Esophagus Flashcards
1
Q
MCC of dysphagia and first line treatment?
A
Benign strictures, serial dilations
2
Q
hiatal hernia ulcer? Mechanism
A
Cameron ulcer, constant movement
3
Q
Child drinks drain cleaner and p/w drooling/vomiting but otherwise stable…. what next?
A
PO challenge
4
Q
Benefit of hiatal mesh? what type is preferred? What if hiatus will no close with simple repair?
A
short term recurrence
absorbable
bridging mesh with NA
5
Q
First line for hiatal hernia evaluation/imaging?
A
Upper GI
6
Q
GS for esophageal loco-regional staging?
A
PET-CT chest
7
Q
Diet for Nissen post op
A
1-2 weeks liquid diet to avoid worsening edema
8
Q
Which operation for Right mid esophagus perforation with large defect, sick patient
A
R PLat thoracotomy, spit fistula, esophagectomy
9
Q
Size for endoscopic zenkers tx?
A
> 3cm
10
Q
Structural cause of zenkers?
A
cricopharyngeus
11
Q
Key step in zenker’s surgery
A
myotomy
11
Q
Barrier to endoscopic zenkers tx?
A
rigid neck, small sack
11
Q
treatment of peptic esoph stricture?
A
dilation
12
Q
Triad for gastric volvulus
A
Borchardt triad (severe epigastric pain, inability to vomit, and inability to pass a nasogastric tube)
12
Q
Tx for met esophageal ca, chemo reg? Notable receptor target?
A
palliative – needs med onc, FOLFOX/ cisplatin/5fu or nivolumab
PDL-1
13
Q
high grad dysplasia for esoph with short segment … tx?
A
EMR
14
Q
low grade dysplasia on EGD, what next
A
6 month surveillance
15
Q
demeester score indicating surgery appropriateness
A
14.7
16
Q
Percent of population with GERD
A
20%
17
Q
4 big causes of GERD
A
Diet/obesity, Scleroderma, lung path, hiatal hernia
18
Q
4 dg studies for GERD s/s
A
manometry, Egd, motility, impedence, pHstudies
19
Q
3 measures of a weak LES
A
P<6mmHg, 2cm length, abd length 1 cm
20
Q
MC esoph dysmotility disorder
A
Achalasia
21
Q
2 usual achalasia findings on manometry
A
no LES relaxation and absent esoph peristalsis
22
GS for achalasia surg tx
myotomy
22
med tx for DES
nitrates, sildenafil, tricylcics
22
Gold standard for esophageal leaks
gastrograffin and barium if negative initially
22
Nutcracker med tx?
nitrates, sildenafil, tricylcics
22
4 landmarks for EGD path start to finish
Vocal cords/aryepiglottic folds, UES(crichopharyngeal m), Aortic Arch(skeletal to smooth muscle), Squamocolumnar junction(LES)
22
4 steps of GERD workup
1 - Acid Test(demeester)
2 - Manometry
3- Esophagram
4 - EGD(can be same day as surgery
23
GS for esoph dysmotility?
manometry
24
5 risk factors for GERD
Obesity, pregnancy, conn tiss disorders, hiatal hernia, DGE
25
GS start for GERD testing
acid test + impedence
26
6 PPI side effects
HypoMg, osteoporosis, hypergastrinemia, AIN, B12 deficiency, Lupus
27
4 surgical goals of anti-reflux procedure
1 - Reduce hernia
2- Tension free intra-abd
3 - Approx crura
4 - Fundo
28
Medical steps before fundo after confirmed GERD
diet, double ppi
29
6 GERD surgical indication
Failed BID
GERD complications
Preference
Cx of PPI
Lung Tx patients
Atypical pH proven(14.7)
30
Structural elements predisposing GERD? Inciting disease?
Hiatal hernia; scleroderma
31
4 studies for GERD preop
manometry, EGD, impedence, motility
32
3 objective measures of a defective LES predisposing to GERD
P<6; length<2cm; abdominal length>2cm
33
What is the most common esoph dysmotility disorder? 2 big dg tests and their findings
Achalasia
Manometry: poor LES relaxation with absent peristalsis
Esophogram: Bird's Beak
34
Pseudoachalasia?
