Chapter 29: Esophagus Flashcards
1
Q
Layers of the esophagus
A
Mucosa (squamous epithelium), submucosa, and muscular propria (longitudinal muscle layer); no serosa
2
Q
Does the esophagus have serosa?
A
No
3
Q
Muscle: upper 1/3 esophagus
A
Striated muscle
4
Q
Muscle: middle 1/3 and lower 1/3 esophagus
A
Smooth muscle
5
Q
Major blood supply to the thoracic esophaugs
A
Vessels directly off the aorta are the major blood supply to the thoracic esophagus
6
Q
Artery: cervical esophagus
A
Supplied by the inferior thyroid artery
7
Q
Artery: abdominal esophagus
A
Supplied by left gastric and inferior phrenic arteries
8
Q
Venous drainage of the esophagus
A
Hema-Azygous and azygous veins in chest
9
Q
Lymphatics of esophagus
A
Upper 2/3 drains cephalad, lower 1/3 caudad
10
Q
Travels on posterior portion of stomach as it exits chest; becomes celiac plexus
A
Right vagus nerve
11
Q
Right vagus nerve: can cause persistently high acid levels postoperatively if left undivided after vagotomy
A
Criminal nerve of Grassi
12
Q
Travels on the anterior portion of stomach; goes to liver and biliary tree
A
Left vagus nerve
13
Q
Travels from right to left at T4-5 as it ascends mediastinum; inserts into left subclavian vein
A
Thoracic duct
14
Q
Where is the upper esophageal sphincter in relation to the incisors?
A
UES is 15cm from incisors
15
Q
Is the cricopharyngeus muscle (circular muscle, prevents air swallowing); recurrent laryngeal nerve innervation
A
Upper esophageal sphincter (UES)
16
Q
Normal UES pressure at rest
A
60 mmHg
17
Q
Normal UES pressure with food bolus
A
15 mmHg
18
Q
Most common site of esophageal perforation (usually occurs with EGD)
A
Cricopharyngeus muscle
19
Q
What causes aspiration with brainstem stroke?
A
Failure of cricopharyngeus to relax
20
Q
Where is lower esophageal sphincter in relation to incisors?
A
LES is 40 cm from incisors
21
Q
Relaxation mediated by inhibitory neurons; normally contracted at resting state (prevents reflux); is an anatomic zone of high pressure, not an anatomic sphincter
A
Lower esophageal sphincter (LES)
22
Q
Normal LES pressure at rest
A
15 mmHg
23
Q
Normal LES pressure with food bolus
A
0 mmHg
24
Q
Anatomic areas of esophageal narrowing
A
- Cricopharyngeus muscle
- Compression by the left mainstem bronchus and aortic arch
- Diaphragm
25
Swallowing stages
- Primary peristalsis: occurs with food bolus and swallow initiation
- Secondary peristalsis: occurs with incomplete emptying and esophageal distention; propagating waves
- Tertiary peristalsis: non-propagating, non-peristalsing (dysfunctional)
26
What initiates swallowing stages?
CNS initiates swallow
27
Normally contracted between meals
UES and LES
28
Swallowing mechanism
Soft palate occludes nasopharynx.
Larynx rises and airway opening is blocked by epiglottis.
Cricopharyngeus relaxes.
Pharyngeal contraction moves food into esophagus.
29
What relaxes soon after initiation of swallow?
LES - vagus mediated.
30
Surgical approach:
- Cervical esophagus
- Upper 2/3 thoracic
- Lower 1/3 thoracic
- Cervical: left
- Upper 2/3: right (avoids the aorta)
- Lower 1/3 thoracic: left (left-sided course in this region)
31
Causes hiccoughs
Gastric distention, temperature changes, ETOH, tobacco
32
Hiccough reflex arc
Vagus, phrenic, sympathetic chain T6-T12
33
Primary esophageal dysfunction
Achalasia, diffuse esophageal spasm, nutcracker esophagus
34
Secondary esophageal dysfunction
GERD (most common), scleroderma
35
Best test for heartburn (can visualize esophagitis)
Endoscopy
36
Best test for dysphagia or odynophagia (better at picking up masses)
Barium swallow
37
Dx / Tx: meat impaction
Endoscopy
38
- Trouble in transferring food from mouth to esophagus
| - Liquids worse than solids
Pharyngoesophageal disorders
39
What are pharyngoesophageal disorders most likely secondary to?
