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Surgery > Dysphagia > Flashcards

Dysphagia Flashcards

1
Q

Achalasia

Pathogenesis

A

Oesophageal Motor Disorder

• Degeneration + loss of ganglion cells in auerbach plexus
− LOS not able to relax = raised resting pressure
− Loss of peristalsis in lower half of oesophagus = no waves of peristalstic waves = dilation

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2
Q

Achalasia

Diagnosis

A

• Barium swallow
− Stricture
− Smooth mucosa
− Progressive narrowing; achalasia (rat’s tail; birds beak)

• Mannometry
− Loss of peristalsis

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3
Q

Achalasia

Management

A

• Acutely

• Definitve
− Pharmacologically: CCB
− Endoscopically: botulin injections; dilation
− Surgery: oesophagomyotomy (Heller operation) = myotomy of LOS

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4
Q

Scleroderma

Pathogenesis

A

Oesophageal Motor Disorder

Blood vessel damage -> intramural neuronal dysfunction -> distal esophageal muscle -> weakening -> aperistalsis and loss of LES tone -> reflux -> stricture -> dysphagia

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5
Q

Scleroderma

Diagnosis

A

• Mannometry
− Decreased pressure in LES
− Decreased peristalsis in body of oesophagus

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6
Q

Scleroderma

Management

A

As for GORD

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7
Q

Diffuse Oesophageal Spasm

Pathogenesis

A

Oesophageal Motor Disorder

Normal peristalsis interspersed with frequent, repetitive, spontaneous, high pressure, non-peristaltic waves

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8
Q

Diffuse Oesophageal Spasm

Diagnosis

A

• Barium enema
− Cork screw pattern
• Mannometry
− >30% (but <100%) of esophageal contractions are aperistaltic

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9
Q

Oesophageal Cancer

SCC (70%) and Adenocarcinoma (29%)

(Others: Soft Tissue Carcinoma)

Clinical

A

Early
• Retrosternal discomfort
• Odynophagia

Late (late presentation: oesophagus = expansible musculature)
• Progressive dysphagia
• Weight loss
− Not eating -> will gain wait on parenteral nutrition
− Paraneoplastic syndrome -> won’t gain weight on parenteral nutrition
• Dehydration

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10
Q

Oesophageal Cancer

SCC

Epidemiology

A
  • Black, rural: limpopo, trans-ski, Natal
  • 2nd most common country secondary to east asia
  • M>F
  • 50-60 years
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11
Q

Oesophageal Cancer

SCC

Risk Factors

A 
•	Behavioural
        −	Smoking (10x)
        −	Alcohol (2x)
        −	Chewing betel nuts
        −	  Vitamin and mineral deficiencies (selenium, vitamin E, beta-carotene)

• Chronic inflammation
− Stricture food bolus + fermentation
⎫ Achalasia
− Hot beverages

• Caustic injury: scar/strictures

• Genetics: Tylosis
⎫ Characterized by thickening of the skin on the palms of the hands and soles of the feet

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12
Q

Oesophageal Cancer

SCC

Diagnosis

A

• Barium swallow
− Can be in any third, most common in middle third (guideline: carina of bronchus divides upper oesophagus into upper 1/3 and lower 2/3; lower 2/3 divided in half from carina to oesophageal gastric junction)
− Pathopneumonic
1. Dilated proximal oesophagus; fluid level
2. Abrupt narrowing: shouldering
3. Stricture with irregular mucosa of stricture (rats tail)
4. Complications
♣ Sinus
♣ Fistula : into trachea
♣ Local infiltration -> axial deviation

• Gastroscopy + biopsy
− Fungating (60%), ulcerative (25%), infiltrative (15%)

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13
Q

Oesophageal Cancer

SCC

Complications: Local Invasion

A

• Respiratory
− Fistula trachea + bronchus (as they drink they cough)
⎫ Recurrent LRTI
⎫ Abscess