Tumor
35
MOA achalasia
dec inhib ganglion cells of LES
36
How is HTN LES diif than achalasia
Inc LES P but it does relax normally
37
DES treatment? med vs surgery
Nitrates, Tricyclics, Sildenafil
Long myotomy
38
Nutcracker tx?
Same as DES
39
Gold standard for esophageal leaks
Esophogram
40
3 components of the LES complex
esoph muscle
phrenoesophligament
Diaphragm
41
4 landmarks on the path of your EGD esoph approach
vocal cords and aryepiglottic folds
UES(cricopahryng m)
Aortic Arch(skeletal to smooth)
Squamocolumnar junction(LES)
42
GS test for esoph motility
manometry
43
5 indications for manometry
Dysphagia after EGD
Non cardiac chest pain
preop
postop
Dg motil dis
44
Demeester cutoff for GERD
14.72 (95%)
45
4 tests for GERD wu
acid(demeester)
Manometry
Esophogram
EGD
46
Impedence test is looking for....
bile reflux
47
5 alarm signs of GERD
WL
hematemesis
Dysphagia
Melena
Early satiety
48
starting point for classic GERD signs
PPI
49
6 side effects of PPI
Hypomg
Osteo
AIN
Lupus
B12 defic
Hypergastinemia
50
After suspicion of GERD, what do you start on
if that fails
if confirmed GERD
PPI
Workup
Double PPI
51
6 indication for GERD surgery
Failed medical
pt pref
Gerd med compl issues
PPI cx
Lung tx pt
52
If there is dysplasia but ready for anti-reflux surgery
ablation first
53
4 tenets to a successful anti-reflux procedure
Reduce hernia
Tension free intra abdominal esoph
Approx crura
Fundo
54
When to avoid full fundo
dysmotility
55
Post op care for fundo pts
Limit narcs
Anti emetics
Barium esoph in am
Advance diet after, soft for 6 weeks
Stop PPI
crush meds
56
2 common post fundo complaints post op
dysphagia
Gas bloat syndrome
57
path finding for barrets
columnar lined esoph, intestinal dysplasia, goblet cells
58
Major cause of barrets
GERD
59
What can we do for prevention of worsening barrets + GERD
anti reflux med v surgery
60
Tx for LGD Barrett's, surveillance time
If it works
If it persists
PPI, diet 6 months
PPI
ARS
61
Non dysplastic barrets surveillance timing
yearly then 3 to 5
62
What is the relationship of HGD, T1a and T1b from a management standpoint
HGD/T1a adeno ---- ablation/ER/PPI plus minus ARS
T1b submuc --- esophagectomy
63
what type of esoph cancer can get ESD
Squamous only
64
1 yr risks for barrets
ND
LGD
HGD
What trial set these stats
0.2
0.7
7
AIM Dysplasia
65
EGD screening guidelines
>5y GERD symptoms
2 or more of these:
-white male
-50
-central obestiy
-smoker
-1st degree relative
66
4 reasons for pt to get esophagectomy for HGD/
t1a
high risk for mets, young, fam hx, long lesions
67
Ablation success percents for HGD/t1a esoph ca
RFA
AIM dysphagia trial
81v19
90%remission at 3
low stricture rate
68
% nodal mets estimated for a T1b
esophagectomy 30d mortality in these patients
27%
1%
69
3 PEsoph types
1 - sliding
2 - true
3 - mixed
70
2 indications for PE hernia repair
3 investigation tools
ALL symptomatics
consider young incidentals
CT/esoph
manometry
EGD
71
5 principles of PE repair
1. Reduce
2. Excise Sac
3. REduce GEJ
4.2-3cm tension free intra abdominal esoph
5.Repair defect
72
port placement for lap PE hernia repair
73
POD1 for PEH repair
Next diet progression day and what duration
UGIS, clears 72h
Soft 1 week
74
What mesh to use if can't close PEH?
biologic
75
MC type of esoph diverticulum
What type is it
Zenker's
False
76
Pathophys for zenker's
poor UES relaxation
77
4 big s/s for zenkers
halitosis, regurg, cough, dysphagia
78
4 steps to zenkers open diverticulectomy
What size sacs are these best for
1L cervical incsion
2 - Platysma, SCM and carotid sheath lateral
3 - diverticulectomy, stapler vs pexy
4 - myotomy no matter what!!!
