Esophagus 2 Flashcards
What is the commonest cause of esophageal perforation?
IATROGENIC
What is Boerhave’s syndrome?
uncoordinated esophageal motility in drunks or head trauma leading to increase in intra-esophageal pressure without relaxation during vomiting -> perforation
How does a patient with esophageal perforation present?
- severe chest pain
- severe dysphagia
- surgical emphysema at neck & chest
- fever & toxemia
What investigations should be used in perforation?
XRAY -> pneumomediastinum
- > pleural effusion
- > surgical emphysema
GASTROGRAFIN SWALLOW
THORACOCENTESIS -> purulent aspirate
How should a perforation in the cervical portion of the esophagus be treated?
- could heal spontaneously
- NPO
- IV fluids
- antibiotics
- drainage
- surgical repair is (early or conservative fails for 2 weeks)
How should a perforation in the thoracic portion of the esophagus be treated?
- never heals spontaneously
- primary repair
- stenting
- esophagectomy & gastric pull-up in case of bad general condition or extensive tear)
acidic injury leads to?
coagulative necrosis -> prevents deeper injury
Alkaline injury leads to?
liquefactive necrosis -> deeper penetration -> perforation
What complications could corrosive esophageal injury lead to?
EARLY -> laryngeal edema, shock, dehydration, perforation, & sepsis
LATE -> stricture & malignant transformation
How should corrosive injury be managed?
AT SITE -> ensure patent airway (cricothyroidotomy if needed)
-> swallow water
AT HOSPITAL -> NPO
- > IV Fluids
- > parenteral antibiotics
- > steroids to decrease edema & prevent stricture
2 DAYS LATER -> GASTROGRAFIN SWALLOW shows leakage or double level stricture
ESPHAGOSCOPE -> after 24 hrs
What minimally invasive management should be done in case of corrosive injury?
DILATATION
- needs long term follow up to detect recurrent strictures or malignant transformation
What management is done in corrosive injury when dilatation fails & malignant transformation needs to be eliminated?
ESOPHAGECTOMY
- ends by gastric pull up
What is done for corrosive injury when the esophagus is extensively fibrosed & is irresectable?
BYPASS
- through gastric pull up, colonic bypass, or jejunal bypass
What is the commonest benign esophageal neoplasm? What does it originate from?
leiomyoma
- smooth muscles of musculosa
How does a patient with leiomyoma present & what investigations should be performed?
- dysphagia to SOLIDS
BARIUM SWALLOW -> smooth filling defect
ENDOSCOPIC US -> confirmation + biopsy (exclude GIST)
How should esophageal leiomyoma be treated?
small (<5cm) & asymptomatic -> follow up
large (>5cm) OR symptomatic -> excision
old male presents with recent onset of dysphagia progressing rapidly, what is the first thing to suspect?
cancer esophagus
What are the predisposing factors to cancer esophagus?
- chronic irritation
- achalasia of cardia
- Barret’s esophagus
- post-corrosives
- benign tumors: papilloma
- food preservatives
What is the macroscopic picture of cancer esophagus?
- proliferative mass
- infiltrating mass
- malignant ulcer
What is the microscopic picture of cancer esophagus?
- squamous cell carcinoma
- adenocarcinoma from cardia, Barret’s, upward spread of gastric carcinoma
- anaplastic
How does cancer esophagus spread directly?
- circumferentially then beyond wall
- cervical -> trachea & RLN
- thoracic -> trachea, aorta, lung & vertebrae
- abdominal -> liver, stomach & diaphragm
What lymph nodes does cancer esophagus spread to?
- CERVICAL -> deep cervical LNs
- THORACIC -> mediastinal LNs
- ABDOMINAL -> left gastric & celiac LNs
Which part in cancer esophagus can spread transcelomically?
ABDOMINAL PART
- causes Krukenberg’s tumor, malignant ascites & peritoneal nodules
What is the clinical picture of cancer esophagus?
- old males
- dysphagia: insidious, progressive in short period, more to solids, excessive salivation with dribbling
- regurgitation
- rapid weight loss
- hematemesis
- recurrent chest infections
What signs are considered as late manifestations of cancer esophagus?
- cachexia
- chest infection
- palpable cervical LN
- malignant ascites
What investigations should be done for diagnosis of cancer esophagus?
BARIUM SWALLOW -> RAT TAIL
ESOPHAGOSCOPY -> BEST
What investigation should be used to stage cancer esophagus?
endoluminal US
How is cancer esophagus treated?
CURATIVE TREATMENT IF OPERABLE
- patient has good general condition
- tumor is not advanced
PALLIATIVE IF INOPERABLE
- patient has bad general condition
- tumor is advanced of fixed to vital organs
How is the curative treatment performed in case of operable cancer esophagus?
BUILD UP PERIOD for 1-2 weeks
- jejunostomy to correct nutritional deficiency
- IV Fluids
- hypokalemia & hyponatremia
- respiratory tract infections
ESOPHAGECTOMY
- Ivor Lewis -> resect abdominal & part of thoracic -> anastomose at chest (if it leaks its fatal)
- McKeown -> resect the whole esophagus & anastomose at neck using cervical, thoracic, abdominal, & neck incisions
- Tranhiatal dissection (most common) -> resect whole esophagus without thoracic incision & anastomose at neck
What is done is palliative treatment?
relieving dysphagia to improve the quality of life
- bypass -> only if medically fit
- stenting -> in surgically fit
- radiotherapy -> in upper esophagus
- laser photocoagulation -> vaporization of tumor
- feeding gastrostomy
- chemotherapy
What is the cause for post-cricoid carcinoma? How does it present?
occurs on top of Plummer Vinson syndrome
- pain instead of dysphagia
- pain referred to the ear
how is post-cricoid carcinoma treated?
- operable -> total pharyngeolaryngectomy with block neck dissection
- inoperable -> radiotherapy
