esophagus Flashcards
what does the esophagus do
muscular alimentary tube 25cm long that connects the pharynx to the stomach
levels of the esophagus
starts at cricoid cartilage (6th cerv vert) and ends just below diaphragm (11th thoracic vert)
15cm from incisors to about 40cm from incisors
3 areas of esophageal narrowing
- prox esophagus at level of cricopharyngeus muscle
- midesophageal at level of aortic arch
- dist narrowing as level of diaphragm
two functional sphincters in esophagus
- UES at cricopharyngeus muscle
- LES between esophagus and stomach
arterial/venous/lymphatic supply of cervical esophagus
- inferior thyroid artery from thyrocervical trunk artery
- inferior thyroid vein
- deep cervical (jugular) nodes
arterial/venous/lymphatic supply of thoracic esophagus
- bronchial arteries and small esophageal arteries from thoracic aorta
- azygos being and hemiazygos vein
- nodes in posterior mediastinum (paratracheal and pulmonary hilar)
arterial/venous/lymphatic supply of distal esophagus
- left gastric artery
- coronary and left gastric vein
- celiac, left gastric, parahiatal nodes
what leads to esophageal varices
in liver cirrhosis w portal vein htn, the lower esophageal venous plexus provides collateral drainage from portal venous system to azygos veins
nerves of the proximal esophagus
recurrent laryngeal nerves of the vagus nerve and cervical sympathetic chain
what happens when there is damage to the recurrent laryngeal nerve
disrupts vocal cords and swallowing mechanism of upper esophagus inc risk of aspiration
nerves of mid and distal esophagus
vagus and thoracic sympathetic chain
what happens when the myenteric plexus is damaged
leads to achalasia (failure of esophageal muscle relaxation)
motor innervation of the esophagus is supplied through
vagus
4 layers of esophageal wall
mucosa(superficial and deep), submucosa, muscularis propria, adventitia
cell type of muscularis propria
striated muscle fibers of prox 1/3 to smooth muscle distal 2/3
cell type of mucosa
nonkeratinizing, stratified squamous epithelium
Barrett’s esophagus
presence of columnar epithelium in the esophagus; results from a metaplastic change caused by repeated inflammation of normal squamous epithelium; small, but significant tendency toward the development of cancer.
GERD
what does the resting high pressures of the sphincters help prevent
reflux and regurg of digestive material back up the esophagus
dysphagia
difficulty w transition of ingested substances from the mouth to the stomach; liquids and solids
food becomes “stuck”
odynophagia
painful swallowing; can be due to esophageal infx, foreign body in esophagus or injury of esophagus
globus hystericus
“lump in throat”
heartburn
pyrosis or water brash; assoc w GERD, achalasia, esophageal stricutes;
regurgitation
passive return of ingested material into oropharynx
vomiting
active return of stomach contents into oropharynx
mc cause of esophageal bleeding
ulcerative esophagitis; usually causes occult blood in stool
singultus
“hiccup”; diaphragmatic irritation and may indicate hernia
different dx eval of esophagus
- barium esophagography: pt swallows barium and monitored w real time video to assess esophageal motility and look for hiatal hernia, diverticula or obstruction
- esophageal manometry:direct simultaneous measurement of intraluminal pressures at multiple levels; function of both UES and LES; tube in nose and swallow water; achalasia, esophageal spasm and GERD
- esophageal pH monitoring:distal esophagus for GERD, 24hr study w pH probe in nose ph
imaging studies
- CT: esophageal perf
- upper endoscopy: visualization and bx, dilations, injections
- endoscopic us (EUS): detailed imaging of esophageal wall and adjacent lymph node;fine needle aspiration; cancer,lesions
causes of poor LES function leading to GERD
-hiatal hernia, inc intra abd or gastric pressures, food/drug induced relaxation, abnorm esophageal peristaltic activity
pt with heartburn, regurg, and dysphagia, dyspepsia after heavy/greasy meal
GERD
how can symptoms of GERD be induced
lie supine or lean over to tie shoes
late complications of GERD
- schatzki’s ring: stricture of distal esophagus
- Barrett’s esophagus: intestinal metaplasia of distal esophageal mucosa
recommendation for managing Barretts esophagus assoc w low grade dysplasia
routine f/u endoscopy every 6-12m w 4 quadrant bx ever 1-2cm of involved esophagus
w/u for GERD
- barium swallow
- esophageal manometry
- 24 hr ph study
- upper endoscopy
tx GERD
- behavioral modifications: eating habits, posture, avoid triggers (smoking, alcohol, anticholinergics, calcium, beta blockers, xanthines, aspirin, acidic foods, fatty meals, caffeine, chocolate)
- PPIs- nexium, prevacid, prilosec, protonix,
- surgery
principles of antireflux surgery
(1) restoration of an intra-abdominal segment of esophagus, (2) reconstruction of the esophageal hiatus in the diaphragm, and (3) reinforcement of the LES, usually with a fundoplication.