Most commonly neuromuscular disease - myasthenia gravis, muscular dystrophy, stroke
40
Can have upper esophageal web, iron deficiency anemia
| - Tx: dilation, iron, need to screen for oral cancer
Plummer-Vinson syndrome
41
Caused by increased pressure during swallowing
Zenker's diverticulum
42
What type of diverticulum is Zenker's?
Is a false diverticulum located posteriorly.
43
Where does Zenker's diverticulum occur?
Occurs between the pharyngeal constrictors and cricopharyngeus
44
What causes Zenker's diverticulum?
Caused by failure of the cricopharyngeus to relax
45
Symptoms: upper esophageal dysphagia, choking, halitosis
Zenker's diverticulum
46
Dx: Zenker's diverticulum
Barium swallow studies, manometry; risk for perforation with EGD and Zenker's
47
Tx: Zenker's diverticulum
Cricopharyngeal myotomy (key point); Zenker's itself can either be resected or suspended (removal of diverticula is not necessary)
48
Post op management of Zenker's diverticulum
Left cervical incision, leave drains in, esophagogram POD#1.
49
- Is a true diverticulum - usually lies lateral
- Due to inflammation, granulomatous disease, tumor.
- Usually found in the mid-esophagus
- Symptoms: regurgitation of undigested food, dysphagia
Traction diverticulum
50
Tx: traction diverticulum
Excision and primary closure if symptomatic, may need palliative therapy (i.e. XRT) if due to invasive CA; if asymptomatic, leave alone
51
- Rare, associated with esophageal motility disorders (e.g., achalasia)
- Most common in the distal 10 cm of the esophagus
- Most are asymptomatic; can have dysphagia and regurgitation
Epiphrenic diverticulum
52
Dx / Tx: epiphrenic diverticulum
Dx: esophagram and esophageal manometry
Tx: diverticulectomy and esophageal myotomy on the side opposite the diverticulectomy if symptomatic
53
Where are epiphrenic diverticulum most common?
Most common in the distal 10 cm of the esophagus
54
- Dysphagia, regurgitation, weight loss, respiratory symptoms
- Caused by lack of peristalsis and failure of LES to relax after food bolus
- Secondary to neuronal degeneration in muscle wall
Achalasia
55
What will manometry show in achalasia?
Increased LES pressure, incomplete LES relaxation, no peristalsis
56
Can get tortuous dilated esophagus and epiphrenic diverticula; bird's beak appearance
Achalasia
57
Initial Medical Treatment: achalasia
Balloon dilatation of LES -> effective in 80%; nitrates, calcium channel blocker
58
Treatment for achalasia when medical treatment and dilation fail
Heller myotomy (left thoractomy, myotome of lower esophagus only; also need partial Nissen fundoplication
59
Organism producing similar symptoms as achalasia
T. cruzi
60
Chest pain, may have dysphagia; may have psychiatric history
Diffuse esophageal spasm
61
Manometry in diffuse esophageal spasm
Frequent strong non-peristaltic unorganized contractions, LES relaxes normally
62
Treatment: diffuse esophageal spasm
Calcium channel blocker, nitrates; Heller myotomy if those fail (myotomy of upper and lower esophagus)
63
What is a Heller myotomy?
procedure in which muscles of the cardia are cut (lower esophageal sphincter)
64
What is surgery more effective for achalasia or diffuse esophageal spasm?
Surgery usually less effective for diffuse esophageal spasm than for achalasia
65
Chest pain and dysphagia
Manometry: high-amplitude peristaltic contractions; LES relaxes normally
Nutcracker esophagus
66
Treatment: nutcracker esophagus
Calcium channel blocker, nitrates; Heller myotomy if those fail (myotomy of upper and lower esophagus)
67
Manometry: nutcracker esophagus
High-amplitude peristaltic contractions; LES relaxes normally
68
Fibrous replacement of esophageal smooth muscle
Causes dysphagia and loss of LES tone with massive reflux and strictures
Scleroderma
69
Tx: scleroderma
Esophagectomy if severe
70
Normal anatomic protection from GERD
Need LES competence, normal esophageal body, normal gastric reservoir
71
What causes GERD?
