Esophageal Injury Flashcards

1
Q

Key issues to consider to determine managment of patient with esophageal injury

A
  • Characteristics of injury
    • Etiology (caustic, penetrating truam, iatrogentic, FB)
    • Location (cervical, upper, mid, lower esophagus)
    • Severity
    • Timing of injury relative to presentation
  • Characteristics of patient (age, comorbidities, immune status)
  • Characteristivs of pre-existing esophagus
    • tumor
    • achalasia
    • distal obstruction
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2
Q

Two categories of esophageal stricture

A

Benign

Malignant

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3
Q

Categories of benign esophageal strictures

A
  • Congenital
  • Acquired
    • peptic (Schatzki’s rings)
    • pill-induced
    • autoimmune (eosinophilic esophagitis, Crohn’s scleroderma)
    • iatrogenic (anastomotic, XRT induced)
    • infectious (fungal, bacertial, mycobacterial)
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4
Q

% narrowing of esophagus before dysphagia presents

A

Typically ~ 50%

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5
Q

Diagnosis and Treatment of esophageal strictures

A
  • Diagnosis
    • Esophagram and EGD
  • Treatment:
    • Dilation (may need to be repeated)
      • Long-segment or near total obstruction stricutes require dilation under fluoroscopy with a guide wire
    • Esophagectomy with reconstruction
      • Strictures not responsive to dilation
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6
Q

Characteristics of alkali corosive agents and injury

A

Alkalies (vs. acids)

  • Viscous (long exposure)
  • Deep tissue penetration
  • Liquifactive necrosis
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7
Q

Characteristics of acid corosive agents and injury

A

Acid (vs. alkali) injury:

  • Less viscous (rapid transit time)
  • More superficial coagulative necroiss
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8
Q

3 phases of corrosive esophageal injury and healing

A
  • Inflammation/necrosis
  • Sloughing/ulceration
  • Fibrosis/scarring
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9
Q

MC presentation of corrosive esophageal injuries

A
  • Dysphagia
  • Odynophagia
  • Chest/abdominal pain
  • May present with sepsis
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10
Q

Initial managment of corrosive esophagel injuries

A
  • IVF resuscitation
  • Emperic broad-spectrum antibiotics
  • Plain X-ray (CXR and AXR - evaluate for obvious perforation)
  • Laryngoscopy
  • Early endoscopy
  • NO BLIND NGT and NO ATTEMPT AT NEURTALIZATION of burn
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11
Q

3rd degree burns of esophagus

A

Full thickness involvement with possiblity of:

  • perforation
  • mediastinitis
  • peritonitis
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12
Q

Potential late complicaton of corrisive esophageal injury

A

Long-segment esophageal stricture (not responsive to dilation)

  • Tx: esophagectomy with reconstruction (gastric conduit preferred if not injured)
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13
Q

MCC of esophageal perforation

A

Iatrogenic (during endoscopy and dilation)

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14
Q

MC site of perforation during endoscopy on a patient with a hiatal hernia

A

GEJ or the gastric cardia

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15
Q

2nd and 3rd MCC of esophageal perforation

A

2 Spontaneous (Boerhaave’s syndrome)

(MCC iatrogenic perforation)

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16
Q

Diagnostic eval for suspected esophageal perforation

A
  • CXR (pleural effusion, pneumomediastinum, pneumoperitoneum)
    • First modality (sensitivity low: 10-20%)
  • Esophagogram (water soluable contrast)
    • Thin barium if Gastrograffin study negative
    • Sensitivity 80%
  • CT (oral contrast)
    • Eval surrounding structures and associated injuries (trauma)
  • EGD (foreign body and penetrating trauma)
17
Q

Sensitivity of CXR and Esophagogram for diagnosis of esophageal perforation

A
  • CXR: 10-20%
  • Esophagogram: 80%
18
Q

Indications for non-operative managment of esophageal perforation

A
  • Clinically stable
  • Recent injury
  • No evidence of extraluminal contrast
  • No distal obstruction
19
Q

Treatment approach for non-operative management of esophageal perforation

A
  • Emperic broad-spectrum Abx
  • NPO
  • IVF hydration
20
Q

Indications for operative managment of esophageal perforation

A
  • Extraluminal contrast
  • Medistinal or peritoneal contamination
  • Sepsis
21
Q

Surgical approach to cervical perforation

A

Debridement and drainage via oblique incisoin anterior to SCM on ipsilateral side of injury

22
Q

Surgical approach for intrathoracic esophageal perforations

A
  • Access:
    • Upper and middle esophageal perforations (righ thoracotomy)
    • Lower 1/3 esophageal perforations (left thoracotomy)
  • Exposure of perforation (extend myotomy)
  • Debridement to healthy tissue
  • Primary repair (2 layers, absorbable mucosa, silk muscularis)
  • Butress repair
    • pedicled intercostal muscle flap
    • pericardium, pleura, omentum
  • Drain widely
23
Q

Use of t-tube for esophageal perforation

A

Development of controlled esophageal fistula that closes over time as the tube is withdrawn

24
Q

Approach for perforation during dilation for achalasia

A

Primary repair with contralateral esophagomyotomy (180 degrees opposite the perforation

25
Q

Surgical options for:

  • Delayed diagnosis
  • Unrepairable tissue
  • Poor patient physiology
A
  • Initial management:
    • Debridement
    • Drainage
    • Control further contamination with proximal and distal diversion
26
Q

Patients at highest risk for foreign body ingestion and impaction

A
  • Children
  • Elderly
  • Psychiatric
27
Q

Diagnostic w/u for foreign body aspiration

A
  • CXR
  • Swallow study (occasionally)
  • Upper endoscopy (snare and remove foreign body)
    • If object’s orientation is such that removal is likely to lacerate esophagus, rigid esophagoscopy can be used.
  • Most objects can be advanced into stomach and allowed to pass distally without consequence.
    • Objects that must be removed:
      • Watch batteries
      • Two magnets or multple magnet pieces