fundoplication
operation to restore competence to the esophagogastric junction as part of the treatment of sliding hiatal hernia and reflux esophagitis; the most common is the Nissen fundoplication, in which the gastric fundus is wrapped around the lower and intra-abdominal segment of the esophagus to produce an acute angle of His and other functional changes.
two types of esophageal cancer
- squamous cell carcinoma
- adenocarcinoma
SCC of esophagus
- AA male
- mid to pro segment but can involve distal
- strong assoc w alcohol and tobacco
adenocarcinoma
- now mc
- whites
- distal and assoc w Barretts
s/sx of carcinoma
- both dysphagia w solid foot and weight loss
- adeno also assoc w reflux
dx of carcinoma
- barium swallow
- endoscopic eval
-ct and pet for metastasis
tx carcinoma
surgical resection
pros and cons of using the stomach as an esophageal substitute
pro: rich vascular supply, ease of surgical mobilization as vascularized pedicle, cease 2 less GI anastomosis
cons: risk of ischemia, postop GERD
pros and cons of using the left colon as an esophageal substitute
pros: longer length, vascular, close size match, more resistant to reflux
cons: two additional anastomoses, greater technical experience needed in assessing and mobilizing colon vasculature
two ways for surgical resection of the esophagus
thoracotomy or transhiatal approach
the 3 main surgical approaches in performing a thoractomy
- Ivor Lewis: mc via right thorax combined w abd incision; gastroesophageal anastomosis is located in right chest
- McKeown: for tumors involving prox and midesophagus w 3 incisions (abd, right thoracotomy, cervical) plus cervical gastroesophageal anastomosis
- enbloc resection: distal esophagus tumor ext into stomach; left thoracoabd incision
pros and cons of a transmittal approach
pros: avoidance of painful thoracotomy incision, dec lung trauma from mechanical retraction, avoidance of intrathoracic anastomosis
cons: limited resection of large tumors, greater potential for local tumor spillage from blunt dissection, greater stretch of stomach to reach neck
what is the goal of neoadjuvant therapy (preop therapy)
down stage the tumor and improve cancer survival after surgical resection
(5fluorouracil and cisplatinum w 45gy radiation over 6-7weeks)
palliative interventions for pt w terminal esophageal carcinoma are directed toward
relief of severe dysphagia and obstruction
types of palliative interventions
- dilatation
- stents
- laser and photodynamic therapy
- radiation and chemo
Boerhaave’s syndrome
spontaneous tear of the distal esophagus can also occur after episode of violent vomiting and retching
where do most cervical esophagus injuries due to endoscopic instrumentation occur
level of cricopharyngeal sphincter
immediate concern of cervical esophageal injury
sepsis
pain w swallowing and neck flexion; tenderness and crepitus; air in retrovsiceral space on X-ray
cervical esophageal injury
tx cervical esophageal injury
- IV abx
- surgical debridement
- drainage
acute signs of sepsis, chest pain, respiratory distress, pleural effusion
thoracic esophageal injury
tx thoracic esophageal injury
- med manag: abx, ng drainage, distal tube feeds
- surgery
sliding hiatal hernia (type 1)
- GE junction slides in and out of chest through esophageal hiatus; assoc w GERD
paraesophageal hernia (type 2)
-isolated stomach prolapsed through a weakened phrenoesophageal ligament but preservation of GE junction in abdomen
type 3 hernia
combination of sliding and paraesophageal hernia
type 4 hernia
herniation of other organs including colon and spleen
imaging for hernias
- plain chest xray to show presece of air fluid level in mediastinum or left chest
- contrast upper GI w swallow is considered gold standard for id’ing adv hernies
tx type 1 (sliding) hernia
- asymp= observed if no risk for incarceration
- surgery= esophagus shortened; Collis gastroplasty needed to reconstruct distal esophagus in addition to fundoplication procedure
mc motility disorder affecting esophagus
achalasia= failure to relax; degenerative ds of myenteric (Auerbach’s) neural plexus which leads to denervation of the esophagus w resultant failure of relaxation of LES upon swallowing
