ESOPHAGUS Flashcards
Esophagus (C6-T11)
Blood Supply
cervical INFERIOR thyroid a
thoracic BRONCHIAL a
abdominal L GASTRIC a
INFERIOR phrenic a
Venous Drainage of Esophagus
cervical INFERIOR thyroid v
thoracic BRONCHIAL v
AZYGOUS AND HEMIAZYGOUS VEINS
abdominal CORONARY v
Hormones that INCREASE LES pressure
motilin
gastrin
Hormones the DECREASE LES pressure
cholecystokinin estrogen glucagon progesterone somatostatin secretin
1st diagnostic test in patients w/ suspected esophageal diseases
Barium swallow
Indicated in patients complaining of dysphagia even w/ normal radiographic study
Endoscopic Evaluation
Indicated when a motor abnormality of the esophagus is considered on the basis of complaints an barium swallow and endoscopy does not show a structural abnormality
Manometry
GOLD STAbDARD for the diagnosis of GERD
24 hr ambulatory pH monitoring
MC esophageal pathology d.t. loss of high pressure zone at the esophagogastric junction
Gastroesophageal Reflux Disease
Lower Esophageal Sphincter - NOT a true anatomic sphincter
resting pressure - 6-26 mmHg
overall length - 3-5 cm
intraabdominal length exposed to positive pressure - 2-4 cm
Defective Sphincter
mean resting pressure < 6mmHg
overall length < 2 cm
intraabdominal length < 1 cm - MOST COMMON
Indications for Anti-Reflux Surgery
symptomatic patients w/ or w/o esophagitis structurally defective LES young patients w/ documented reflux severe esophagitis presence of stricture uncomplicated Barrett esophagus
MC antireflux surgical procedure; mostly done laparoscopically
360 fundoplication
Nissen Fundoplication
AE: dysphagia, inability to belch, flatulence, structure
Alternative to Nissen fundoplication
180 posterior fundoplication around the distal 4 cm of esophagus
Toupet Fundoplication
180 ANTERIOR fundoplication of the distal esophagus
Dor Fundoplication
240-270 fundoplication performed through a THORACIC approach
Belsey Mark IV
Columnar lined epithelium of esophagus rather than squamous epithelium
Barrett Esophagus
30-125% increased risk of developing adenocarcinoma
Histologic Hallmark of Barrett Esophagus
Goblet cells
Congenital defect in which an OPENING is present in DIAPHRAGM allowing ABDOMINAL ORGANS to move into the CHEST CAVITY
Diaphragmatic (Hiatal) Hernia
MC type of hiatal hernia
upward dislocation of GE JUNCTION and CARDIA into thorax through the ESOPHAGEAL HIATUS of diaphragm
Type 1 (SLIDING HERNIA) reflux, dysphagia, aspiration
Upward dislocation of the GASTRIC FUNDUS alongside a normally positioned hcardia
Herniation of part of the stomach WITHOUT displacement of GE junction
Type II (ROLLING/PARAESOPHAGEAL HERNIA) obstructive symptoms, dysphagia, gastric ulcer, strangulation
Combined herniation of the CARDIA and FUNDUS
Type III (COMBINED HERNIA)
Borchardt triad
indicative of incarcerated intrathoracic stomach
chest pain
retching w/ inability to vomit
inability to pass NGT
Key Indications for Antireflux Surgery
objectively proven GERD
typical symptoms of GERD despite adequate medical management
younger patient unwilling to take lifelong medication
MC form of esophageal diverticula
False diverticulum w/ MUCOSA and SUBMUCOSA at UES through the Killian Triangle
Zenker diverticulum
d.t. increased pressure in the hypopharynx during swallowing against a closed UES
Killian triangle - are of potential weakness behind the esophagus at the level of cricopharyngeus
<2 cm - pharyngomyotomy >2cm - diverticulectomy, diverticulopexy
Loss of PERISTALTIC waveform in the esophageal body and FAILURE of LES to relax during swallowing
Neurogenic degeneration of ganglion cells causes a functional outflow obstruction
Achalasia
TRIAD: hypertensive LES + aperistalsis of esophageal body + failure of LES to relax
dysphagia for BOTH solids and liquids then regurgitation
Barium swallow findings (ACHALASIA)
dilated esophagus
bird beak esophagus (tapering of LES and GE)