Caused by increased acid exposure to esophagus from loss of gastroesophageal barrier
72
Get heartburn symptoms 30-60 minutes after meals; worse with lying down
Can also have asthma symptoms (cough), choking, aspiration
GERD
73
What do you worry about with dysphagia / odynophagia?
Need to worry about tumors
74
What do you worry about with bloating?
Suggest aerophagia and delayed gastric emptying
Dx: gastric empything study
75
What do you worry about with epigastric pain?
Suggests peptic ulcer, tumor
76
Failure of PPI in GERD despite escalating doses (give it 3-4 weeks) -> ___?
Need diagnostic studies
77
Dx: GERD
pH probe (best test), endoscopy, histology, manometry (resting LES
78
Surgical indications in GERD
failure of medical treatment, avoidance lifetime meds, young patients
79
Tx: GERD
Nissen fundoplication
80
What is a Nissen fundoplication?
Divide short gastrics, pull esophagus into abdomen, approximate crura, 270- (partial) or 360-degree gastric fundus wrap
81
What is the phrenoesophageal membrane an extension of?
Transversalis fascia
82
Key maneuver for wrap in Nissen fundoplication
Left crura
83
Complications Nissen fundoplication
Injury to spleen, diaphragm, esophagus, or pneumothorax
84
Treatment for GERD with approach going through chest
Belsey approach
85
What is Collis gastroplasty?
When not enough esophagus exists to pull down into abdomen, can staple along stomach cardia and create a "new" esophagus (neo-esophagus)
86
Most common cause of dysphagia following Nissen
Wrap is too tight
87
Hiatal Hernia: sliding hernia from dilation of hiatus (most common); associated with GERD
Type 1 Hiatal hernia
88
Hiatal Hernia: paraesophageal; hole in the diagphragm alongside the esophagus, normal GE junction
Symptoms: chest pain, dysphagia, early satiety
Type 2 Hiatal Hernia
89
Hiatal Hernia: combined Type 1 and type 2
Type 3: sliding hernia from dilation of hiatus; paraesopageal (hole in the diaphragm)
90
Hiatal Hernia: entire stomach in the chest plus another organ (i.e. colon, spleen)
Type 4 hiatal hernia
91
Why do you need Nissen with type 2 hiatal hernia?
Still need Nissen as diaphragm repair can affect LES; also helps anchor stomach
92
Hiatal hernia: usually need repair -> high risk of incarceration; may want to avoid repair in the elderly and frail
Paraesophageal hernia (type 2)
93
- Almost all patients have an associated sliding hiatal hernia
- Symptoms: dysphagia
Tx: dilation of the ring and PPI usually sufficient, do not resect
Schatzki's ring
94
- Squamous metaplasia to columnar epithelium
| - Occurs with long-standing exposure to gastric reflux
Barret's esophagus
95
Cancer risk in Barrett's esophagus
Cancer risk increased 50 times (adenocarcinoma)
96
Treatment: severe Barrett's dysplasia
Indication for esophagectomy
97
Treatment uncomplicated Barrett's esophagus
Indication for esophagectomy
98
How does surgery affect cancer risk in Barrett's esophagus?
Surgery will decrease esophagitis and further metaplasia but will not prevent malignancy or cause regression of the columnar lining
99
Follow up for Barrett's esophagus
Need careful follow-up with EGD for lifetime, even after Nissen
100
Malignancy potential of esophageal cancer
Esophageal tumors are almost always malignant; early invasion of nodes
101
How does esophageal cancer spread?
Spreads quickly along submucosal lymphatic channels
102
Symptoms: dysphagia (especially solids), weight loss
Risk factors: ETOH, tobacco, achalasia, caustic injury, nitrosamines
Esophageal cancer
103
Dx: esophageal cancer
Esophagram (best test for dysphagia)
104
When is esophageal cancer considered unresectable?
