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Fiser's ABSITE Review > Chapter 29 – Esophagus > Flashcards

Chapter 29 – Esophagus Flashcards

1
Q

Anatomy of the esophagus includes what type of epithelium? What layers?

A

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

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2
Q

What blood vessel supplies the cervical esophagus? Abdominal esophagus?

A

Cervical esophagus - inferior thyroid artery; abdominal esophagus – left gastric artery and inferior phrenic arteries; main supply of blood from vessels directly off the aorta

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3
Q

Upper esophagus made up of what kind of muscle? Lower esophagus?

A

Upper – striated muscle, lower – smooth

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4
Q

What is the lymphatic drainage of the esophagus?

A

Upper 2/3 drains cephalad, lower 1/3 caudad

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5
Q

Course after exiting the chest and branches of the right vagus nerve?

A

Travels on posterior portion of stomach as it exits chest; becomes celiac plexus, also has the criminal nerve of Grassi which can cause persistently high acid levels if left undivided

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6
Q

Course of the left vagus nerve as it exits chest and branches?

A

Travels on anterior portion of stomach; go to liver and biliary tree

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7
Q

Course of the thoracic duct?

A

Travels from right to left in chest at upper 1/3 of mediastinum, inserts into left subclavian vein

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8
Q

What is the upper esophageal sphincter? How far is it from incisors? What is it’s innervation?

A

Cricopharyngeus muscle, 15 cm from incisors, circular muscle, prevents air swallowing, has recurrent laryngeal nerve innervation

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9
Q

What is the normal UES pressure with food bolus? At rest?

A

Food bolus – 12 to 14 mmHg, at rest - 50 to 70 mmHg

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10
Q

What is the most common site of esophageal perforation, usually occurs with EGD?

A

Cricopharyngeus muscle

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11
Q

What is the cause of aspiration with brainstem stroke?

A

Failure of UES to relax

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12
Q

How far from the incisors is the lower esophageal sphincter?

A

40 cm

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13
Q

What mediates relaxation of the LES?

A

Inhibitory neurons; muscle normally contracted at resting state, prevents reflux

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14
Q

What is the normal LES pressure at rest?

A

10 to 20 mmHg

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15
Q

What are the three anatomic areas of narrowing of the esophagus?

A

Cricopharyngeus, compression by the left mainstem bronchus and aortic arch, diaphragm

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16
Q

What is the normal esophageal pressures with food bolus?

A

70 - 120 mmHg

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17
Q

What are the three stages of swallowing?

A

Primary peristalsis – occurs with food bolus and swallow initiation by CNS, secondary peristalsis – occurs with incomplete emptying and esophageal distention propagating waves, tertiary peristalsis – non-propagating, non-peristasing

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18
Q

What is the surgical approach to the cervical esophagus? Upper 2/3 thoracic? Lower 1/3 thoracic?

A

Cervical – left, upper – right, lower – left

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19
Q

What causes hiccups?

A

Gastric distention, temperature changes, EtOH, tobacco

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20
Q

What is the reflex arc of hiccups?

A

Vagus, phrenic, sympathetic chain T6 - 12

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21
Q

What are primary and secondary causes of esophageal dysfunction?

A

Primary – unknown, secondary – systemic disease, Gerd, scleroderma, polymyositis

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22
Q

What is the most common cause of esophageal dysfunction?

A

Gerd

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23
Q

What is the procedure of choice for heartburn?

A

Endoscopy

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24
Q

What is the procedure of choice for dysphasia and Odynophasia?

A

Barium swallow, better at picking up masses

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25
Q

What is the diagnosis and treatment for meat impaction?

A

Endoscopy

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26
Q

What is the definition of pharyngoesophageal disorders? Causes?

A

Trouble in transferring food from mouth to esophagus; neuromuscular disease – MG, Parkinson’s disease, polymyositis, MD, Zenker’s diverticulum, lye ingestion, stroke; liquid worse than solid

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27
Q

What causes cervical esophageal dysphasia?

A

Plumber – Vinson syndrome, usually due to web

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28
Q

What is the treatment for Plumber – Vinson syndrome?

A

Dilation, iron, need to screen for oral cancer

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29
Q

What causes Zenker’s diverticulum? Where?

A

Increased pressure during swallowing, posterior, occurs between the cricopharyngeus and pharyngeal constrictors

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30
Q

Symptoms of Zenker’s diverticulum? Diagnosis?

A

Upper esophageal dysphasia, choking, halitosis; barium swallow studies, manometry, risk for perforation with EGD

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31
Q

Treatment for Zenker’s diverticulum?

A

Cricopharyngeal myotomy, Zenker’s itself can either be resected or suspended; via left cervical incision, leave drains in, esophagram postop day 1

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32
Q

What is a traction diverticulum? Causes?

A

True diverticulum, usually lies lateral in midesophagus; due to inflammation, granulomatous disease, tumor

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33
Q

What are the symptoms of traction diverticulum? Treatment?

A

Regurgitation of undigested food, dysphagia; excision and primary closure, may need palliative therapy if due to invasive cancer

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34
Q

What is an epiphrenic diverticulum? Where is it found?

