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Esophagus Master > Esophageal Injury > Flashcards

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
  1. Dysphagia
  2. Odynophagia
  3. Chest/abdominal pain
  4. 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
28
Q

Other potential injuries that can happen with caustic ingestion?

A

Aspiration of either acid or alkali can also induce both laryngeal and tracheobronchial injury.

29
Q

what are the alkali compounds that can be ingested?

A

strong alkali: sodium or potassium hydroxide - contained in drain cleaners, other household cleaning products, or disc batteries.

The term “lye” implies substances that contain NaOH or KOH

30
Q

Mechanism of alklai induced injury

A
  1. penetrating injury called liquefactive necrosis.
  2. The injury extends rapidly (within seconds) through the mucosa and wall of the esophagus towards
  3. the mediastinum until tissue fluids buffer the alkali.
  4. Extensive transmural damage may result in esophageal perforation, mediastinitis, and death
  5. The process usually lasts 3-4 days and is associated with vascular thrombosis and mucosal inflammation, resulting in focal or extensive sloughing and ulceration
31
Q

Natural proscess of liquifactive necrosis

A

The process of liquefactive necrosis

Lasts: usually 3 to 4 days

Associated with:

  • vascular thrombosis
  • mucosal inflammation

resulting in focal or extensive sloughing and ulceration

32
Q

Which type of caustic ingestion causes more airway injury?

A

Acid: Upper airway injuries are more common

  • perhaps related to their bad taste
  • tends to stimulate gagging and choking,
  • attempts to spit out the ingested material
33
Q

What is the pattern of injury for liquid alkali ingestion?

A
  • They pass rapidly through the upper gastrointestinal tract, producing:
  1. severe injury to the esophagus at physiologic points of narrowing (cricopharyngeus, upper thoracic esophagus at the tracheal bifurcation, and the distal thoracic esophagus)
  2. the stomach and adjacent intra-abdominal organs.
34
Q

Symptoms associated with liquid alkali ingestion?

A

Significant liquid caustic ingestion typically produces:

  1. dysphagia
  2. odynophagia
  3. chest and abdominal pain
  4. signs of mediastinitis or peritonitis.
35
Q

Symptoms of solid alkali ingestion?

A

Significant solid corrosive ingestion may produce:

oral pain, drooling, excessive salivation,

inability or refusal to swallow or drink, hoarseness, aphonia, dyspnea, stridor, and ulceration of the mouth, pharynx, or larynx.

36
Q

Principles of treatment of caustic injury with esophageal perforation

A

The principles of surgical treatment are :

  1. débridement of infected or necrotic tissue
  2. closure of the perforation
  3. treatment of underlying esophageal pathology (if present)
  4. drainage of the mediastinum.
37
Q

Elements of surgical management of a caustic perforation

A

myotomy at the site of perforation allows the full extent of damage to the mucosa to be recognized and repaired.

Reinforcement of the repair results in decreased mortality rate and decreased incidence of fistula formation.

38
Q

surgical management of a delayed recognized perforation?

A

Delayed recognition of a perforation makes successful primary repair less likely.

Therapy should be directed toward defunctioning, débridement, drainage, and resection.

Descending mediastinitis requires prompt treatment of the mediastinal component of a cervical perforation and may necessitate the addition of a right thoracotomy to the cervical incision.

Esophagus Master (11 decks)

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