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)
Diagnostic eval for suspected esophageal perforation
- 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)
Sensitivity of CXR and Esophagogram for diagnosis of esophageal perforation
- CXR: 10-20%
- Esophagogram: 80%
Indications for non-operative managment of esophageal perforation
- Clinically stable
- Recent injury
- No evidence of extraluminal contrast
- No distal obstruction
Treatment approach for non-operative management of esophageal perforation
- Emperic broad-spectrum Abx
- NPO
- IVF hydration
Indications for operative managment of esophageal perforation
- Extraluminal contrast
- Medistinal or peritoneal contamination
- Sepsis
Surgical approach to cervical perforation
Debridement and drainage via oblique incisoin anterior to SCM on ipsilateral side of injury
Surgical approach for intrathoracic esophageal perforations
- 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
Use of t-tube for esophageal perforation
Development of controlled esophageal fistula that closes over time as the tube is withdrawn
Approach for perforation during dilation for achalasia
Primary repair with contralateral esophagomyotomy (180 degrees opposite the perforation
Surgical options for:
- Delayed diagnosis
- Unrepairable tissue
- Poor patient physiology
- Initial management:
- Debridement
- Drainage
- Control further contamination with proximal and distal diversion
Patients at highest risk for foreign body ingestion and impaction
- Children
- Elderly
- Psychiatric
Diagnostic w/u for foreign body aspiration
- 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
- Objects that must be removed:
