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BTK Book Review > Esophagus > Flashcards

Esophagus Flashcards

1
Q

What are the layers of the esophagus?

A
  • mucosa
  • submucosa
  • muscularis propia
  • no serosa!
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2
Q

What is the bloody supply to the esophagus?

A
  • cervical: the inferior thyroid artery
  • thoracic: vessels off the aorta
  • abdominal: left gastric and inferior phrenic arteries
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3
Q

What forms and what innervates the upper esophageal sphincter?

A

the cricopharnygeus, innervated by the superior laryngeal nerve

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4
Q

How far from the incisors is the UES and the GEJ?

A
  • 15cm to the UES

- 40cm to the GEJ

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5
Q

What is Killian’s Triangle?

A
  • it is a triangular area in the wall of the pharynx superior to the cricopharyngeus muscle and inferior to the inferior constrictor muscles
  • it is a potential weak spot where a pharyngoesophageal diverticulum (Zenker’s diverticulum) is most likely
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6
Q

Describe the diagnosis of esophageal perforation.

A
  • may have an abnormal CXR; can look for pneumomediastinum, subq emphysema, pix, or pleural effusion
  • study of choice is gastrografin esophagram
  • if negative but index of suspicion remains high, can follow with a dilute barium study
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7
Q

When should a barium esophagram be performed for suspected esophageal perforation?

A
  • for those in whom a gastrografin esophagram was negative but suspicion remains high
  • as first line for those who are an aspiration risk
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8
Q

What is the most common site of esophageal perforation? What is the most common site of iatrogenic perforation?

A
  • the distal esophagus in the left posterolateral aspect, 2-3 cm above the GEJ is most common
  • the cricopharyngeus is the most common for iatrogenic injury
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9
Q

How should cervical esophageal perforation be managed?

A
  • resuscitate
  • start antibiotics (gram - rods, anaerobes, fungus)
  • open the neck and place drains
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10
Q

How should thoracic esophageal perforation be managed?

A
  • resuscitate
  • start antibiotics (gram - rods, anaerobes, fungus)
  • primary repair is preferred: left thoracotomy, debridement, myotomy to visualize full mucosal injury, two layers of repair (inner absorbable, outer permanent), cover with vascularized flap, perform a leak test, drop an NGT, place drains
  • consider esophagectomy for malignancy, caustic perforation, megaesophagus from achalasia
  • consider contralateral mytomy if secondary to achalasia with normal esophagus
  • consider exclusion and diversion for unstable patients: closure, drainage, cervical esophagostomy, T-tube for external drainage as controlled fistula, J-tube access
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11
Q

How is a thoracic esophageal perforation diagnosed and treated in stable patients?

A
  • diagnose with gastrografin esophagram followed by a dilute barium esophagram if negative
  • begin treatment with resuscitation and antibiotics/antifungals
  • primary closure: left thoracotomy, debridement, myotome to expose mucosa, two layer repair (inner absorbable, outer permanent), cover with vascularized flap, leak test, place drains, drop NGT,
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12
Q

Esophageal Perforation

A
  • most commonly in the thoracic esophagus, 2-3 cm proximal to the GEJ in the left posterolateral aspect
  • most commonly at the cricopharyngeus when iatrogenic
  • diagnose with gastrografin esophagram unless an aspiration risk; second line is dilute barium swallow
  • initiate treatment with resuscitation and antibiotics/antifungals
  • for cervical injuries, treat with wide local drainage
  • for thoracic, primary repair in two layers with vascularized flap, NGT, and drains is preferred
  • consider esophagectomy for malignancy, caustic ingestion, megaesophagus secondary to achalasia
  • consider contralateral myotomy if secondary to achalasia with normal esophagus
  • consider exclusion for unstable patients with closure of injury, cervical esophagostomy, T-tube drainage, J-tube access
  • also consider, clip and stents
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13
Q

What is achalasia? What are the three kinds?

A
  • incomplete relaxation of the LES along with peristalsis or hypotonic esophageal contractions
  • type I: normal esophageal pressure
  • type II: increased pan esophageal pressure
  • type III: spastic distal esophageal contractions
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14
Q

Describe the diagnosis of achalasia.

A
  • will see a bird’s beak sign on barium swallow

- diagnosis requires normal/high LES pressure, incomplete LES relaxation, hypotonic or absent peristalsis

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15
Q

What is the pathophysiology of achalasia?

A
  • degenerative loss of NO-producing inhibitory neurons within the LES
  • has a mixed etiology of autoimmune, genetics, and infectious (Chagas’ disease)
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16
Q

How is achalasia treated?

A
  • can use endoscopic therapies such as pneumatic dilation and botox injection; however, these are less effective and increase the rate of surgical complication later
  • most effective is a minimally invasive Heller myotomy with partial fundoplication
  • if patient’s perforate secondary to dilation, perform a contralateral myotomy after the repair
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17
Q

Achalasia

A
  • an esophageal dysmotility disorder characterized by normal/high LES tone, incomplete LES relaxation, and absent or hypotonic esophageal contractions
  • due to the loss of NO-producing, inhibitory neurons
  • diagnosed based on barium swallow showing bird’s beak appearance and manometry
  • type I has a normal esophageal pressure, type II has high panesophageal pressure, type III has spastic distal contractions
  • first line treatment is Heller myotomy (2cm on stomach, 6cm on esophagus) as endoscopic therapies are less effective and increase later risk of surgical complications
  • if repairing a perf secondary to dilation, perform a contralateral myotomy after the repair
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18
Q

What is isolated hypertensive LES and how is it treated?

