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ABSITE (EVAN) > Chapter 29: Esophagus > Flashcards

Chapter 29: Esophagus Flashcards

1
Q

Layers of the esophagus

A

Mucosa (squamous epithelium), submucosa, and muscular propria (longitudinal muscle layer); no serosa

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2
Q

Does the esophagus have serosa?

A

No

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3
Q

Muscle: upper 1/3 esophagus

A

Striated muscle

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4
Q

Muscle: middle 1/3 and lower 1/3 esophagus

A

Smooth muscle

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5
Q

Major blood supply to the thoracic esophaugs

A

Vessels directly off the aorta are the major blood supply to the thoracic esophagus

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6
Q

Artery: cervical esophagus

A

Supplied by the inferior thyroid artery

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7
Q

Artery: abdominal esophagus

A

Supplied by left gastric and inferior phrenic arteries

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8
Q

Venous drainage of the esophagus

A

Hema-Azygous and azygous veins in chest

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9
Q

Lymphatics of esophagus

A

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

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10
Q

Travels on posterior portion of stomach as it exits chest; becomes celiac plexus

A

Right vagus nerve

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11
Q

Right vagus nerve: can cause persistently high acid levels postoperatively if left undivided after vagotomy

A

Criminal nerve of Grassi

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12
Q

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

A

Left vagus nerve

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13
Q

Travels from right to left at T4-5 as it ascends mediastinum; inserts into left subclavian vein

A

Thoracic duct

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14
Q

Where is the upper esophageal sphincter in relation to the incisors?

A

UES is 15cm from incisors

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15
Q

Is the cricopharyngeus muscle (circular muscle, prevents air swallowing); recurrent laryngeal nerve innervation

A

Upper esophageal sphincter (UES)

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16
Q

Normal UES pressure at rest

A

60 mmHg

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17
Q

Normal UES pressure with food bolus

A

15 mmHg

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18
Q

Most common site of esophageal perforation (usually occurs with EGD)

A

Cricopharyngeus muscle

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19
Q

What causes aspiration with brainstem stroke?

A

Failure of cricopharyngeus to relax

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20
Q

Where is lower esophageal sphincter in relation to incisors?

A

LES is 40 cm from incisors

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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)

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22
Q

Normal LES pressure at rest

A

15 mmHg

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23
Q

Normal LES pressure with food bolus

A

0 mmHg

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24
Q

Anatomic areas of esophageal narrowing

A
  • Cricopharyngeus muscle
  • Compression by the left mainstem bronchus and aortic arch
  • Diaphragm
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25
Q

Swallowing stages

A
  • 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)
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26
Q

What initiates swallowing stages?

A

CNS initiates swallow

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27
Q

Normally contracted between meals

A

UES and LES

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28
Q

Swallowing mechanism

A

Soft palate occludes nasopharynx.
Larynx rises and airway opening is blocked by epiglottis.
Cricopharyngeus relaxes.
Pharyngeal contraction moves food into esophagus.

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29
Q

What relaxes soon after initiation of swallow?

A

LES - vagus mediated.

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30
Q

Surgical approach:

  • Cervical esophagus
  • Upper 2/3 thoracic
  • Lower 1/3 thoracic
A
  • Cervical: left
  • Upper 2/3: right (avoids the aorta)
  • Lower 1/3 thoracic: left (left-sided course in this region)
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31
Q

Causes hiccoughs

A

Gastric distention, temperature changes, ETOH, tobacco

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32
Q

Hiccough reflex arc

A

Vagus, phrenic, sympathetic chain T6-T12

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33
Q

Primary esophageal dysfunction

A

Achalasia, diffuse esophageal spasm, nutcracker esophagus

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34
Q

Secondary esophageal dysfunction

A

GERD (most common), scleroderma

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35
Q

Best test for heartburn (can visualize esophagitis)

A

Endoscopy

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36
Q

Best test for dysphagia or odynophagia (better at picking up masses)

A

Barium swallow

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37
Q

Dx / Tx: meat impaction

A

Endoscopy

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38
Q
  • Trouble in transferring food from mouth to esophagus

- Liquids worse than solids

A

Pharyngoesophageal disorders

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39
Q

What are pharyngoesophageal disorders most likely secondary to?

