Esophagus Flashcards
Blood supply to the esophagus
Cervical: inferior thyroid artery
Thoracic: Branches of bronchial arteries and directly off aorta
Abdominal: Branches of L gastric, L inferior phrenic artery, Belsey’s artery (connective b/w L gastric & inf phrenic art), splenic artery
Hill esophagogastropexy
Patients who require antireflux surgery who have had prior gastric surgery and with inadequate fundus for plication
plication of lesser gastric curvature around right side of esophagus with esophagogastropexy to median arcuate ligament
Surveillance for Barrett’s esophagus
No dysplasia: EGD 3-5 years
Low-grade dysplasia: endoscopic eradication w/ RFA or surveillance (EGD 6 mo)
High-grade dysplasia: Endoscopic eradication
Vagal innervation to esophagus/stomach
Motor and sensory functions
Nerve injury -> gastroparesis, delayed gastric emptying, reflux, diarrhea (liquid emptying is accelerated)
Achalasia
Absent esophageal peristalsis
Abnormal LES relaxation
Raised LES pressure (>45mmHg)
Dysphasia MC sxs
Occurs w/ solids & liquids (functional vs obstruction)
Dysphagia can plateau as pts learn to alleviate sxs w/ certain postural maneuvers that increase esophageal pressure and emptying
Killian Triangle
Oblique fibers of thyropharyngeus muscle (sup) and horizontal fibers of cricopharyngeus muscle (inf) in upper esophagus
Esophageal perforation treatment
Broad-spectrum Abx
Fungal coverage
CXR - PA/Lat (hydropneumothorax)
Upright abd film if intra-abd portion suspected
Water-soluble esophagram in R lateral decubitus position
(upright makes contrast flow too fast). 10% false neg rate
Barium Esophagram (superior in detecting small perfs; causes mediastinitis)
Esophageal cancer
T1: mucosal confined. Tx: rsxn (T1a - EMR + RFA; T1b - +/- chemo d/t 15-25% of LN dz)
T2-3: regional dz
Areas of narrowing in esophagus
1st area (Narrowest part): cricopharyngeus muscle (14mm diameter)
2nd area: aortic arch/L mainstem bronchus (15-17mm)
3rd area: diaphragmatic hiatus (19mm)
Diffuse esophageal spasm (DES)
Simultaneous contraction >20% wet swallows, intermittent peristalsis
Repetitive or multi-peak contractions (>2 peaks)
Contractions not assoc w/ swallows
Contraction amplitude >30mmHg
Nutcracker esophagus
Increased mean distal amplitude (>180mmHg)
Normal peristalsis
Increased distal duration (>6sec)
Hypertensive lower esophageal sphincter
Resting LES pressure >45mmHg
Incomplete lower exophageal sphincter relaxation
Esophageal adenocarcinoma
Early stage T1a: Endo rsxn
Med fit pts w/ N+ dz, T3 or greater dz, or T2 + high risk features –> neoadj chemorads
High-risk features: >3cm, lymph vascular invasion, poor differentiation
Tumor above carina: bronch
serve esophageal ca: laryngoscopy
W/u esophageal cancer
EGD + Bx, EUS, CT C/A, FDG-PET
+pelvic sxs -> CT Pelvis
Access esophagus
Cervical esophagus: L, ant to SCM
Mid esophagus: R posterolateral thoracotomy
Distal esophagus: L thoracotomy (through 7/8th intercostal spaces)
Alarm sxs for GERD
dysphagia (can be first sxs of Barrett’s), early satiety, hemoptysis, odynophagia, weight loss, continual pain
indicate complication from GERD (Barrett’s, strictures, cancer)
Caustic esophageal injuries
Acid: some cleaning agents and battery fluids. Superficial coagulation necrosis, more prominent in oropharynx
Alkali: drain cleaners. Liquefactive necrosis, transmural damage. Worse than acid
Zargar classification
Grade 0: Normal mucosa
Grade 1: Superficial edema/erythema
Grade 2: Mucosal/submucosal ulceration (2a: superficial, 2b: deep)
Grade 3: Transmural ulceration w/ necrosis
Grade 4: perforation
Margins esophageal cancer resection
5cm
Siewert Classification GEJ Tumors
Type I: +5cm - +1cm from GEJ
Type II: +1cm - -2cm from GEJ
Type III: -2cm - -5cm from GEJ
Plummer-Vinson Syndrome
IDA + esophageal webs + dysphagia
spoon-shaped fingernails (koilonychia)
aka: sideropenic dysphagia
Complications of GERD
Shortening of esophagus (2/2 inflammation & fibrosis) Stricture Intestinal metaplasia (columnar) Erosive esophagitis Adenocarcinoma
Extra-esophageal: Asthma Laryngitis Cough Pneumonitis Dental erosions
