Esophageal Injury Flashcards
Key issues to consider to determine managment of patient with esophageal injury
- 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
Two categories of esophageal stricture
Benign
Malignant
Categories of benign esophageal strictures
- Congenital
- Acquired
- peptic (Schatzki’s rings)
- pill-induced
- autoimmune (eosinophilic esophagitis, Crohn’s scleroderma)
- iatrogenic (anastomotic, XRT induced)
- infectious (fungal, bacertial, mycobacterial)
% narrowing of esophagus before dysphagia presents
Typically ~ 50%
Diagnosis and Treatment of esophageal strictures
- 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
- Dilation (may need to be repeated)
Characteristics of alkali corosive agents and injury
Alkalies (vs. acids)
- Viscous (long exposure)
- Deep tissue penetration
- Liquifactive necrosis
Characteristics of acid corosive agents and injury
Acid (vs. alkali) injury:
- Less viscous (rapid transit time)
- More superficial coagulative necroiss
3 phases of corrosive esophageal injury and healing
- Inflammation/necrosis
- Sloughing/ulceration
- Fibrosis/scarring
MC presentation of corrosive esophageal injuries
- Dysphagia
- Odynophagia
- Chest/abdominal pain
- May present with sepsis
Initial managment of corrosive esophagel injuries
- 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
3rd degree burns of esophagus
Full thickness involvement with possiblity of:
- perforation
- mediastinitis
- peritonitis
Potential late complicaton of corrisive esophageal injury
Long-segment esophageal stricture (not responsive to dilation)
- Tx: esophagectomy with reconstruction (gastric conduit preferred if not injured)
MCC of esophageal perforation
Iatrogenic (during endoscopy and dilation)
MC site of perforation during endoscopy on a patient with a hiatal hernia
GEJ or the gastric cardia
2nd and 3rd MCC of esophageal perforation
2 Spontaneous (Boerhaave’s syndrome)
(MCC iatrogenic perforation)