• Nerves
− Nerves: hoarseness
− Nerves: persistent pain

• Blood vessels
− Blood vessels (in oesophagus or aorta): haememesis anaemia

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14
Q

Oesophageal Cancer

Adenocarcinoma

Epidemiology

A

• White, male, suburban, well fed + obese

  • M>F
  • 50-60 years
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15
Q

Oesophageal Cancer

Adenocarcinoma

Risk Factors

A

• GORD Barrett’s oesophagus (fastest growing cancer: lifestyle disease)

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16
Q

Oesophageal Cancer

Adenocarcinoma

Diagnosis

A

• Barium swallow
− Lower 1/3 (guideline: carina of bronchus divides upper oesophagus into upper 1/3 and lower 2/3; lower 2/3 divided in half from carina to oesophageal gastric junction)
− Pathopneumonic
1. Dilated proximal oesophagus; fluid level
2. Abrupt narrowing: shouldering
3. Stricture with irregular mucosa of stricture
4. Complications
♣ Sinus
♣ Fistula : into trachea
♣ Local infiltration axial deviation

• Gastroscopy + biopsy

17
Q

Oesophageal Cancer

Spread

A 
•	Local invasion
•	Lymphatic spread
        −	  Virchow’s node
•	Haematogenous spread
        −	Lung
        −	Liver
        −	Bone: to bone marrow (in adults = flat bones)
18
Q

Oesophageal Cancer

Approach

A
  1. Local (T staging)
    − Endoscopic ultrasound
    − Barium swallow
    − Bronchoscopy
  2. Nodes
    − Virchow’s node
    − Endoscopic ultrasound
    − CT chest
  3. Metastases
    − Lung
    ⎫ Examination: pleural effusion
    ⎫ Chest x-ray: pleural effusions; cannonball lesions
    ⎫ CT chest
    − Liver
    ⎫ Palpate: hepatomegaly
    ⎫ LFT: AST, ALT
    ⎫ Ultrasound/CT abdomen
    − Bone
    ⎫ Examination: palpate bones
    ⎫ Chest x-ray (sternum, ribs, vertebrae); pelvic x-ray (pelvis)
    ⎫ LFT: ALP; calcium levels
    ⎫ If no evidence on chest-x-ray but clinical signs bone scan
19
Q

Oesophageal Cancer

Staging (TNM)

A

• T
− 1:
A. lamina propria and/or muscularis propria
B. Submucosa
− 2: muscularis propria
− 3: adventitia
− 4: local invasion

•	N
        −	1: 
                A.	1
                B.	4-7
                C.	>7

• M
− 1
A. Nonregional lymph nodes
B. Distant mets

20
Q

Oesophageal Cancer

Stages

A

• Stage 1: T1

• Stage 2
A. T2-3
B. T1-2, N1

  • Stage 3: T3, N1 or T4, any N
  • Stage 4: M1
21
Q

Oesophageal Cancer

Management

T1 - Curative

A

• Surgery (need 10cm proximal margin making upper 1/3 oesophageal cancer difficult)
− Endoluminal surgery: confined
− Oesophagectomy (+ two-field lymphadenectomy - upper abdominal and mediastinal - if LNs involved)
⎫ Lower 1/3
♣ Ivor-Lewis
ϖ Stage 1: gastric mobilisation (done through upper midline abdominal incision)
ϖ Stage 2: oesophagectomy and gastro-oesophageal anastomosis in the chest ( through right thoracotomy incision)
⎫ Middle or upper 1/3
♣ Trans-hiatal (less morbidity than Ivor-Lewis as the chest is not opened, but controversial)
ϖ Done via two incisions – one in the abdomen and one in the neck
ϖ Blunt oesophagectomy, gastric mobilisation, and gastro-oesophageal anastomosis in the neck
♣ Tri-incisional
ϖ Three incisions – abdominal, chest, and also left neck incision for gastro-oesophageal anastomosis in the neck