A
  • it is high basal LES pressure with complete relaxation and normal peristalsis
  • treated with calcium channel blockers, nitrates, or Heller myotomy
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19
Q

What is diffuse esophageal spasm and how is it treated?

A
  • normal LES pressure and relaxation but high amplitude and uncoordinated esophageal contractions (> 30 mmHg)
  • treat with calcium channel blockers and nitrates; long-segment myotomy can be an option in rare cases
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20
Q

What is nutcracker esophagus and how is it treated?

A
  • normal LES pressure and relaxation but high amplitude and coordinated esophageal contractions
  • treat with calcium channel blockers and nitrates; long-segment motomy can be an option in rare cases
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21
Q

Define each of the following:

  • achalasia
  • pseudoachalasia
  • isolated hypertensive LES
  • diffuse esophageal spasm
  • nutcracker esophagus
A
  • achalasia: normal/high LES with incomplete relaxation and hypotonic or absent peristalsis
  • achalasia secondary to malignancy
  • isolated HTN LES: high LES with normal relaxation and normal peristalsis
  • diffuse spasm: high amplitude, uncoordinated contractions greater than 30 mmHg
  • nutcracker: high amplitude, coordinated contractions
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22
Q

What is an infectious cause of achalasia?

A

Chagas’ disease (Trypanosoma Cruzi)

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23
Q

What is pseudoachalasia?

A

achalasia caused by malignancy

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24
Q

What is a Zenker’s diverticulum?

A

a cervical esophageal false pulsion diverticulum due to dysfunction of the upper esophageal sphincter muscles

25
Q

What is a pulsion diverticulum?

A

a false diverticulum without muscular extrusion

26
Q

How is a Zenker’s diverticulum treated?

A
  • if greater than 3cm, endoscopic division of the UES, creating a common lumen between the diverticulum and esophagus
  • if less than 3cm, perform an open myotomy via left neck incision with or without diverticulectomy
27
Q

What is an epiphrenic diverticulum and how is it treated?

A
  • a pulsion esophageal diverticulum associated with motility disorders
  • treated with diverticulectomy and treatment of the underlying motility disorder (usually requiring Heller)
28
Q

What is a thoracic, mid-esophageal diverticula and how is it treated?

A
  • it is usually a true, traction diverticula associated with adjacent inflammatory or malignant conditions but can also be a pulsion diverticulum
  • treated with VATS diverticulectomy and myotomy
29
Q

What is the difference between the following esophageal diverticulum?

  • Zenker
  • Epiphrenic
  • Thoracic
A
  • Zenker: false, pulsion diverticulum of the cervical esophagus associated with cricopharyngeus dysfunction
  • Epiphrenic: false, pulsion diverticulum of the distal esophagus associated with motility disorders
  • Thoracic: more commonly true, traction diverticulum than false, pulsion diverticulum of the thoracic esophagus associated with inflammatory or malignant conditions
30
Q

What histologic change does Barrett’s esophagus involve?

A

columnar metaplasia

31
Q

What is the risk associated with Barrett’s?

A

30-60x increased risk of esophageal adenocarcinoma

32
Q

What surveillance is indicated for those with Barrett’s?

A
  • annual EGD with 4-quadrant biopsies every 1-2cm
  • after two consecutive years negative for dysplasia, can transition to every three years
  • if low-grade dysplasia: repeat in 6 months
  • if high-grade dysplasia: repeat immediately for endoscopic mucosal resection
33
Q

Compare and contrast the two types of esophageal cancer.

A
  • both more common in men
  • SCC more common in Asia and Eastern Europe while ACA more common in N. America and W. Europe
  • smoking and alcohol use are risk factors for SCC while obesity, GERD, and Barrett’s are risk factors for ACA
34
Q

What should be included in the workup of esophageal cancer?

A
  • basic labs
  • endoscopy with biopsy
  • bronchoscopy if above the carina
  • CT C/A/P and PET
  • EUA with FNA of suspicious nodes
35
Q

Describe the staging for esophageal cancer.

A
  • T1a: invades lamina propria or muscularis mucosa
  • T1b: invades the submucosa (rich in lymphatics)
  • T2: invades muscularis propria
  • T3: invades the adventitia
  • T4a: invades surrounding structures but remains resectable
  • T4b: invades aorta, vertebrae, or trachea and is therefore unresectable
  • N1: involves 1-2 nodes
  • N2: involves 3-6 nodes
  • N3: invades 7+ nodes
  • M1: distant metastasis
  • stage I: T1, N0, M0
  • stage II: T3, N0 or T2, N1
  • stage III: T4, N3, M0
  • stage IV: M1
36
Q

Why is histologic grading important for esophageal cancer?

