Esophagus 1 Flashcards
What is the course of the esophagus?
starts at C6
passes the hiatal opening at T10
reaches stomach at T11
What are the 3 points of constriction in the esophagus?
- at the start behind the cricoid cartilage
- where its crossed by the aortic arch in front & the left main bronchus in the posterior mediastinum
- esophageal hiatus
dysfunction of which sphincter causes GERD?
lower esophageal sphincter (physiological)
What is the anti-reflux mechanism of the lower esophageal sphincter?
- angle of Hiss
- higher pressure intra abdominally
- rosette arrangement of gastric folds present at cardia
- pinchock effect of the right crus of the diaphragm
- continuous release of acetylcholine
What is the cause of the spread of malignancy from lower to upper part of the esophagus?
bidirectional flow of lymph
What is the lining of the esophagus?
stratified squamous epithelium NON KERATINIZED
EXCEPT LOS turns into simple columnar
What is the musculature of the esophagus composed of?
Upper 1/3 = striated muscles
middle 1/3 = mixed
lower 1/3 = smooth muscles
What induces the relaxation of the LOS?
peristalsis pushing the food towards it
What are the causes of GERD?
- sliding hiatus hernia (MOST COMMON)
- physiological in < 2 years
- obesity
- smoking
- alcohol
- scleroderma
- delayed gastric emptying
What are the complications of GERD?
- deep ulceration
- bleeding
- stricture
- esophageal shortening
- Barret’s esophagus (columnar metaplasia)
How does GERD present?
- heart burn (retrosternal, simulates angina, increased by fatty meals & lying flat)
- dysphagia ( due to esophageal stricture or spam)
- regurgitation (increased by laying flat)
- recurrent chest infections
- hematemesis & anemia
What is the most diagnostic investigation for GERD?
24hrs ambulatory PH monitoring
What are the investigations used for GERD?
BARIUM MEAL -> hiatus hernia diagnosis in Trendelenburg position
UPPER GI ENDOSCOPY -> demonstrates presence of complications & guides biopsy
ESOPHAGEAL MANOMETRY -> assess pressure of LOS
24HR AMBULATORY PH -> pH <4 in distal 5cm for > 30mins
What are the grades in Belsy Classification?
I -> hyperemic mucosa
II -> superficial ulceration
III -> extensive ulceration
IV -> stricture or Barret’s
What is the main line of treatment in GERD?
CONSERVATIVE
- change lifestyle (reduce weight, stop smoking, small meals)
- medical treatment
- decrease gastric acidity: H2 blockers, antacids, PPI
- regulate motility: metoclopramide, cisapride
What are the indications for surgical intervention in GERD?
- failure of conservative for 6 months
- presence of complications
- Saint’s triad (hiatal hernia, chronic cholecystitis, diverticular disease)
- non complaint patient
What surgical procedure is used in GERD?
Nissen’s Fundoplication
- wrapping fundus around the lower esophagus
What causes Barret’s esophagus?
response to chronic irritation -> columnar metaplasia -> can progress to dysplasia & malignant transformation
What is the treatment of Barret’s esophagus?
- higher dose of PPI + close surveillance + endoscopic follow up
- Nissen’s fundoplication
- local ablation
- resection (if high grade dysplasia is present)
What are the predisposing factors for a sliding hernia?
- obesity
- tight corsets
- repeated pregnancies
What is the difference between a sliding hernia & a rolling hernia?
SLIDING -> herniation of cardia & adjoining part of stomach through hiatus
ROLLING -> herniation of part of greater curvature through hiatus while GEJ is below diaphragm
What investigation should be preformed for sliding & rolling hiatal hernia?
BARIUM MEAL in Trendelenburg position
What is the presentation of a sliding hernia? How should it be treated?
GERD (GEJ is intra-thoracic)
Nissen’s Fundoplication + repair of right diaphragmatic crus
What is the presentation of a rolling hiatal hernia? (para-esophageal hernia)
pressure manifestations
- esophagus -> dysphagia
- heart -> arrhythmia
- phrenic nerve -> hiccough
What are the complications of a rolling hernia?
strangulation & gangrene
rupture & mediastinitis
How should a rolling HH be treated?
surgical reduction & diaphragm repair
What is achalesia of the cardia?
failure of LOS relaxation with absent peristalsis
How does achalesia of the cardia present?
in young & middle ages
- dysphagia -> more to liquids
- retrosternal pain -> due to esophagitis
- regurgitation -> bad odor & alkaline
- halithosis -> putrefaction of retained food causing bad mouth odor
What are the complications of achalasia?
- recurrent respiratory infections
- sigmoid esophagus
- anemia & malnutrition
- esophageal diverticulum
- malignant changes
What is the most important investigation that should be used in achalasia?
BARIUM SWALLOW
- delayed emptying
- parrot break
- if late -> sigmoid esophagus
What investigation is mandatory PRE-OP?
ESOPHAGEAL MANOMETRY
- hypertensive LOS (n=8/25mmHg)
- failure of relaxation
- absent peristalsis
What will be seen on an X-ray in case of achalasia?
- widened mediastinum
- absent gastric air bubbles
What is the esophagoscope used for?
FOLLOW UP
to exclude carcinoma
How should Achalasia be treated?
- medical (nitrates & Ca channel blockers)
- endoscopic treatment (injection of botox in LOS or balloon dilatation)
What are the indications for surgery in achalasia?
- failure of previous measures
- severe cases from the start
- incompliant patients
- complicated cases
- assosicated pathology (HH)
USE MODIFIED HELLER’S MYOTOMY
What is Killian’s triangle?
space between transverse cricopharyngeus & oblique thyropharyngeus in lateral pharyngeal wall
What is the cause of Zenker’s diverticulum?
spasm of cricopharyngeus muscle -> increase intrapharyngeal pressure -> herniation of mucosa
What are the complications of Zenker’s diverticulum?
- recurrent respiratory chest infections
- diverticulitis
- perforation
- malignant transformation
How does Zenker’s diverticulum present?
- in old males
- progressive dysphagia
- regurgitation of undigested food
- swelling on left side of the neck that increases with eating, is soft, compressible, and has gurgling sensation of compression
What is the best investigation for Zenker’s diverticulum?
Barium swallow -> flask shaped pouch
- endoscopy is diagnostic & therapeutic BUT DANGEROUS
What is the treatment of Zenker’s diverticulum?
ENDOSCOPIC -> repeated dilation of cricopharyngeus musch (if small pouch)
-> cut through cricopharyngeus muscle with stapler
SURGICAL -> small: inversion of pouch with repair of the triangle
-> large: diverticulectomy with cricopharyngeus myotomy
What is the nutcracker esophagus?
- hypercontractile esophagus
- prolonged & high amplitude peristaltic waves
What is the corkscrew esophagus?
- diffuse esophageal spasm
- NOT PERISTALTIC
- simultaneous repetitive contractions
What are the clinical features & investigations done for nutcracker & corkscrew esophagus?
CLINICALLY
- pain: retrosternal, acute, severe pain, simulating angina pectoris
- dysphagia: TO FLUIDS
INVESTIGATIONS
- Barium swallow
- esophageal manometry is DIAGNOSTIC
How is nutcracker esophagus treated?
MEDICALLY (main line)
- nitrates & Ca channel blockers
Endoscopic dilatation
How is Corkscrew esophagus treated?
Medically (1st line)
Surgically: longitudinal myotomy