• Adjuvant
− Chemotherapy
PLUS
− Radiation: external beam, brachytherapy

22
Q

Oesophageal Cancer

Management

T2,3,4 - Curative

A

• Neoadjuvant
− Chemotherapy: increases rates of complete resection

• Surgery (need 10cm proximal margin making upper 1/3 oesophageal cancer difficult)
− Oesophagectomy + two-field lymphadenectomy = upper abdominal and mediastinal)
⎫ Ivor-Lewis
⎫ Trans-hiatal (less morbidity than Ivor-Lewis as the chest is not opened, but controversial)
⎫ Tri-incisional

• Adjuvant
− Chemotherapy
PLUS
− Radiation: external beam, brachytherapy

23
Q

Oesophageal Cancer

Management

Stage 4 - Palliative

A

• Symptomatic
− Oesophagus
⎫ Swallowing
♣ Dilation – last 3 weeks (risk: perforation)
♣ Stent - lasts 6 months; ideal in that it also closes off fistula if present
♣ Surgical debulking
⎫ Pain
♣ Analgesia
♣ Radiotherapy
− Bone

24
Q

Oesophageal Cancer

Prognosis

A

• 80% mortality at 1 year, overall 5-year survival <10%

25
Q

Oesophageal Diverticulum

Pharyngoesophogeal (Zenker’s Diverticulum)

Clinical

A
  • Dysphagia
  • Odynophagia
  • Regurgitation
  • Halitosis
26
Q

Oesophageal Diverticulum

Pharyngoesophogeal (Zenker’s Diverticulum)

Anatomy

A

• Posterior pharyngeal outpouching most often on the left side, above cricopharyngeal muscle and below the inferior pharyngeal constrictor muscle

27
Q

Oesophageal Diverticulum

Pharyngoesophogeal (Zenker’s Diverticulum)

Complications

A

• Inability swallow; vomiting
− Dehydration; electrolyte disturbances
− Malnutrition
• Aspirating aspiration pneumonia

28
Q

Oesophageal Diverticulum

Pharyngoesophogeal (Zenker’s Diverticulum)

Diagnosis

A

• Barium swallow

29
Q

Oesophageal Diverticulum

Pharyngoesophogeal (Zenker’s Diverticulum)

Management

A

• Surgery

30
Q

Oesophageal Diverticulum

Mid-Oesophageal

Clinical

A
  • Dysphagia
  • Odynophagia
  • Regurgitation
  • Halitosis
31
Q

Oesophageal Diverticulum

Mid-Oesophageal

Aetiology

A

• Oesophageal motor disorders

32
Q

Oesophageal Diverticulum

Mid-Oesophageal

Complications

A

• Inability swallow; vomiting
− Dehydration; electrolyte disturbances
− Malnutrition
• Aspirating aspiration pneumonia

33
Q

Oesophageal Diverticulum

Mid-Oesophageal

Diagnosis

A

• Barium swallow

34
Q

Oesophageal Diverticulum

Mid-Oesophageal

Management

A

• Manage oesophageal motor disorders

35
Q

Oesophageal Diverticulum

Epiphrenic (just proximal to LOS)

Clinical

A
  • Dysphagia
  • Odynophagia
  • Regurgitation
  • Halitosis
36
Q

Oesophageal Diverticulum

Epiphrenic (just proximal to LOS)

Aetiology

A

• Oesophageal motor disorders

37
Q

Oesophageal Diverticulum

Epiphrenic (just proximal to LOS)

Complications

A

• Inability swallow; vomiting
− Dehydration; electrolyte disturbances
− Malnutrition
• Aspirating aspiration pneumonia

38
Q

Oesophageal Diverticulum

Epiphrenic (just proximal to LOS)

Diagnosis

A

• Barium swallow

39
Q

Oesophageal Diverticulum

Epiphrenic (just proximal to LOS)

Management

A

• Manage oesophageal motor disorders

Surgery (5 decks)

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