air fluid level
sigmoid esophagus
Management of Achalasia
Medical and Surgical
CCB, nitrates, botulinum toxin
Laparoscopic Heller myotomy of LES
muscles of cardia (LES) are cut allowing food and liquids to pass to the stomach
MC primary esophageal motility disorder w/ very strong peristaltic waves
Nutcracker Esophagus (Hypertensive Peristalsis)
Cause injury by LIQUEFACTIVE necrosis (saponification of fats)
penetrates deeply
alkali agents (pH > 7)
Causes COAGULATION necrosis
more superficial
Acids (pH <7)
Common sequelae of caustic infection
fibrosis and stricture
fistula
esophageal SCC
MC type of esophageal carcinoma worldwide
MEN - affected 3-4 times
Squamous Cell Carcinoma
middle 3rd of THORACIC carcinoma - usual location
MC type of esophageal carcinoma in developed countries
MEN - affected 6-8 times
Adenocarcinoma
DISTAL esophagus
Barrett metaplasia: PRECURSOR LESION
MC presenting symptom of esophageal carcinoma (occurs when >60% of esophageal lumen is infiltrated w/ tumor)
Dysphagia
Signs and symptoms of Advanced Esophageal Carcinoma
dysphagia odynphagia weight loss supraclavicular lymphadenopathy dyspnea (if w/ phrenic nerve inv) cough (if w/ tracheoesophageal fistula) hoarseness (if w/ recurrent laryngeal nerve invasion) upper body trauma (if w/ SVC) malignant pleural effusion
Essential for all patients suspected of having esophageal cancer
Endoscopy (EGD) w/ biopsy
histology, location, degree of obstruction and extent of lesion
Visualize the mucosa, distensibility and extent of lesion
Barium swallow
Determines the local extent and relationship to adjacent structures and distant metastases (lung, liver)
CT scan of chest and abdomen
Provides more accurate T and N staging
Endoscopic Ultrasound (EUS)
Management for esophageal tumor that invades into the submucosa, without visible LN
involvement
Esophagectomy
Management for tumor that demonstrates spread through the wall of the esophagus,
especially if LNs are enlarged
Induction Chemoradiation therapy (Neodadjuvant therapy)
Management for tumor w/ invasion into the pleura ( T4a) in the absence of malignant effusion
Surgical Resection
Technique of resecting an esophageal cancer which remains symptomatic after definitive chemoradiotherapy
Salvage Esophagectomy
Patients with dysphagia secondary to esophagea cancer treated with radiation can expect the benefit to last
2-3 months
How long after completion of neoadjuvant chemoradiotherapy should esophagectomy be performed
6-8 weeks
Optimal treatment of an incidentally discovered 3 cm leiomyoma of the upper esophagus in a 45-year-old otherwise healthy man
Enucleation
Mucosal tears located at the GEJ
Characterized by arterial bleeding (may be massive)
Mallory Weiss Tear
UGIB after repeated vomiting
observation medical management- blood replacement, decompression, antiemetics surgical management - laparotomy + high gastrotomy + oversewing the tear
Involves simultaneous non-peristaltic contractions of the esophagus
Diffuse Esophageal Spasm (DES)
CLASSIC MANOMETRIC FINDINGS:
frequent occurrence of simultaneous waveforms
multipeaked esophagea contractions
Gold Standard test for Achalasia
Manometry
Spontaneous rupture of esophagus w/ usual history of resisting of vomiting
Boerhaave syndrome
Indications for surgery in the acute setting of caustic ingestion
free air under the diaphragm
cervical crepitus
full-thickness necrosis of the esophagus or stomach
Indications for esophageal resection in Barrett’s esophagus
presence of invasive cancer
carcinoma in situ
high-grade dysplasia
Disorders of the esophagus associated with the development of esophageal carcinoma?
Lye ingestion
Achalasia
Barrett’s esophagus
Plummer–Vinson syndrome
The most important determinants of survival after resection of an esophageal carcinoma?
Depth of invasion
Presence or absence of lymph node metastases
Presence or absence of distant metastases
