • Endoscope-guided graded dilation of the LES
  • LES myotomy (Heller myotomy)

If a high surgical risk

  • Botulinum toxin injection in the LES
  • nitrates or calcium channel blockers
31
Q

Achalasia Complications

A
  • Pulmonary complications (e.g., pneumonia, abscess, asthma) caused by aspiration
  • Megaesophagus
  • Increased risk of esophageal cancer.
32
Q

Mallory Weiss Syndrome

A

Upper gastrointestinal bleeding caused by tears to the longitudinal mucous membrane at the gastroesophageal junction

male:female 3:1

33
Q

Mallory Weiss Syndrome

Etiology

A

Mechanism:

  • 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

Precipitating factors

  • Severe vomiting

Predisposing conditions

  • Alcoholism
  • Bulimia nervosa
34
Q

Mallory Weiss Syndrome Clinical Findings

A
  • May be asymptomatic
  • Epigastric or back pain
  • Hematemesis
35
Q

Mallory Weiss Syndrome Diagnostics

A

Esophagogastroduodenoscopy

  • Often a single longitudinal tear (multiple tears are possible) in the mucosa at the gastroesophageal junction; limited to mucosa and submucosa
  • A clot or active bleeding may be evident.
36
Q

Mallory Weiss DDx

A

Boerhaave syndrome

Esophagitis

Esophageal ulcers

37
Q

Mallory Weiss Tx

A

If bleedings stops spontaneously conservative treatment is usually sufficient

Surgical treatment

  • Indication: actively bleeding lesion
  • Gold standard: esophagogastroduodenoscopy
    • injection of an adrenaline solution or a fibrin sealant
    • Electrocoagulation
    • Endoscopic band ligation
  • Second-line treatment : angiography
38
Q

Boerhaave Syndrome

A

spontaneous subtype of esophageal perforation characterized by transmural rupture of the esophagus following an episode of forceful vomiting/retching or increased intrathoracic pressure

39
Q

Boerhaave Syndrome Risk Factors

A
  • Intake of large amounts of alcohol or food in the recent past
  • Repeated episodes of vomiting
  • Prolonged coughing
40
Q

Boerhaave Syndrome Pathophysiology

A
  • Severe vomiting/increased intrathoracic pressure →
  • rupture of all layers of the esophageal wall (transmural perforation)
  • the rupture occurs in the distal third of the esophagus
41
Q

Esophageal Perforation Clinical Features

A
  • Neck, retrosternal chest, and/or epigastric pain with radiation to the back
  • Mackler triad, esp. in Boerhaave syndrome
  • History of recent endoscopy:
    • Symptoms usually occur within 24 hours of endoscopy.
42
Q

Mackler Triad

A
  1. Vomiting and/or retching
  2. Severe retrosternal pain that often radiates to the back
  3. Subcutaneous or mediastinal emphysema:
    • crepitus in the suprasternal notch or crunching or crackling sound on chest auscultation(Hamman sign)
43
Q

Esophageal Perforation Diagnostics

A

Approach: a chest x-ray is first conducted;

If inconclusive, an esophagram and/or CT scan is conducted to confirm the diagnosis

  • Initial diagnostic study- Chest x-ray
    • Widened mediastinum
    • Pneumomediastinum, pneumothorax, pneumoperitoneum, subcutaneous emphysema
    • Pleural effusion
  • Confirmatory test that reveals location and size of rupture
    • Contrast esophagography (gold standard): Contrast leak
  • CT is inconclusive
44
Q

Esophageal Perforation Tx

A
  1. NPO
  2. Broad Spectrum Abx

Non OP: small contained perforation

Surgical repais: hemodynamically instable

45
Q

Esophageal Perforation Complications

A
  • Mediastinitis
  • Peritonitis in intra-abdominal perforations
  • Empyema
  • Severe sepsis or shock
  • Multiorgan dysfunction
46
Q

Mediastinitis

clinical features

A
  • Retrosternal and/or back pain
  • Subcutaneous emphysema
  • Fever
  • Superior vena cava syndrome
47
Q

Mediastinitis

Diagnosis

A

Chest x-ray shows a widened mediastinum and mediastinal emphysema.

48
Q

Mediastinitis TX

A

resuscitation, IV antibiotic therapy, and surgical debridement

49
Q

Esophageal Neoplasia

Epidimiology

A
  • Sex: ♂ > ♀
  • Peak incidence: 60–70 years of age
  • Adenocarcinoma: most common type of esophageal cancer in the US
  • Squamous cell carcinoma (SCC): most common type of esophageal cancer worldwide
50
Q

Esophageal Adenocarcinoma

Risk Factors

A

Risk factors

  • Gastroesophageal reflux: Barrett’s esophagus
  • Obesity
  • Smoking
  • Achalasia

Localization: mostly in the lower third of the esophagus

51
Q

Esophageal SSC

Risk Factors

A

Risk factors

  • Alcohol consumption
  • Smoking
  • Diet low in fruits and vegetables
  • Drinking hot beverages
  • Achalasia
  • Nitrosamines exposure (e.g., cured meat, fish, bacon)

Localization: mostly in the upper two-thirds of the esophagus

52
Q

Esophageal Neoplasia

Clinical Features

A

Early stages: Often asymptomatic but may present with swallowing difficulties or retrosternal discomfort

Late stages

  • Common
    • Progressive dysphagia (from solids to liquids) with possible odynophagia
    • Weight loss
    • Retrosternal chest or back pain
    • Anemia
  • Less common
    • Hematemesis, melena
    • Hoarseness
53
Q

Esophageal Neoplasia

Diagnostics

A
  • Esophagogastroduodenoscopy (best initial and confirmatory test)
    • With biopsy of any suspicious lesions
  • Barium swallow: apple core lesion
  • Staging
    • Transesophageal endoscopic ultrasound
    • Chest and abdominal CT; PET
54
Q

Apple Core Lesion

A

asymmetrical and irregular borders of the esophagus with characteristic stenosis and proximaldilatation

55
Q

Esophageal Neoplasia

Tx

A

Curative

  • Indication:
    • Locally invasive disease that has not invaded surrounding structures
    • High-grade metaplasia in Barrett syndrome
  • Methods:
    • Neoadjuvant chemoradiation
    • Surgical resection

Palliative

  • Indication: patients with advanced disease (majority of patients)
  • Methods: Chemoradiation
56
Q

Esophageal Neoplasia

Complications

A

Esophageal stenosis

Tracheoesophageal fistula

57
Q

Esophageal Neoplasia Prognosis

A
  • Generally poor prognosis due to an aggressive course and typically late diagnosis
  • Metastasizes early because of the absence of serosa in parts of the esophagus

Surgery Clerkship- Amboss Study Plan (6 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions