Abdominal Surgery- Esophagus Flashcards
Reflux vs GERD
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
GERD risk factors
- Lifestyle habits such as smoking, caffeine and alcohol consumption
- Stress
- Obesity
- Pregnancy
- Scleroderma
- Sliding hiatal hernia: ≥ 90% of patients with severe GERD
GERD Clinical Features
- 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
GERD
Diagnostics
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
GERD Tx
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)
Indications for surgical tx of GERD
Barrett esophagus, strictures, recurrent aspiration
Barett Esophagus
Pathophysiology
- Reflux esophagitis →
- stomach acid damages squamous epithelium →
- squamous epithelium becomes replaced by columnar epithelium and goblet cells (intestinal metaplasia, Barrett’s metaplasia)
Barretts Esophagus
Complications
precancerous condition for adenocarcinoma
Barrets Esophagus
Tx
- 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
- If low-grade dysplasia
Complications of GERD
- Iron deficiency anemia
- Esophageal stricture
- Esophageal ring
- Aspiration of gastric contents leads to:
- Aspiration pneumonia
- Chronic bronchitis
- Asthma (exacerbation)
- Laryngitis and hoarseness
- Barrett esophagus
Esophageal stricture
clinical features / diagnosis
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
Esophageal stricture Tx
First-line treatment: dilation with bougie dilator/balloon dilator
Most common type of esophageal ring
Schatzki rings at the squamocolumnar junction are the most common type
Esophafeal diverticula
abnormal pouches that arise from the wall of the esophagus.
True vs False Diverticula
- 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.
Location of esophageal diverticula
- Upper esophageal diverticulum: Zenker’s diverticulum at Killian’s triangle
- Middle esophageal diverticulum: diverticulum at the tracheal bifurcation
- Lower esophageal diverticulum: epiphrenic diverticulum
Killians Triangle
A triangular weak point in the muscular wall between the thyropharyngeal and cricopharyngeal parts of the inferior pharyngeal constrictor muscle.
Esophageal Diverticula Pathophysiology
- Inadequate relaxation of the esophageal sphincter (e.g., caused by achalasia or spastic motility) and increased intraluminal pressure
- results in outpouching of the esophageal wall →
- pulsion diverticulum (usually false diverticulum)
- Inflammation of the mediastinum
- scarring and retraction (e.g., secondary to tuberculosis or fungal infection) →
- traction diverticulum (usually true)
Esophageal Diverticula
Clinical Features
- Dysphagia (most common)
- Regurgitation of undigested food
- Aspiration
- Coughing after food intake
- Retrosternal pressure sensation and pain
- Halitosis
- Weight loss
- Neck mass (Zenker’s)
Esophageal Diverticula
Diagnostics
- Barium swallow (best confirmatory test) with dynamiccontinuous fluoroscopy
- Visualization of diverticula
- Lateral projection
- Endoscopy
- rule out malignancy
- diverticula with small opening may be missed
Esophageal diverticula
Tx
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
Zankers Diverticulum pathopysh
caused by an inadequate relaxation of the upper esophageal sphincter (UES) leading to increased intraluminal pressure that results in outpouching of the pharyngeal wall
Zenker’s Diverticula Complication
Aspiration Pneumonia
Rare: perforation and fistula
Achalasia
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
Achalasia Pathophysiology
- 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 Clinical Findings
- Dysphagia to solids and liquids; can be progressive or paradoxical
- Regurgitation
- Retrosternal pain
- Weight loss
Achalasia vs Esophageal obstruction
Achalasia typically manifests with progressive dysphagia to solids and liquids while esophageal obstruction manifests with dysphagia to solids only.
Achalasia Diagnostics
- 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
Bird Beak sign
dilation of the proximal esophagus with stenosis of the gastroesophageal junction
Achalasia Tx
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
Achalasia Complications
- Pulmonary complications (e.g., pneumonia, abscess, asthma) caused by aspiration
- Megaesophagus
- Increased risk of esophageal cancer.
Mallory Weiss Syndrome
Upper gastrointestinal bleeding caused by tears to the longitudinal mucous membrane at the gastroesophageal junction
male:female 3:1
Mallory Weiss Syndrome
Etiology
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
Mallory Weiss Syndrome Clinical Findings
- May be asymptomatic
- Epigastric or back pain
- Hematemesis
Mallory Weiss Syndrome Diagnostics
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.
Mallory Weiss DDx
Boerhaave syndrome
Esophagitis
Esophageal ulcers
Mallory Weiss Tx
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
Boerhaave Syndrome
spontaneous subtype of esophageal perforation characterized by transmural rupture of the esophagus following an episode of forceful vomiting/retching or increased intrathoracic pressure
Boerhaave Syndrome Risk Factors
- Intake of large amounts of alcohol or food in the recent past
- Repeated episodes of vomiting
- Prolonged coughing
Boerhaave Syndrome Pathophysiology
- 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
Esophageal Perforation Clinical Features
- 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.
Mackler Triad
- Vomiting and/or retching
- Severe retrosternal pain that often radiates to the back
- Subcutaneous or mediastinal emphysema:
- crepitus in the suprasternal notch or crunching or crackling sound on chest auscultation(Hamman sign)
Esophageal Perforation Diagnostics
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
Esophageal Perforation Tx
- NPO
- Broad Spectrum Abx
Non OP: small contained perforation
Surgical repais: hemodynamically instable
Esophageal Perforation Complications
- Mediastinitis
- Peritonitis in intra-abdominal perforations
- Empyema
- Severe sepsis or shock
- Multiorgan dysfunction
Mediastinitis
clinical features
- Retrosternal and/or back pain
- Subcutaneous emphysema
- Fever
- Superior vena cava syndrome
Mediastinitis
Diagnosis
Chest x-ray shows a widened mediastinum and mediastinal emphysema.
Mediastinitis TX
resuscitation, IV antibiotic therapy, and surgical debridement
Esophageal Neoplasia
Epidimiology
- 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
Esophageal Adenocarcinoma
Risk Factors
Risk factors
- Gastroesophageal reflux: Barrett’s esophagus
- Obesity
- Smoking
- Achalasia
Localization: mostly in the lower third of the esophagus
Esophageal SSC
Risk Factors
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
Esophageal Neoplasia
Clinical Features
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
Esophageal Neoplasia
Diagnostics
- 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
Apple Core Lesion
asymmetrical and irregular borders of the esophagus with characteristic stenosis and proximaldilatation
Esophageal Neoplasia
Tx
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
Esophageal Neoplasia
Complications
Esophageal stenosis
Tracheoesophageal fistula
Esophageal Neoplasia Prognosis
- 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