dx achalasia
barium swallow showing birds beak sign and manometric studies showing failure of LES to relax w swallowing
-endoscopy to rule out other possible causes
tx achalasia
- palliative since can’t be cured
- initial=oral/sublingual nitrates and CCB to promote LES relaxation prior to meals (nitro and nifedipine)
- endoscopic balloon dilation of LES
- botox
- Heller myotomy surgery: distal esophageal sphincter divided down to mucosa
hypermotility ds of the esophagus include
- diffuse esophageal spasm
- nutcracker esophagus
tx hypermotility ds
- nitrates and CCB
- extended esophageal myotomy from aortic arch level to stomach
two types of esophageal diverticulum
- pulsion= more common and assoc w esophageal motility dysfunction; located in prox/distal esophagus; “false diverticula” because lack full muscle layer
- traction= midesoph and dev from local lymph node inflammatory rxn causing traction on esophageal wall; no assoc w esophageal dysmotility and considered true diverticula since all lays are involved
Zenker’s diverticula
pulsion diverticula and occur at cervical esophagus; assoc w cricopharyngeal muscle dysfunction w failure to relax on swallowing causing prix obstruction
where does zenkers diverticula occur
posteriorly, in the transition area of weakness between hypo pharynx and esophagus just above cricopharyngeus muscle
assoc w regurg of recently swallowed food/pills, dysphagia, choking, or halitosis
zenkers
dx of zenkers
barium swallow
tx symptomatic zenkers
myotomy of cricopharyngeal muscle and diverticulectomy or diverticulopexy (inversion and fixation of diverticulu to promote drainage by gravity)
tx for epiphrenic diverticula (distal third of esophagus)
left thoractomy, w diverticulum resection and repair, followed by stricture dilation or an extensive distal myectomy to prevent recurrence
inflammatory paratracheal lymph node ds assoc w tuberculosis or histoplasmosis
traction diverticula- asymp and left alone
mc benign neoplasm of esophagus
leiomyoma located in muscularis layer
mc mucosal/submucosal lesions of esophagus
granular cell tumor and fibrovascular polyp
tx asymp masses
observation because fine needle aspiration or bx don’t differentiate benign from malignant and manipulation of a cyst can result in iatrogenic infx
dx of foreign body ingestion
X-ray of neck and chest w later views of neck to rule out cervical or mediastinal emphysema
ct scan
why is barium study contraindicated with foreign body ingestion
high risk for aspiration and contrast delineation does not add to management of pt
tx foreign body ingestion
-gentle extraction using a rigid esophagoscope under general anesthesia
long term complication from ingestion of caustic material
stricture formation
dx ingestion of caustic material
hx and pe then flex endoscopy within 48hrs
tx of ingestion of caustic material
- first priority is airway maintenance
- 2nd priority maintenance of esophageal patency
tx if initial endoscopic eval of caustic material is 2nd or 3rd degree burns
percutaneous gastrostomy
A 50-year-old man has the onset of chest pain shortly after he undergoes pneumatic dilatation of the lower esophageal sphincter to treat achalasia. An upper gastrointestinal (GI) water-soluble contrast study shows free extravasation of the contrast material at the level of the distal esophagus. The decision is made to take the patient to the operating room for Immediate repair. The best surgical incision to use is a(n)
The best exposure of the distal thoracic esophagus is through a left thoracotomy. Anatomically, the upper and middle thoracic esophagus runs along the right side of the aorta, but the distal esophagus swings anterior and then to the left of the aorta to exit into the abdomen. The esophagus is not accessible through a median sternotomy because it lies in the posterior mediastinum with the heart lying anterior to it. A right thoracotomy is used to expose the proximal and middle thoracic esophagus. A left thoracoabdominal incision is a large morbid incision and is not necessary for the repair of the perforation and to perform a myotomy.
