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Fiser's ABSITE Ryan SHORT > 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

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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6
Q

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

A

Cricopharyngeus muscle

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7
Q

How far from the incisors is the lower esophageal sphincter?

A

40 cm

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8
Q

What mediates relaxation of the LES?

A

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

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9
Q

What is the normal LES pressure at rest?

A

10 to 20 mmHg

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10
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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11
Q

What is the normal esophageal pressures with food bolus?

A

70 - 120 mmHg

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12
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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13
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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14
Q

What causes hiccups?

A

Gastric distention, temperature changes, EtOH, tobacco

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15
Q

What is the reflex arc of hiccups?

A

Vagus, phrenic, sympathetic chain T6 - 12

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16
Q

What are primary and secondary causes of esophageal dysfunction?

A

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

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17
Q

What is the most common cause of esophageal dysfunction?

A

Gerd

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18
Q

What is the procedure of choice for heartburn?

A

Endoscopy

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19
Q

What is the procedure of choice for dysphasia and Odynophasia?

A

Barium swallow, better at picking up masses

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20
Q

What is the diagnosis and treatment for meat impaction?

A

Endoscopy

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21
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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22
Q

What causes cervical esophageal dysphasia?

A

Plumber – Vinson syndrome, usually due to web

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23
Q

What is the treatment for Plumber – Vinson syndrome?

A

Dilation, iron, need to screen for oral cancer

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24
Q

What causes Zenker’s diverticulum? Where?