A

Associated with esophageal motility disorders, most commonly in the distal 10 cm of the esophagus

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35
Q

Diagnosis of epiphrenic diverticulum? Treatment?

A

Esophagram and esophageal manometry; diverticulectomy and long esophageal myotomy on the side opposite the diverticulectomy

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36
Q

What causes achalasia? Symptoms?

A

Caused by failure of peristalsis and lack of LES relaxation after food bolus, secondary to neuronal degeneration in muscle wall; dysphasia, regurgitation, weight loss, respiratory symptoms

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37
Q

Diagnosis of achalasia?

A

Manometry – high LES pressure, incomplete LES relaxation, no peristalsis; bird beak appearance

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38
Q

Treatment for achalasia?

A

Calcium channel blocker, LES dilation (effective in 60%), nitrates; if medical treatment fails – Heller myotomy and partial Nissen fundoplication

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39
Q

What bacteria can produce similar symptoms to achalasia?

A

T. cruzi

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40
Q

Symptoms of diffuse esophageal spasm? Associated with?

A

Chest pain, other symptoms similar to achalasia; psychiatric history

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41
Q

Diagnosis of diffuse esophageal spasm?

A

Manometry – frequent strong body contractions of high amplitude and duration, normal LES tone, strong and organized contractions

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42
Q

Treatment for diffuse esophageal spasm?

A

Calcium channel blocker, nitrates, anti-spasmodics, Heller myotomy; treatment usually less effective for diffuse esophageal spasm than for achalasia

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43
Q

What are the symptoms of scleroderma of the esophagus? Treatment?

A

Dysphasia, loss of LES tone, most have strictures, fibrous replacement of smooth muscle; esophagectomy

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44
Q

What is the normal anatomic protection from Gerd?

A

LES competence, normal esophageal body, normal gastric reservoir

45
Q

Symptoms of GERD?

A

Heartburn 30-60m after meals, asthma (cough), choking, PNA; worse symptoms when lying down

46
Q

Dx of GERD?

A

Endoscopy, pH probe (best test), manomentry, histology

47
Q

Tx for GERD?

A

Medical tx 1st: omeprazole for 12 weeks; surgical tx 2nd.

48
Q

Indications for surgery for GERD?

A

GERD on pH monitoring, failure of medical tx, complications (stricture, Barrett’s, cancer)

49
Q

Surgical treatment for GERD?

A

Nissen: divide short gastrics, pull esophagus into abdomen, repair defect in phrenoesophageal membrane, fundal wrap

50
Q

What is the key maneuver during Nissen?

A

Left cura

51
Q

Complications from Nissen?

A

Injury to spleen, diaphragm, esophagus or pneumothorax

52
Q

What maneuver necessary if there is not enough esophagus to pull down into the abdomen?

A

Collis gastroplasty; staple along stomach and create a “new” esophagus

53
Q

Most common cause of dysphagia following Nissen?

A

Wrap is too tight

54
Q

What is a type I hiatal hernia?

A

Sliding hernia from dilation of hiatus (most common); often associated with GERD

55
Q

What is a type II hiatal hernia?

A

Paraesophageal; hole in the diaphragm alongside the esophagus with herniation of fundus, normal GE junction

56
Q

What is a type III hiatal hernia?

A

Combined, GE junction in chest, herniation of stomach

57
Q

What is a type IV hiatal hernia?

A

Entire stomach + another organ in chest

58
Q

Timing of repair of paraesophageal hernias?

A

Type II-IV; all need repair, high risk of incarceration

59
Q

What condition is associated with Schatzki’s ring?

A

Sliding hiatal hernia

60
Q

Symptoms of Schatzki’s ring?

A

Short episodes of dysphagia following rapid swallowing

61
Q

Treatment of Schatzki’s ring?

A

Dilation of the ring usually sufficient; may need antireflux procedure

62
Q

What is Barrett’s esophagus?

A

Squamous metaplasia to columnar epithelium

63
Q

What is the risk of cancer with Barrett’s/

A

Risk of adenocarcinoma increased 50x

64
Q

Treatment for Barrett’s?

A

Uncomplicated: like GERD (PPI, Nissen), surgery witll dec. esophagitis but will not prevent malignancy; Complicated: indication for esophagectomy

65
Q

What is the route of spread of esophageal ca?

A

Spreads quickly along submucosal lymphatic channels

66
Q

Symptoms of esophageal ca?

A

Difficulty swallowing solids, dysphagia, weight loss

67
Q

Risk factors for esophageal ca?

A

Achalasia, caustic injury, ETOH, tobacco, nitrosamides

68
Q

Diagnosis of esophageal ca?

A

Esophagram (for pts with dysphagia, odynophagia, suspected mass lesions)

69
Q

What makes esophageal ca unresectable?

A

Hoarseness (RLN), Horner’s syndrome, phrenic nerve involvement, malignant pleural effusion, malignant fistula, airway invasion, vertebral invasion (CT chest for diagnosis of unresectability)

70
Q

What is the #1 cancer of the esophagus?