A

Most commonly neuromuscular disease - myasthenia gravis, muscular dystrophy, stroke

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40
Q

Can have upper esophageal web, iron deficiency anemia

- Tx: dilation, iron, need to screen for oral cancer

A

Plummer-Vinson syndrome

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41
Q

Caused by increased pressure during swallowing

A

Zenker’s diverticulum

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42
Q

What type of diverticulum is Zenker’s?

A

Is a false diverticulum located posteriorly.

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43
Q

Where does Zenker’s diverticulum occur?

A

Occurs between the pharyngeal constrictors and cricopharyngeus

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44
Q

What causes Zenker’s diverticulum?

A

Caused by failure of the cricopharyngeus to relax

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45
Q

Symptoms: upper esophageal dysphagia, choking, halitosis

A

Zenker’s diverticulum

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46
Q

Dx: Zenker’s diverticulum

A

Barium swallow studies, manometry; risk for perforation with EGD and Zenker’s

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47
Q

Tx: Zenker’s diverticulum

A

Cricopharyngeal myotomy (key point); Zenker’s itself can either be resected or suspended (removal of diverticula is not necessary)

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48
Q

Post op management of Zenker’s diverticulum

A

Left cervical incision, leave drains in, esophagogram POD#1.

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49
Q
  • 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
A

Traction diverticulum

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50
Q

Tx: traction diverticulum

A

Excision and primary closure if symptomatic, may need palliative therapy (i.e. XRT) if due to invasive CA; if asymptomatic, leave alone

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51
Q
  • 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
A

Epiphrenic diverticulum

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52
Q

Dx / Tx: epiphrenic diverticulum

A

Dx: esophagram and esophageal manometry

Tx: diverticulectomy and esophageal myotomy on the side opposite the diverticulectomy if symptomatic

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53
Q

Where are epiphrenic diverticulum most common?

A

Most common in the distal 10 cm of the esophagus

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54
Q
  • 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
A

Achalasia

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55
Q

What will manometry show in achalasia?

A

Increased LES pressure, incomplete LES relaxation, no peristalsis

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56
Q

Can get tortuous dilated esophagus and epiphrenic diverticula; bird’s beak appearance

A

Achalasia

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57
Q

Initial Medical Treatment: achalasia

A

Balloon dilatation of LES -> effective in 80%; nitrates, calcium channel blocker

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58
Q

Treatment for achalasia when medical treatment and dilation fail

A

Heller myotomy (left thoractomy, myotome of lower esophagus only; also need partial Nissen fundoplication

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59
Q

Organism producing similar symptoms as achalasia

A

T. cruzi

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60
Q

Chest pain, may have dysphagia; may have psychiatric history

A

Diffuse esophageal spasm

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61
Q

Manometry in diffuse esophageal spasm

A

Frequent strong non-peristaltic unorganized contractions, LES relaxes normally

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62
Q

Treatment: diffuse esophageal spasm

A

Calcium channel blocker, nitrates; Heller myotomy if those fail (myotomy of upper and lower esophagus)

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63
Q

What is a Heller myotomy?

A

procedure in which muscles of the cardia are cut (lower esophageal sphincter)

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64
Q

What is surgery more effective for achalasia or diffuse esophageal spasm?