A

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

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25
Symptoms of Zenker's diverticulum? Diagnosis?
Upper esophageal dysphasia, choking, halitosis; barium swallow studies, manometry, risk for perforation with EGD
26
Treatment for Zenker's diverticulum?
Cricopharyngeal myotomy, Zenker's itself can either be resected or suspended; via left cervical incision, leave drains in, esophagram postop day 1
27
What is a traction diverticulum? Causes?
True diverticulum, usually lies lateral in midesophagus; due to inflammation, granulomatous disease, tumor
28
What are the symptoms of traction diverticulum? Treatment?
Regurgitation of undigested food, dysphagia; excision and primary closure, may need palliative therapy if due to invasive cancer
29
What is an epiphrenic diverticulum? Where is it found?
Associated with esophageal motility disorders, most commonly in the distal 10 cm of the esophagus
30
Diagnosis of epiphrenic diverticulum? Treatment?
Esophagram and esophageal manometry; diverticulectomy and long esophageal myotomy on the side opposite the diverticulectomy
31
What causes achalasia? Symptoms?
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
32
Diagnosis of achalasia?
Manometry – high LES pressure, incomplete LES relaxation, no peristalsis; bird beak appearance
33
Treatment for achalasia?
Calcium channel blocker, LES dilation (effective in 60%), nitrates; if medical treatment fails – Heller myotomy and partial Nissen fundoplication
34
What bacteria can produce similar symptoms to achalasia?
T. cruzi
35
Symptoms of diffuse esophageal spasm? Associated with?
Chest pain, other symptoms similar to achalasia; psychiatric history
36
Diagnosis of diffuse esophageal spasm?
Manometry – frequent strong body contractions of high amplitude and duration, normal LES tone, strong and organized contractions
37
Treatment for diffuse esophageal spasm?
Calcium channel blocker, nitrates, anti-spasmodics, Heller myotomy; treatment usually less effective for diffuse esophageal spasm than for achalasia
38
What are the symptoms of scleroderma of the esophagus? Treatment?
Dysphasia, loss of LES tone, most have strictures, fibrous replacement of smooth muscle; esophagectomy
39
What is the normal anatomic protection from Gerd?
LES competence, normal esophageal body, normal gastric reservoir
40
Symptoms of GERD?
Heartburn 30-60m after meals, asthma (cough), choking, PNA; worse symptoms when lying down
41
Dx of GERD?
Endoscopy, pH probe (best test), manomentry, histology
42
Tx for GERD?
Medical tx 1st: omeprazole for 12 weeks; surgical tx 2nd.
43
Indications for surgery for GERD?
GERD on pH monitoring, failure of medical tx, complications (stricture, Barrett's, cancer)
44
Surgical treatment for GERD?
Nissen: divide short gastrics, pull esophagus into abdomen, repair defect in phrenoesophageal membrane, fundal wrap
45
What is the key maneuver during Nissen?
Left cura
46
Complications from Nissen?
Injury to spleen, diaphragm, esophagus or pneumothorax
47
What maneuver necessary if there is not enough esophagus to pull down into the abdomen?
Collis gastroplasty; staple along stomach and create a "new" esophagus
48
Most common cause of dysphagia following Nissen?
Wrap is too tight
49
What is a type I hiatal hernia?
Sliding hernia from dilation of hiatus (most common); often associated with GERD
50
What is a type II hiatal hernia?
Paraesophageal; hole in the diaphragm alongside the esophagus with herniation of fundus, normal GE junction
51
What is a type III hiatal hernia?
Combined, GE junction in chest, herniation of stomach
52
What is a type IV hiatal hernia?
Entire stomach + another organ in chest
53
Timing of repair of paraesophageal hernias?
Type II-IV; all need repair, high risk of incarceration
54
What condition is associated with Schatzki's ring?
Sliding hiatal hernia
55
Symptoms of Schatzki's ring?
Short episodes of dysphagia following rapid swallowing
56
Treatment of Schatzki's ring?
Dilation of the ring usually sufficient; may need antireflux procedure
57
What is Barrett's esophagus?
Squamous metaplasia to columnar epithelium
58
What is the risk of cancer with Barrett's/
Risk of adenocarcinoma increased 50x
59
Treatment for Barrett's?
Uncomplicated: like GERD (PPI, Nissen), surgery witll dec. esophagitis but will not prevent malignancy; Complicated: indication for esophagectomy
60
What is the route of spread of esophageal ca?
Spreads quickly along submucosal lymphatic channels
61
Symptoms of esophageal ca?
Difficulty swallowing solids, dysphagia, weight loss
62
Risk factors for esophageal ca?
Achalasia, caustic injury, ETOH, tobacco, nitrosamides
63
Diagnosis of esophageal ca?
Esophagram (for pts with dysphagia, odynophagia, suspected mass lesions)
64
What makes esophageal ca unresectable?
Hoarseness (RLN), Horner's syndrome, phrenic nerve involvement, malignant pleural effusion, malignant fistula, airway invasion, vertebral invasion (CT chest for diagnosis of unresectability)
65
What is the #1 cancer of the esophagus?
Adenocarcinoma; occurs in lower 1/3
66
Where do distant mets from esophageal cancer go?
Lung or liver; contraindication to esophagectomy
67
What nodal groups indicate unresectable disease?
Supraclavicular, nodal disease outside the area of resection; preoperative XRT and chemo may downstage tumors and make them resectable
68
What is the mortality of esophagectomy? What is the cure rate?
Mortality: 5%, cure rate: 20%
69
What is the primary blood supply to the stomach after replacing the esophagus?
Right gastroepiploic artery
70
What are the incisions with transhiatal approach? Benefit?
Abdominal and neck incisions, bluntly dissect intrathoracic esophagus; decreased mortality from esophageal leaks with cervical anastamosis
71
Incisions with Ivor Lewis?
Abdominal incision and right thoracotomy; exposes all of the esophagus; intrathoracic anastomosis
72
What additional procedure is necessary with esophagectomy?
Pyloromyotomy
73
What patients are candidates for colonic interposition?
Younger patients with benign disease where you want to preserve gastric function
74
Treatment for postop stricture?
Dilation
75
Chemo for esophageal cancer?
5FU and cisplatin
76
Role of XRT with esophageal cancer?
Proven to be effective both pre and postop
77
What is the cause of death with malignant fistulas?
Most die within 3 months due to aspiration
78
What is the most common benign tumor of the esophagus? Where is it located?
Leiomyoma; submucosal
79
Diagnosis of leiomyoma?
Esophagram, endoscopy to r/o cancer
80
Symptoms of leiomyoma?
Dysphagia, pain usually in lower 2/3 of esophagus
81
Are biopsies necessary with leiomyoma?
No, can form scar and make subsequent resection difficult
82
Treatment for leiomyoma?
>5cm or symptomatic: excision (enucleation) via thoracotomy
83
Symptoms of esophageal polyps?
Dysphagia, hematemesis
84
What is the 2nd most common benign tumor of the esophagus? Location?
Esophageal polyp; cervical esophagus
85
Treatment for esophageal polyp?
Small lesions can be resected with endoscopy; larger lesions require cervical incision
86
General principles of treatment for caustic esophageal injuries?
No NGT, do NOT induce vomiting, nothing to drink
87
Effects of alkali on the esophagus?
Deep liquefaction necrosis (Drano); causes worse injury than acid, also more likely to cause cancer
88
Acid effects on the esophagus?
Coagulation necrosis; mostly causes gastric injury
89
Imaging following caustic esophageal injury?
CXR and AXR to look for free air; endoscopy to assess lesion, do not go past site of injury
90
Definition of primary burn of esophagus? Treatment?
Hyperemia; observation and conservative therapy (IVF, spitting, abx, oral intake after 3-4d, may need future serial dilation for strictures
91
Definition of secondary burn? Treatment?
Ulcerations, exudates, sloughing; prolonged observation and conservative therapy
92
Indications for surgery for secondary burn?
Sepsis, peritonitis, persistent back and chest pain, metabolic acidosis, mediastinitis, free air, mediastinal air, crepitance, contrast extravasation, pneumothorax, effusion, air in stomach wall
93
Definition of tertiary burn? Treatment?
Deep ulcers, charring, lumen narrowing; conservative treatment, esophagectomy usually necessary
94
What is the most common cause of esophageal perforation? Most common location?
EGD; near cricopharyngeus muscle
95
Symptoms of esophageal perforation?
Pain, dysphagia, respiratory distress, fever, tachycardia
96
Criteria for nonsurgical management of esophageal perforation?
Contained perforation by contrast, self-draining, no systemic effects
97
What is conservative management for esophageal perforations?
No NGT with caustic injury; IVF, NPO, spit, broad-spectrum abx
98
Treatment for noncontained perforations in the chest?
<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
99
What procedure is necessary to see full injury of esophagus?
Longitudinal myotomy
100
How long do drains stay in place following repair of esophageal perforation?
Until pt taking good oral intake without increase in drainage from drains
101
What is Boerhaave's syndrome? Where is the perforation?
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
102
What is Hartmann's sign?
Mediastinal crunching on auscultation
103
Diagnosis of Boerhaave's? Treatment?
Gastrografin swallow; L. thoracotomy, longitudinal myotomy, primary repair, leave chest tubes

Fiser's ABSITE Ryan SHORT (50 decks)

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