Diseases of the esophagus- KS's notes

Question 1

Esophageal motility disorders often present with

Answer 1

dysphagia, heartburn, or chest pain

Question 2

Achalasia is a

Answer 2

neuromuscular disorder of the esophagus

esophageal outflow obstruction d/t inadequate relaxation of the LES and dilated hypomotile esophagus

Question 3

Achalasia is the result of

Answer 3

degenerative neuronal disease or infection

Question 4

With achalasia, unopposed ____ stimulation of the lower esophageal sphincter exists

Answer 4

cholinergic; fails to relax

Question 5

Symptoms of achalasia include

Answer 5

dysphagia, heartburn, and chest pain

pulmonary aspiration is common

Question 6

Diagnosis of achalasia is from

Answer 6

esophagram reveals “bird’s beak” appearance, EGD, esophageal manometry

Question 7

Describe the three types of achalasia.

Answer 7

type 1 (classic)- minimal esophageal pressurization, better outcome 
type 2: pressurization of entire esophagus, best outcome regardless of treatment
Type 3: esophageal spasm with premature contractions, worst outcome

Question 8

Treatment for achalasia includes

Answer 8

palliative
can relieve obstruction but can’t correct lack of peristalsis
calcium channel blockers used to relax LES
POEM procedure- takes out the circular layer of the LES but leaves the longitudinal muscle intact. biggest risk is pneumothorax

Question 9

Patients with achalasia undergoing surgery have a high risk of

Answer 9

perioperative aspiration- require RSI or awake intubation

esophagus may retain food for DAYS after ingestion

Question 10

Describe distal esophageal spasm.

Answer 10

diffuse esophageal spasm due to autonomic nervous system dysfunction

Question 11

Diagnosis of distal esophageal spasm is typically via

Answer 11

esophagram shows “corkscrew” or “rosary bead” esophagus

-occurs in elderly

Question 12

Symptoms of distal esophageal spasm include

Answer 12

pain mimics angina, responds favorably to nitroglycerin

Question 13

Treatment of distal esophageal spasm includes

Answer 13

nitroglycerin, trazadone, imipramide, and sildenafil

Question 14

Describe GERD

Answer 14

causes mucosal injury in the esophagus/extraesophageal sites

Question 15

The most common symptoms of GERD are

Answer 15

heartburn and regurgitation, less common include dysphagia & chest pain

Question 16

Describe the pathophysiology of GERD.

Answer 16

LES incompetence

1. transient LES relaxation (caused by gastric distension)
2. LES hypotension (resting tone <13 mmHg, normal is 29)
3. Anatomic distortion of GE junction such as hiatal hernia

Question 17

Reflux contents in GERD can include

Answer 17

HCl, pepsin, pancreatic enzymes, and bile

Bile causes Barrett’s metaplasia and adenocarcinoma

Question 18

Complications of GERD include

Answer 18

chronic peptic esophagitis (causes heartburn)
esophagitis
strictures
ulcers
Barrett’s metaplasia, associated with adenocarcinoma
reflux into pharynx, larynx, tracheobronchial tree
aspiration–> pulmonary fibrosis, chronic asthma

Question 19

Treatment for GERD includes

Answer 19

lifestyle modification–> avoiding foods that reduce LES tone (fat, alcohol, peppermint, chocolate), avoiding acidic foods
pharmacologic treatment–> PPI, increase pH which allows esophagus to heal; H2 antagonists but PPIs are better
Surgery: Nissen fundoplication- wrap around the proximal stomach around the distal esophagus

Question 20

Perioperative management of the patient with GERD includes

Answer 20

sodium citrate given to pregnant/morbidly obese patients
large aspiration risk- volume must 25 mL and pH<2.5
RSI may be necessary
need ETT

Question 21

Describe esophageal diverticula.

Answer 21

outpouchings of the wall of the esophagus

Question 22

The most common locations of esophageal diverticula are the

Answer 22

pharyngoesophageal (Zenker’s Diverticulum), midesophageal, and epiphrenic

Question 23

For patients with esophageal diverticula it is important to

Answer 23

avoid NG tube insertion– risk of perf
TEE could end up in the diverticulum
pouch can be emptied by patient exerting external pressure

Question 24

A hiatal hernia occurs when

Answer 24

a part of the stomach herniates into the thoracic cavity through the esophageal hiatus of the diaphragm
may be caused by weakening of the anchors at the GE junction to the diaphragm

Question 25

Symptoms of hiatal hernia include

Answer 25

asymptomatic most of the time because LES is still good

Question 26

Esophageal tumors present with

Answer 26

progressive dysphagia to solid food and weight loss

poor survival rate b/c tons of lymph node metastasis

Question 27

Treatment for esophageal tumors include

Answer 27

esophagectomy (curative or palliative) mortality rate about 50%
-complications include ARDS

Question 28

Anesthetic considerations for the patient with esophageal tumors include

Answer 28

patients are usually malnourished & dehydrated
risk of recurrent laryngeal nerve injury
thoracic epidural good choice