A
  • helps with decision of EMR vs. esophagectomy for small superficial lesions
  • helps decide whether neoadjuvant chemo or surgery first should be offered
37
Q

What are the principles of management for esophageal cancer?

A
  • preoperative chemo improves survival for patients with resectable lesions (CROSS)
  • neoadjuvant chemo may be of benefit for young patients and those with high-grade T1 lesions
  • perioperative chemo improves survival for patients with resectable lesions (MAGIC)
  • consider esophagectomy for patients with lesions >5cm distal to the cricopharyngeus
  • chemoradiation for those with lesions in the cervical esophagus or < 5cm distal to the cricopharnygeus
38
Q

Which esophageal cancers are suitable for endoscopic resection and ablation?

A
  • HGD, Tis, T1a tumors (<2cm and well-to-moderately differentiated)
  • some advocate for T1b tumors without NVI
39
Q

What is the chemotherapy of choice for esophageal cancer?

A

fluorouracil or taxane-based therapies

40
Q

What is an Ivor-Lewis esophagectomy?

A
  • involves a laparotomy and right thoracotomy with upper thoracic esophagogastric anastomosis
  • must preserve the right gastric and right gastroepiploic artery for the gastric conduit
  • good for distal tumors
41
Q

What is a McKeown esophagectomy?

A

similar to an Ivor-Lewis except with a cervical anastomosis, therefore better for more proximal lesions

42
Q

What is a transhiatal esophagectomy?

A
  • involves a laparotomy and left cervical incision with cervical anastomosis
  • avoids the morbidity of a thoracotomy and cervical leaks are tolerated better than thoracic
  • downside is potentially fewer LNs harvested and there may be difficulty mobilizing large mid-thoracic tumors
43
Q

Is a cervical or thoracic esophageal anastomosis better tolerated by patients?

A

cervical

44
Q

What is the conduit of choice for patients undergoing esophagectomy with a history of gastric resection?

A

colon interposition conduit

45
Q

What is the role of adjuvant chemotherapy for esophageal cancer?

A
  • SCC does not require adjuvant therapy if there is an R0 resection, regardless of LN status
  • ACA usually get adjuvant therapy except when they have T1, N0 disease and did not receive neoadjuvant therapy
46
Q

Describe chemotherapy in patients with esophageal cancer.

A
  • typically fluorouracil or taxane based
  • survival benefit for neoadjuvant and peri-operative chemotherapy in patients with resectable lesions
  • chemoradation is the definitive therapy for unresectable disease
  • adjuvant therapy indicated for ACA (except T1, N0 disease that did not get neoadjuvant therapy) but not SCC
47
Q

What are the anatomic areas of esophageal narrowing? Why is this important?

A
  • important because they are most vulnerable to injury

- cricopharyngeus, aortic arch, left mainstream bronchus, LES

48
Q

What is the primary blood supply to a gastric conduit after esophagectomy?

A

right gastroepiploic

49
Q

Why is Tylosis?

A
  • an autosomal dominant condition linked to chromosome 17q25
  • presents with dysphagia and skin thickening on the palms and soles
  • carries at 40-90% risk of esophageal SCC by age 70 and therefore requires annual EGD starting at age 20
50
Q

What diagnosis is suggested by SCC of the head, neck, and esophagus along with pancytopenia?

A

Fanconi Anemia

51
Q

What kind of enteral access is indicated for locally advanced esophageal cancer?

A

J-tube since you want to preserve the stomach as a conduit

52
Q

What is the most common benign tumor of the esophagus?

A

esophageal leiomyoma

53
Q

What diagnosis is most likely for a patient with dysphagia and a well-circumscribed, ovoid mass on barium swallow in the wall of the mid-esophagus?

A

esophageal leiomyoma, the most common benign tumor of the esophagus

54
Q

How is esophageal leiomyoma diagnosed and treated?

A
  • typically diagnosed based on characteristic appearance on barium swallow
  • should not biopsy because this creates mucosal scarring and makes enucleation more difficult/dangerous
  • treat with enucleation via VATS or thoracotomy (right-side for mid-thoracic, left-side for distal) if tumors are symptomatic or greater than 5cm
55
Q

What is the indication for surgical intervention for patients with esophageal leiomyomas?

A

enucleation via VATS or thoracotomy (right-side for mid-thoracic, left-side for distal lesions) for tumors >5 cm or that are symptomatic

56
Q

What is a Schatzki’s ring?

A
  • a narrowed ring of mucosa just above the GEJ at the squamocolumnar junction secondary to long-standing GERD
  • typically presents with dysphagia
  • treat with dilation and PPI
57
Q

From which side should you approach the esophagus at the following levels:

  • cervical
  • mid-thoracic
  • dista
A
  • cervical: left
  • mid-thoracic: right
  • distal: left
58
Q

How are esophago-gastric junction tumors classified?

A
  • type I: distal part of the esophagus located between 1-5 cm above the GEJ
  • type II: in the cardia, within 1cm above and 2cm below the GEJ
  • type III: in the subcardial stomach, 2-5 cm below the GEJ

BTK Book Review (13 decks)

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