A

Surgery usually less effective for diffuse esophageal spasm than for achalasia

65
Q

Chest pain and dysphagia

Manometry: high-amplitude peristaltic contractions; LES relaxes normally

A

Nutcracker esophagus

66
Q

Treatment: nutcracker esophagus

A

Calcium channel blocker, nitrates; Heller myotomy if those fail (myotomy of upper and lower esophagus)

67
Q

Manometry: nutcracker esophagus

A

High-amplitude peristaltic contractions; LES relaxes normally

68
Q

Fibrous replacement of esophageal smooth muscle

Causes dysphagia and loss of LES tone with massive reflux and strictures

A

Scleroderma

69
Q

Tx: scleroderma

A

Esophagectomy if severe

70
Q

Normal anatomic protection from GERD

A

Need LES competence, normal esophageal body, normal gastric reservoir

71
Q

What causes GERD?

A

Caused by increased acid exposure to esophagus from loss of gastroesophageal barrier

72
Q

Get heartburn symptoms 30-60 minutes after meals; worse with lying down

Can also have asthma symptoms (cough), choking, aspiration

73
Q

What do you worry about with dysphagia / odynophagia?

A

Need to worry about tumors

74
Q

What do you worry about with bloating?

A

Suggest aerophagia and delayed gastric emptying

Dx: gastric empything study

75
Q

What do you worry about with epigastric pain?

A

Suggests peptic ulcer, tumor

76
Q

Failure of PPI in GERD despite escalating doses (give it 3-4 weeks) -> ___?

A

Need diagnostic studies

77
Q

Dx: GERD

A

pH probe (best test), endoscopy, histology, manometry (resting LES

78
Q

Surgical indications in GERD

A

failure of medical treatment, avoidance lifetime meds, young patients

79
Q

Tx: GERD

A

Nissen fundoplication

80
Q

What is a Nissen fundoplication?

A

Divide short gastrics, pull esophagus into abdomen, approximate crura, 270- (partial) or 360-degree gastric fundus wrap

81
Q

What is the phrenoesophageal membrane an extension of?

A

Transversalis fascia

82
Q

Key maneuver for wrap in Nissen fundoplication

A

Left crura

83
Q

Complications Nissen fundoplication

A

Injury to spleen, diaphragm, esophagus, or pneumothorax

84
Q

Treatment for GERD with approach going through chest

A

Belsey approach

85
Q

What is Collis gastroplasty?

A

When not enough esophagus exists to pull down into abdomen, can staple along stomach cardia and create a “new” esophagus (neo-esophagus)

86
Q

Most common cause of dysphagia following Nissen

A

Wrap is too tight

87
Q

Hiatal Hernia: sliding hernia from dilation of hiatus (most common); associated with GERD

A

Type 1 Hiatal hernia

88
Q

Hiatal Hernia: paraesophageal; hole in the diagphragm alongside the esophagus, normal GE junction

Symptoms: chest pain, dysphagia, early satiety

A

Type 2 Hiatal Hernia

89
Q

Hiatal Hernia: combined Type 1 and type 2

A

Type 3: sliding hernia from dilation of hiatus; paraesopageal (hole in the diaphragm)

90
Q

Hiatal Hernia: entire stomach in the chest plus another organ (i.e. colon, spleen)

A

Type 4 hiatal hernia

91
Q

Why do you need Nissen with type 2 hiatal hernia?

A

Still need Nissen as diaphragm repair can affect LES; also helps anchor stomach

92
Q

Hiatal hernia: usually need repair -> high risk of incarceration; may want to avoid repair in the elderly and frail

A

Paraesophageal hernia (type 2)

93
Q
  • Almost all patients have an associated sliding hiatal hernia
  • Symptoms: dysphagia
    Tx: dilation of the ring and PPI usually sufficient, do not resect
A

Schatzki’s ring

94
Q
  • Squamous metaplasia to columnar epithelium

- Occurs with long-standing exposure to gastric reflux

A

Barret’s esophagus

95
Q

Cancer risk in Barrett’s esophagus

A

Cancer risk increased 50 times (adenocarcinoma)

96
Q

Treatment: severe Barrett’s dysplasia

A

Indication for esophagectomy

97
Q

Treatment uncomplicated Barrett’s esophagus

A

Indication for esophagectomy

98
Q

How does surgery affect cancer risk in Barrett’s esophagus?