A 50-year-old woman comes to the clinic because of severe heartburn and regurgitation after meals and on lying down. She has been on long-term proton pump inhibitors with good relief of symptoms but now wants to have antireflux surgery. Her body mass index (BMI) Is 32.4. The preoperative study most useful in predicting symptomatic relief from antireflux surgery is a(n)
Evidence of abnormal acid reflux obtained from a positive 24-hour pH study is the best indicator for likely benefit of an antireflux procedure in gastroesophageal reflux disease (GERD). The other studies offered above can provide additional information on GERD but are not as sensitive in identifying potential surgical candidates for antireflux procedure. A barium swallow can identify a hiatal hernia, associated strictures, or shortened esophagus. A CT scan provides very little additional information but may demonstrate the presence of a hiatal hernia. Upper endoscopy is useful in identifying and monitoring progression of Barrett’s disease. Manometric study, when abnormal, is useful In Identifying motility dysfunction, which may affect surgical outcome.
A 43-year-old woman is being considered for antireflux surgery. She has a long history of reflux symptoms that are now only partially controlled with lifestyle changes and a proton pump inhibitor. Upper endoscopy showed a small hiatal hernia and a short segment of intestinal metaplasia, but no evidence of dysplasia. She wants to know the possible advantage of the Toupet (partial) fundoplication as compared to the Nissen (full) fundoplication. The theoretical advantage for the Toupet fundoplication procedure is
- dec postop symp of dysphagia and gas bloat
Because the Toupet procedure Is a partial fundoplication, there is less risk for developing dysphagia or from having difficulty burping as compared to a full encircling fundoplication. Both the Toupet and Nissen procedures can be performed laparoscopically with minimal morbidity and mortality. Because the Nissen is a full fundoplication, many proponents argue that it provides better protection from recurrent reflux. No antireflux procedure has been conclusively shown to prevent or reverse Barrett’s disease, and continued periodic endoscopic monitoring is recommended. Both the Toupet and Nissen procedures are usually performed through an abdominal incision.
A 74-year-old man has a recent diagnosis of adenocarcinoma of the distal esophagus. He has a long history of reflux and Barrett’s esophagus, and a recent upper endoscopy and biopsies confirmed the diagnosis. A staging workup Is planned. What is the best study for assessing Τ (tumor Invasion depth)?
The endoscopic ultrasound is the best way to assess the depth of tumor invasion (T stage) and is also useful in identifying adjacent abnormal lymph node for fine needle aspiration (N stage). A barium swallow Is a good initial study in the workup of dysphagia and helps locate the level of the lesion. A CT scan may show gross invasion of adjacent structures but cannot differentiate tumor depth. Upper endoscopy is used to obtain biopsies to confirm carcinoma, but depth of invasion cannot be determined from the biopsy specimen. A PET scan is used to identify distant metastasis but does not have the resolution to determine tumor depth.
A frail 85-year-old man underwent upper endoscopy with dilation and biopsy of a distal esophageal stricture. Concerned about a perforation, the endoscopist obtained a water-soluble contrast upper GI study that confirmed a perforation. Nonsurgical management Is acceptable if
- upper GI study shows leak of contrast, which drains back into esophagus
Conservative management Is acceptable if contrast study shows a contained leak that drains back into the esophageal lumen. A new left pleural effusion is indicative of a more severe leak, which should not be managed conservatively. Obstructing lesions cannot be Ignored, as any obstruction will exacerbate the leak. Pain is indicative of excessive leak of GI contents into the mediastinum and pleura, which cannot be managed conservatively. Duration of perforation should not dictate whether surgical intervention is or is not pursued.