A

Adenocarcinoma; occurs in lower 1/3

71
Q

Where do distant mets from esophageal cancer go?

A

Lung or liver; contraindication to esophagectomy

72
Q

What nodal groups indicate unresectable disease?

A

Supraclavicular, nodal disease outside the area of resection; preoperative XRT and chemo may downstage tumors and make them resectable

73
Q

What is the mortality of esophagectomy? What is the cure rate?

A

Mortality: 5%, cure rate: 20%

74
Q

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

A

Right gastroepiploic artery

75
Q

What are the incisions with transhiatal approach? Benefit?

A

Abdominal and neck incisions, bluntly dissect intrathoracic esophagus; decreased mortality from esophageal leaks with cervical anastamosis

76
Q

Incisions with Ivor Lewis?

A

Abdominal incision and right thoracotomy; exposes all of the esophagus; intrathoracic anastomosis

77
Q

What additional procedure is necessary with esophagectomy?

A

Pyloromyotomy

78
Q

What patients are candidates for colonic interposition?

A

Younger patients with benign disease where you want to preserve gastric function

79
Q

Treatment for postop stricture?

A

Dilation

80
Q

Chemo for esophageal cancer?

A

5FU and cisplatin

81
Q

Role of XRT with esophageal cancer?

A

Proven to be effective both pre and postop

82
Q

What is the cause of death with malignant fistulas?

A

Most die within 3 months due to aspiration

83
Q

What is the most common benign tumor of the esophagus? Where is it located?

A

Leiomyoma; submucosal

84
Q

Diagnosis of leiomyoma?

A

Esophagram, endoscopy to r/o cancer

85
Q

Symptoms of leiomyoma?

A

Dysphagia, pain usually in lower 2/3 of esophagus

86
Q

Are biopsies necessary with leiomyoma?

A

No, can form scar and make subsequent resection difficult

87
Q

Treatment for leiomyoma?

A

> 5cm or symptomatic: excision (enucleation) via thoracotomy

88
Q

Symptoms of esophageal polyps?

A

Dysphagia, hematemesis

89
Q

What is the 2nd most common benign tumor of the esophagus? Location?

A

Esophageal polyp; cervical esophagus

90
Q

Treatment for esophageal polyp?

A

Small lesions can be resected with endoscopy; larger lesions require cervical incision

91
Q

General principles of treatment for caustic esophageal injuries?

A

No NGT, do NOT induce vomiting, nothing to drink

92
Q

Effects of alkali on the esophagus?

A

Deep liquefaction necrosis (Drano); causes worse injury than acid, also more likely to cause cancer

93
Q

Acid effects on the esophagus?

A

Coagulation necrosis; mostly causes gastric injury

94
Q

Imaging following caustic esophageal injury?

A

CXR and AXR to look for free air; endoscopy to assess lesion, do not go past site of injury

95
Q

Definition of primary burn of esophagus? Treatment?

A

Hyperemia; observation and conservative therapy (IVF, spitting, abx, oral intake after 3-4d, may need future serial dilation for strictures

96
Q

Definition of secondary burn? Treatment?

A

Ulcerations, exudates, sloughing; prolonged observation and conservative therapy

97
Q

Indications for surgery for secondary burn?

A

Sepsis, peritonitis, persistent back and chest pain, metabolic acidosis, mediastinitis, free air, mediastinal air, crepitance, contrast extravasation, pneumothorax, effusion, air in stomach wall

98
Q

Definition of tertiary burn? Treatment?

A

Deep ulcers, charring, lumen narrowing; conservative treatment, esophagectomy usually necessary

99
Q

What is the most common cause of esophageal perforation? Most common location?

A

EGD; near cricopharyngeus muscle

100
Q

Symptoms of esophageal perforation?

A

Pain, dysphagia, respiratory distress, fever, tachycardia

101
Q

Criteria for nonsurgical management of esophageal perforation?

A

Contained perforation by contrast, self-draining, no systemic effects

102
Q

What is conservative management for esophageal perforations?

A

No NGT with caustic injury; IVF, NPO, spit, broad-spectrum abx

103
Q

Treatment for noncontained perforations in the chest?

A

<24h from injury: primary repair with drains and intercostal muscle pedicle flap; for sick patients: cervical esophagostomy for diversiton, washout of mediastinum, chest tubes, later placement of feeding G/J tube and later esophagectomy and pull up

104
Q

What procedure is necessary to see full injury of esophagus?

A

Longitudinal myotomy

105
Q

How long do drains stay in place following repair of esophageal perforation?

A

Until pt taking good oral intake without increase in drainage from drains

106
Q

What is Boerhaave’s syndrome? Where is the perforation?

A

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

107
Q

What is Hartmann’s sign?

A

Mediastinal crunching on auscultation

108
Q

Diagnosis of Boerhaave’s? Treatment?

A

Gastrografin swallow; L. thoracotomy, longitudinal myotomy, primary repair, leave chest tubes

Fiser's ABSITE Review (50 decks)

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