Hoarseness (RLN invasion), Horner's syndrome (Brachial plexus invasion), phrenic nerve invasion, malignant pleural effusion, malignant fistula, airway invasion, vertebral invasion
105
Best single test to evaluate for resectability in esophageal cancer
Chest and abdominal CT is the best single test for resectability
106
#1 esophageal cancer
Adenocarcinoma (not squamous)
107
Esophageal cancer:
- Usually in lower 1/3 of esophagus
- Liver metastases most common
Adenocarcinoma
108
Esophageal cancer:
- Usually in upper 2/3 of esophagus
- Lung metastases most common
Squamous cell carcinoma
109
Esophageal cancer: what if there is nodal disease outside the area of resection (i.e. supraclavicular or celiac nodes - M1 disease)?
Contraindication to esophagectomy
110
Esophageal cancer: may downstage tumors and make them resectable
Pre-op chemo-XRT
111
Rates of mortality and cure in esophagectomy for esophageal cancer
5% mortality from surgery; curative in 20%
112
Primary blood supply to stomach after replacing esophagus (have to divide left gastric and short gastrics)
Right gastroepiploic artery
113
Approaches to esophagectomy
Transhiatal approach
Ivor Lewis
3-hole esophagectomy
- Consider colonic interposition in young patients
114
What is the transhiatal approach to esophagectomy?
Abdominal and neck incisions; bluntly dissect intrathoracic esophagus; may have decreased mortality from esophageal leaks with cervical anastomosis
115
What is the Ivor Lewis approach to esophagectomy?
Abdominal incision and right thoracotomy -> exposes all of the intrathoracic esophagus; intrathoracic anastomosis
116
Incisions for 3-hole esophagectomy
Abdominal, thoracic, and cervical incisions
117
What do you need to do in addition to the transhiatal, Ivor Lewis and 3-hole esophagectomy approaches to esophagectomy?
Need pyloromyotomy with these procedures
118
When would you consider colonic interposition for esophagectomy?
May be choice in young patients when you want to preserve gastric function; 3 anastomoses required; blood supply depends on colon marginal vessels
119
Follow up of esophagectomy post op
Need contrast study on post day 7 to rule out leak
120
Treatment of postoperative strictures s/p esophagectomy
Most can be dilated
121
Chemotherapy for esophageal cancer
5-FU and cisplatin (for node-positive disease or use pre-op to shrink tumors)
122
May help downstage esophageal tumors
XRT
123
Mortality rate of malignant fistulas in esophageal cancer
Most die within 3 months due to aspiration
124
Tx: malignant fistula in esophageal cancer
Esophageal stent for palliation
125
Most common benign esophageal tumor; located in muscularis propr.
Symptoms: dysphagia; usually in lower 2/3 of esophagus (smooth muscle cells)
Leiomyoma
126
Dx: leiomyoma
Esophagram, endoscopic US (EUS), CT scan (need to rule out CA)
127
Why would you never biopsy a leiomyoma?
Do not biopsy -> can form scar and make subsequent resection difficult
128
Tx: leiomyoma
> 5 cm or symptomatic -> excision (enucleation) via thoractomy
129
Symptoms: dysphagia, hematemesis
2nd most common benign tumor of the esophagus; usually in the cervical esophagus
Esophageal polyps
130
Management: esophageal polyps
Small lesions can be resected with endoscopy; larger lesions require cervical incision
131
Emergent management of caustic esophageal injury.
No NGT.
Do not induce vomiting.
Nothing to drink.
132
How do alkali cause caustic injury to esophagus?
Causes deep liquefaction necrosis, especially liquid (e.g., Drano)
- Worse injury than acid; more likely to cause cancer
133
How do acids cause caustic injury to the esophagus?
Causes coagualtion necrosis; mostly causes gastric injury
134
Imaging studies in suspected caustic esophageal injury
Chest and abdominal CT scan to look for free air and signs of perforation
- Endoscopy to assess lesion (do not use with suspected perforation and do not go past a site of severe injury)
135
What is important to remember during endoscopy for caustic esophageal injury?
Do not use with suspected perforation and do not go past a site of severe injury.
