ABSITE Review - Esophagus Flashcards by Jessica Gonzalez

What are the muscle layers of the esophagus?

Squamous epithelium, circular inner muscle layer, outer longitudinal muscle layer; no serosa

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What is the blood supply to the cervical, thoracic and abdominal esophagus?

Cervical - inferior thyroid artery
Thoracic - Aorta
Abdominal - Left gastric artery and inferior phrenic arteries

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What is the lymphatic drainage pathway of the esophagus?

Upper 2/3 drains cephalad

Lower 1/3 drains caudad

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What is the type of muscle in the upper and lower esophagus?

Upper - striated muscle

Lower - smooth muscle

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Where travels the right vagus nerve as it exits the chest and what structure it forms?

Travels posterior portion of stomach and becomes celiac plexus

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Where travels the left vagus nerve as it exits the chest and where it goes?

Travels anterior portion of stomach; goes to liver and biliary tree

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Where is the criminal nerve of Grassi contained and was happens if it is left undivided?

Contained in the R vagus nerve; can cause persistently high acid levels postoperatively if left undivided

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Where is the UES located with respect to the incisors? What are the normal pressures with food and at rest?

Located 15cm from incisors
Normal UES pressure with food bolus: 12-14 mmHg
Normal UES pressure at rest: 50-70mmHg

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What is the main muscle at the UES?

Cricopharyngeus muscle (circular muscle, prevents air swallowing)

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Where is the MC site of esophageal perforation during EGD?

Cricopharyngeus muscle

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Where is the LES located with respect to the incisors? What are the normal pressures at rest?

Located 40cm from incisors

Normal UES pressure at rest: 10-20mmHg

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What are the anatomic areas of narrowing of the esophagus?

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

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What is the recommended surgical approach for the cervical, upper and lower esophagus?

Cervical - Left
Upper 2/3 - Right (avoids aorta)
Lower 1/3 - Left (left-sided course in this region)

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What is a Zenker’s diverticulum? What is the cause?

Is a FALSE posterior diverticulum between the cricopharyngeus and pharyngeal constrictors
Caused by increased pressure during swallowing.

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What is the diagnostic study of choice for Zenker’s and what is the treatment?

Dx - Barium Swallow Studies, Manometry
Tx - Cricopharyngeal myotomy, removal of diverticulum not necessary
Left cervical incision; leave drains; esophagogram POD 1

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What is a traction diverticulum? What is the cause? What is the treatment?

Is a TRUE diverticulum - usually lies lateral in midesophagus
Due to granulomatous disease, inflammation, tumor
Tx - excison and primary closure

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What is the cause of an epiphrenic diverticulum? Where it is usually located? What is the treatment?

Rare; associated with esophageal motility disorders
MC in distal 10cm of the esophagus
Tx - diverticulectomy and long esophageal myotomy on the side opposite to the diverticulectomy

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What is the cause of achalasia?

Caused by failure of peristalsis and lack of LES relaxation after food bolus
Secondary to neuronal degeneration in muscle wall

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What is the study of choice for diagnosing achalasia?

Manometry - increase LES pressure, incomplete LES relaxation, no peristalsis

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What is the treatment for achalasia?

CCBs, LES dilation –> effective in 60%
If medical tx and dilation fails –> Heller myotomy - left thorscotomy, transect circular layer of muscle lower esopagus; also need partial Nissen fundoplication

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Which agent can produce similar symptoms to achalasia?

Tympanosoma cruzi

What are the manometric findings of diffuse esophageal spasm?

Frequent strong body contractions of increase amplitude and duration, normal LES tone, strong unorganized contractions

What is the treatment of diffuse esophageal spasm?

CCBs, nitrates, antispasmodics, Heller myotomy

What are the normal anatomic protection from GERD?

Need LES competence, normal esophageal body, normal gastric reservoir

What is the usual work up for GERD?

Endoscopy, pH probe (best test), manometry (resting LES < 6mmHg), histology

What is the medical therapy for GERD?

Omeprazole for 12 weeks

What are the surgical indications for GERD?

GERD on pH monitoring, failue of medical tx, complications of GERD (stricture, Barret's esophagus, cancer)

The phrenoesophageal membrane is an extension of ____ fascia.

Transversalis

What is Collis gastroplasty?

When not enough esophagus exists to pull down into abdomen, can staple along stomach and create a new esophagus.

What is the MCC of dysphagia following a Nissen?

Wrap is too tight

What are the 4 types of hiatal hernia?

Type I - sliding hernia from dilation of hiatus (MC) Type II - paraesophageal; hole in the diaphragm alongside the esophagus, normal GE junction Type III - combined Type IV - entire stomach in the chest plus another organ

Which type of hiatal hernia, you should always repair and why?

Type II due to risk of incarceration

What is treatment for a Schatzki's ring?

Dilatation of the ring usually sufficient; may need antireflux procedure

What is Barret's esophagus? What is the cause?

Squamous metaplasia to columnar epithelium | Occurs with long standing exposure to gastric reflux

What is the cancer risk of Barret's esophagus?

Increases by 50 times

What is the treatment of uncomplicated and severe Barret's?

Uncomplicated Barret's can be treated like GERD - surgery will decrease esophagitis and further metaplasia but will not prevent cancer or cause regression - need carefull follow up with EGD for lifetime Severe Barret's - indication for esophagectomy

How the esophageal cancer spreads quickly?

Along the submucosal lymphatic channels

What are signs of unresectable esophageal cancer?

Hoarseness (RLN), Horner's syndrome, phrenic nerve involvement, malignant pleural effusion, malignant fistula, airway invasion, vertebral invasion

What is the #1 type of esophageal cancer?

Adenocarcinoma

Which cancer most likely occurs in upper and lower esophagus?

Upper 2/3 - squamous cell | Lower 1/3 - adenocarcinoma

What is the primary blood supply to stomach after replacing esophagus?

Right gastroepiploic artery

What is the Ivor-Lewis esophagectomy?

Abdominal incision and right thoracotomy; intrathoracic anastomosis

How many anastomosis are present in a colonic interposition?

Three

What is the MC benign tumor of the esophagus? Which layer it is located?

Leiomyoma; submucosal

What is the treatment for a leiomyoma?

Do not biopsy bc can form scar and make subsequent resection difficult Tx - > 5cm or symptomatic --> excision (enucleation) via thoracotomy

What is the 2nd MC benign tumor of the esophagus?

Esophageal polyps; usually in the cervical esophagus

What are the degree of injury and specific treatment in caustic esophageal injury?

No NGT with caustic injuries Primary burn - hyperemia - observation, IVFs, spitting, Abx Secondary burn - ulcerations, exudates, and sloughing - prolonged observation, esophagogram in HOD 2-3 Tertiary burn - deep ulcers, charring, and lumen narrowing - esophagectomy, esophagogram in HOD 2-3

What is the treatment of a noncontained esophageal perforation diagnosed in < 24 hours?

try primary repair with drainsand intercostal muscle pedicle flap

What is the treatment of a noncontained esophageal perforation diagnosed in a sick patient or more than 24 hours?

Cervical esophagostomy for diversion, washout of the mediastinum, place chest tubes, and later placement of a feeding G or J tube

What is Boerhaave's syndrome?

Forceful vomiting followed by chest pain - perforation most likely to occur in the left lateral wall of esophagus at the level of T8, 3-5 cm above the GE junction