A

Surgery will decrease esophagitis and further metaplasia but will not prevent malignancy or cause regression of the columnar lining

99
Q

Follow up for Barrett’s esophagus

A

Need careful follow-up with EGD for lifetime, even after Nissen

100
Q

Malignancy potential of esophageal cancer

A

Esophageal tumors are almost always malignant; early invasion of nodes

101
Q

How does esophageal cancer spread?

A

Spreads quickly along submucosal lymphatic channels

102
Q

Symptoms: dysphagia (especially solids), weight loss

Risk factors: ETOH, tobacco, achalasia, caustic injury, nitrosamines

A

Esophageal cancer

103
Q

Dx: esophageal cancer

A

Esophagram (best test for dysphagia)

104
Q

When is esophageal cancer considered unresectable?

A

Hoarseness (RLN invasion), Horner’s syndrome (Brachial plexus invasion), phrenic nerve invasion, malignant pleural effusion, malignant fistula, airway invasion, vertebral invasion

105
Q

Best single test to evaluate for resectability in esophageal cancer

A

Chest and abdominal CT is the best single test for resectability

106
Q

1 esophageal cancer

A

Adenocarcinoma (not squamous)

107
Q

Esophageal cancer:

  • Usually in lower 1/3 of esophagus
  • Liver metastases most common
A

Adenocarcinoma

108
Q

Esophageal cancer:

  • Usually in upper 2/3 of esophagus
  • Lung metastases most common
A

Squamous cell carcinoma

109
Q

Esophageal cancer: what if there is nodal disease outside the area of resection (i.e. supraclavicular or celiac nodes - M1 disease)?

A

Contraindication to esophagectomy

110
Q

Esophageal cancer: may downstage tumors and make them resectable

A

Pre-op chemo-XRT

111
Q

Rates of mortality and cure in esophagectomy for esophageal cancer

A

5% mortality from surgery; curative in 20%

112
Q

Primary blood supply to stomach after replacing esophagus (have to divide left gastric and short gastrics)

A

Right gastroepiploic artery

113
Q

Approaches to esophagectomy

A

Transhiatal approach
Ivor Lewis
3-hole esophagectomy
- Consider colonic interposition in young patients

114
Q

What is the transhiatal approach to esophagectomy?

A

Abdominal and neck incisions; bluntly dissect intrathoracic esophagus; may have decreased mortality from esophageal leaks with cervical anastomosis

115
Q

What is the Ivor Lewis approach to esophagectomy?

A

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

116
Q

Incisions for 3-hole esophagectomy

A

Abdominal, thoracic, and cervical incisions

117
Q

What do you need to do in addition to the transhiatal, Ivor Lewis and 3-hole esophagectomy approaches to esophagectomy?

A

Need pyloromyotomy with these procedures

118
Q

When would you consider colonic interposition for esophagectomy?

A

May be choice in young patients when you want to preserve gastric function; 3 anastomoses required; blood supply depends on colon marginal vessels

119
Q

Follow up of esophagectomy post op

A

Need contrast study on post day 7 to rule out leak

120
Q

Treatment of postoperative strictures s/p esophagectomy

A

Most can be dilated

121
Q

Chemotherapy for esophageal cancer

A

5-FU and cisplatin (for node-positive disease or use pre-op to shrink tumors)

122
Q

May help downstage esophageal tumors

123
Q

Mortality rate of malignant fistulas in esophageal cancer

A

Most die within 3 months due to aspiration

124
Q

Tx: malignant fistula in esophageal cancer

A

Esophageal stent for palliation

125
Q

Most common benign esophageal tumor; located in muscularis propr.

Symptoms: dysphagia; usually in lower 2/3 of esophagus (smooth muscle cells)

126
Q

Dx: leiomyoma

A

Esophagram, endoscopic US (EUS), CT scan (need to rule out CA)

127
Q

Why would you never biopsy a leiomyoma?