136
What is required in management of caustic esophageal injury?
Serial exams and plain films required.
137
Caustic esophageal injuries: degree of injury
- Primary burn: hyperemia
- Secondary burn: ulcerations, exudates and sloughing
- Tertiary burn: deep ulcers, charring, and lumen narrowing
138
Treatment: primary burn in caustic esophageal injury
Tx: observation and conservative therapy
Conservative: IVFs, spitting, antibiotics, oral intake after 3-4 days; may need future serial dilation for strictures (usually cervical)
Can also get shortening of esophagus with GERD (tx: PPI)
139
Treatment: secondary burn in caustic esophageal injury
Tx: prolonged observation and conservative therapy.
Conservative: IVFs, spitting, antibiotics, oral intake after 3-4 days; may need future serial dilation for strictures (usually cervical)
140
Indications for esophagectomy in secondary burn caustic esophageal injury
Sepsis, peritonitis, mediastinitis, free air, mediastinal or stomach wall air, crepitant, contrast extravasation, pneumothorax, large effusion
141
Treatment: tertiary burn in caustic esophageal injury
Tx: observation and conservative treatment. Conservative: IVFs, spitting, antibiotics, oral intake after 3-4 days; may need future serial dilation for strictures (usually cervical)
Esophagectomy is usually necessary
142
When is the alimentary tract restored in tertiary burn from caustic esophageal injury?
Alimentary tract not restored until after patient recovers from the caustic injury
143
Treatment: caustic esophageal perforations
Require esophagectomy (are not repaired due to extensive damage)
144
What are the usual cause of esophageal perforations?
Usually the result of EGD
145
Most common site of esophageal perforation
Cervical esophagus near cricopharyngeus muscle
146
Symptoms: pain, dysphagia, tachycardia
Esophageal perforation
147
Dx: esophageal perforation
CXR initially (look for free air); Gastrograffin swallow followed by barium swallow
148
Criteria for nonsurgical management of esophageal perforation
Contained perforation by contrast, self-draining, no systemic effects
Conservative tx: IVFs, NPO, spit, broad-spectrum antibiotics
149
Non-contained esophageal perforations: management if quick to diagnose (
Primary repair with drains.
Need longitudinal myotomy to see the full extent of the injury. Consider muscle flaps (e.g. intercostal) to cover repair
150
Non-contained esophageal perforations: management if late to diagnose (>48hrs) or area has extensive contamination
- Neck: just place drains (no esophagectomy)
- Chest: need 1) resection (esophagectomy, cervical esophagostomy) or 2) exclusion and diversion (cervical esophagostomy, staple across distal esophagus, washout mediastinum, place chest tube - late esophagectomy at time of gastric replacement)
- Gastric replacement of esophagus late when patient fully recovers.
151
May be needed for any esophageal perforation (contained or non-contained) in patients with severe intrinsic disease (e.g. burned out esophagus form achalasia, esophageal CA)
Esophagectomy
152
Forceful vomiting followed by chest pain
Highest mortality of all esophageal perforation - early diagnosis and treatment improve survival
Boerhaave's syndrome
153
Where is perforation in Boerhaave's syndrome most likely to occur?
In the left lateral wall of esophagus, 3-5 cm above the GE junction
154
Mediastinal crunching on auscultation
Hartmann's sign
155
Dx / Tx: boerhaave's syndrome
Dx: gastrograffin swallow
Tx: same for other esophageal perforation
156
Highest mortality of all esophageal perforations
Boerhaave's syndrome: early diagnosis and treatment improves survival
157
Non-contained esophageal perforations: management if late to diagnose (>48hrs) or area has extensive contamination
- Neck
Just place drains (no esophagectomy)
Gastric replacement of esophagus late when patient fully recovers.
158
Non-contained esophageal perforations: management if late to diagnose (>48hrs) or area has extensive contamination
- Chest
1) 1) resection (esophagectomy, cervical esophagostomy)
or
2) exclusion and diversion (cervical esophagostomy, staple across distal esophagus, washout mediastinum, place chest tube - late esophagectomy at time of gastric replacement)
Gastric replacement of esophagus late when patient fully recovers.