less than 3 cm
79
endo parameters for zenkers
more than 3 cm
ANVIL must fit
80
2 muscles that make up killians triangle
pharyngeal cx m and cricopharyngeus m
81
MC dymotility disorder esoph
achalasia
82
Theoretical MOA for achalasia
infection--> loss of post ganglion inhib cells
83
6 ddx for achalasia
gerd, malignancy, webs, esophagitis, strictures, systemic tissue disroders
84
who gets medical management for achalasia and what is its
poor surgical candidates
Nitrates --- isosorbide
CCBs ----nifedipine
Sildenafil(PE5 inhibit)
Botox
85
3 endoscopic treatments for achalasia
botox
dilation
poem
86
Pneumatic dilation of achalasia gerd, relief and relapse rates
30%
60-90
33%
87
4 heller complications
Leak
GERD
Dysphagia
PTX
88
6th leading cause of cancer deaths
esoph ca
89
MC global esoph cancer
risk factors
SCC
Smoking, ETOH, achalasia, caustics
90
Where is esoph adenoCA mc?
risk factors
N america and W europe
FAT, WHITE,MALES
advanced age
TYLOSIS ---thickened palms
91
2 Late signs of esoph ca and their pathophys
Why are they so late????
Dysphagia ---2/3 luminal blockage mass effect
Hoarseness/hiccups ---- R laryngeal n and phrenic n
92
What is the Seattle Protocol
4 quad bx every 1 cm for esoph
93
how is esoph cancer caught early
GERD/barretts surveillance
94
4 parts of a full work up for esoph cancer
BX during egd
PET CT
EUS
Barium
95
Where do the paths split on t staging and tx in esoph cancer
T1a to T1b
mucosal to submucosal
EMR to surgery
96
Diff between T4a and b for esoph
a is take outable organs
pleura, pericardium, diaphragm
97
treatment of HGD for esoph
EMR
98
What is the next move for T2-T4a esoph cancer
what trial supports this
results?
Chemo plus surgery
CROSS
49 vs 24 m
inc R 0 resection
99
regimen for CROSS trial
carpiplatin and paclitaxel + rads 5 weeks
100
3 esophagectomies and their incision sites
McKeown all
Ivor - chest and abd
Trans Hiatal - neck and abdomen
101
what anatomical branching point does rouviers sulcus indicate
The entrance of what structure into the liver forms this sulcus?
bifurcation of the of main hepatic bile duct
right hepatic duct
102
muscle layers of esoph
outer - long
inner - circular
103
Upper GI tumors are 2nd only to ___
lung cancer
104
Combination of these two invest tools give the best sensitivity for esoph cance staging
EUS PET CT
105
What is the timing for esoph cancer surgery after preadjuvant chemo? why? data?
6 weeks
less inflam, inctumor regression
no good data
106
3 oncogenes for esoph ca
NOTCH1
HER2
VEGF
107
2 main indications for esoph stents
what type
Malignancy and fistulas
SEMS
108
esophageal perforation success rate with stents
80%
109
What contrast do we use first for esoph perforation eval
GG over barium, less mediastinitis risk
110
Mortality rate of esoph perf
10-40%
111
what are the causes by percent breakdown
60%
30%
5%
Endoscop
Borrhav
Malign/trauma/FB
112
What is a normal LES pressure. What is high
15-20; 45
113
Unknown ingestions should be assessed urgently with ....
EGD
114
What is the strongest prognostic factor for esophageal CA
Number of regional nodes involved
115
5y met esoph adenoca survival rate
almost 0
116
magnetic sphincter augmentation:
comparison to nissen
how often does erosion occur and what is management
Important post operative tenet
nearly equivalent
RARE, removal
eat solid food to prevent capsule formation
117
first line for scleroderma ind atonic esophagus
ppi
then toupet NOT nissen
118
What stations are important in esoph ca LN harvest
celiac, IPL, lower esoph, crural
119
most important artery for esophagectomy conduit
right gastro epiploic
120
What medication can be given for symptomatic improvement in patients undergoing serial dilations for benign stricure
Mitomycin C
121
what is the choice for bridging mesh repair for large hiatal defects
permanent
122
What percent of distal pancs become T1DM
10%
123