A

Do not biopsy -> can form scar and make subsequent resection difficult

128
Q

Tx: leiomyoma

A

> 5 cm or symptomatic -> excision (enucleation) via thoractomy

129
Q

Symptoms: dysphagia, hematemesis

2nd most common benign tumor of the esophagus; usually in the cervical esophagus

A

Esophageal polyps

130
Q

Management: esophageal polyps

A

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

131
Q

Emergent management of caustic esophageal injury.

A

No NGT.
Do not induce vomiting.
Nothing to drink.

132
Q

How do alkali cause caustic injury to esophagus?

A

Causes deep liquefaction necrosis, especially liquid (e.g., Drano)
- Worse injury than acid; more likely to cause cancer

133
Q

How do acids cause caustic injury to the esophagus?

A

Causes coagualtion necrosis; mostly causes gastric injury

134
Q

Imaging studies in suspected caustic esophageal injury

A

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
Q

What is important to remember during endoscopy for caustic esophageal injury?

A

Do not use with suspected perforation and do not go past a site of severe injury.

136
Q

What is required in management of caustic esophageal injury?

A

Serial exams and plain films required.

137
Q

Caustic esophageal injuries: degree of injury

A
  • Primary burn: hyperemia
  • Secondary burn: ulcerations, exudates and sloughing
  • Tertiary burn: deep ulcers, charring, and lumen narrowing
138
Q

Treatment: primary burn in caustic esophageal injury

A

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
Q

Treatment: secondary burn in caustic esophageal injury

A

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
Q

Indications for esophagectomy in secondary burn caustic esophageal injury

A

Sepsis, peritonitis, mediastinitis, free air, mediastinal or stomach wall air, crepitant, contrast extravasation, pneumothorax, large effusion

141
Q

Treatment: tertiary burn in caustic esophageal injury

A

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
Q

When is the alimentary tract restored in tertiary burn from caustic esophageal injury?

A

Alimentary tract not restored until after patient recovers from the caustic injury

143
Q

Treatment: caustic esophageal perforations

A

Require esophagectomy (are not repaired due to extensive damage)

144
Q

What are the usual cause of esophageal perforations?

A

Usually the result of EGD

145
Q

Most common site of esophageal perforation

A

Cervical esophagus near cricopharyngeus muscle

146
Q

Symptoms: pain, dysphagia, tachycardia

A

Esophageal perforation

147
Q

Dx: esophageal perforation

A

CXR initially (look for free air); Gastrograffin swallow followed by barium swallow

148
Q

Criteria for nonsurgical management of esophageal perforation

A

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

Conservative tx: IVFs, NPO, spit, broad-spectrum antibiotics

149
Q

Non-contained esophageal perforations: management if quick to diagnose (

A

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
Q

Non-contained esophageal perforations: management if late to diagnose (>48hrs) or area has extensive contamination

A
  • 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
Q

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)

A

Esophagectomy

152
Q

Forceful vomiting followed by chest pain

Highest mortality of all esophageal perforation - early diagnosis and treatment improve survival

A

Boerhaave’s syndrome

153
Q

Where is perforation in Boerhaave’s syndrome most likely to occur?

A

In the left lateral wall of esophagus, 3-5 cm above the GE junction

154
Q

Mediastinal crunching on auscultation

A

Hartmann’s sign

155
Q

Dx / Tx: boerhaave’s syndrome

A

Dx: gastrograffin swallow

Tx: same for other esophageal perforation

156
Q

Highest mortality of all esophageal perforations

A

Boerhaave’s syndrome: early diagnosis and treatment improves survival

157
Q

Non-contained esophageal perforations: management if late to diagnose (>48hrs) or area has extensive contamination
- Neck

A

Just place drains (no esophagectomy)

Gastric replacement of esophagus late when patient fully recovers.

158
Q

Non-contained esophageal perforations: management if late to diagnose (>48hrs) or area has extensive contamination
- Chest

A

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.

ABSITE (EVAN) (35 decks)

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