Esophagus Flashcards
What are the layers of the esophagus?
- mucosa
- submucosa
- muscularis propia
What is the blood supply to the esophagus?
- inferior thyroid artery to the cervical esophagus
- vessels off the aorta to the thoracic esophagus
- left gastric and inferior phrenic arteries to the abdominal esophagus
What muscle forms the upper esophageal sphincter? What is it innervated by?
the cricopharyngeus innervated by the superior laryngeal nerve
What is Killian’s triangle?
- an area in the wall of the pharynx which is a potential weak spot where a Zenker’s can form
- superior to the cricopharynxgeus muscle and inferior to the inferior constrictor muscles
Where do Zenker’s diverticulum form?
in Killian’s triangle, above the cricopharyngeus and below the inferior constrictor muscles
What features on a CXR would support a diagnosis of esophageal perforation?
- pneumomediastinum
- pleural effusion
- subcutaneous emphysema
- pneumothorax
- sub diaphragmatic air
What is the study of choice to diagnose an esophageal perforation?
gastrografin (water soluble) swallow
When should you use gastrografin versus dilute barium?
- gastrografin should generally used first to diagnose a leak because it is less likely to cause problems after extravasation
- dilute barium can be used because it has higher sensitivity or in patients at high risk of aspiration
What is the most common site of an esophageal perforation? What about the most common site of iatrogenic perf?
- most common: distal esophagus in the left posterolateral aspect 2-3 cm above the GEJ
- iatrogenic: at the cricopharyngeus
Where is the most common site of iatrogenic esophageal perforation?
at the cricopharyngeus
How should a cervical esophageal perforation be managed?
- IVF resuscitation
- broad spectrum abx (ampicillin, ceftriaxone, flagyl, and fluc)
- wide local drainage
How should thoracic esophageal perforations be managed in a stable patient?
- IVF resuscitation
- broad spectrum abx (ampicillin, ceftriaxone, flagyl, fluc)
- primary repair (left thoracotomy, debride, myotomy to visualize whole mucosal injury, two layer repair with absorbable and permanent suture, buttress, leak test, NGT, mediastinal drain, enteral access, closure)
- consider esophagectomy depending on etiology
Which patients should have an esophagectomy for perforation?
those with malignancy, caustic perforation, or burned out megaesophagus from achalasia
How should thoracic esophageal perforation be managed in an unstable patient?
exclusion and diversion
- closure of perforation over a T-tube
- mediastinal drainage
- cervical esophagostomy
- J-tube placement
What defines achalasia?
incomplete relaxation of the LES with peristalsis or hypotonic esophageal contractions
What are the three types of achalasia?
- type I: normal esophageal pressure with apersitalsis and impaired LES relaxation
- type II: increased intraesophageal pressure, absent peristalsis, impaired LES relaxation
- type III: distal esophageal spastic contractions, absent peristalsis, impaired LES relaxation
Bird’s beak is used to describe what esophageal pathology?
achalasia
What is the etiology of achalasia?
degenerative loss of NO-producing inhibiting neurons within the LES
What is pseudoachalasia?
achalasia caused by malignancy
What is the treatment for achalasia?
- lap Heller myotomy with partial fundoplication (6cm onto esophagus, 2cm onto stomach)
- endoscopic therapies increase the rate of surgical complications in subse
What is the treatment for achalasia?
- lap Heller myotomy with partial fundoplication (6cm onto esophagus, 2cm onto stomach)
- endoscopic therapies increase the rate of surgical complications in subsequent interventions and are thus avoided in healthy patients that can undergo surgery
If a patient with achalasia is undergoing balloon dilation and a perforation is caused, what is the next step?
repair with myotomy at the same time
What is isolated hypertensive LES?
high basal LES with complete relaxation and normal peristalsis
How is isolated hypertensive LES treated?
- calcium channel blockers
- nitrates
- heller
