Esophagus Flashcards
Strongest layer
Mucosa (in small bowel, submucosa is strongest)
Normal LES tone
15-25 mm Hg
Swallowing order of events
soft palate closes nasopharynx, larynx up, larynx closes, UES relaxes, pharyngeal contraction
Zencker’s diverticulum definition
Dysfunction of upper esophageal sphincter muscles
Zenker’s tx
division of upper esophageal sphincter muscles
>3 cm diverticulum: endoscopic division of UES sphincter
<3 cm diverticulum: open division
Mid-esophageal diverticulum
o Traction diverticulum (all three layers of esophageal wall being pulled)
Tx: VATS diverticulotomy and dissection
Barrett’s surveillance
- Surveillance: EGD with bx annually, 4 quadrant biopsy every 1-2 cm of affected segments
o Low grade dysplasia: repeat EGD in 6 months
o High grade dysplasia: repeat and confirm endoscopic mucosal resection
Achalasia manometry findings
High LES/normal basal pressure with incomplete LES relaxation
Absent/incomplete peristalsis
Paraesophageal hernia tx
Operate -> risk of incarceration, strangulation
Diffuse esophageal spasm manometry findings
o Normal LES pressure and relaxation
o High amplitude, uncoordinated esophageal contractions
Achalasia tx
Tx: Hellery myotomy with fundoplication
Myotomy: 6 cm onto the esophagus, 2 cm onto stomach
DES tx
CCB, nitrates -> long segment myotomy
Nutcracker esophagus manometry findings
o Normal LES pressure and relaxation
o High amplitude, coordinated contractions
Nutcracker esophagus tx
CCB, nitrates -> long segment myotomy
Cause of achalasia
o Degenerative loss of inhibitory neurons of LES
o Chagas disease, autoimmune, idiopathic
o Pseudoachalasia: secondary to tumor/malignancy
Barrett’s esophagus definition
metaplasia from squamous to columnar cells. 1-2% get adenocarcinoma (30-100 x risk) P53 associated (tumor suppresor gene)
main supply to stomach when used to replace esophagus?
R gastroepiploic artery
Leiomyoma tx
if symptomatic or > 5cm excise by enucleation via thoracotomy (R if middle, L if lower esophagus). Do not biopsy on EGD.
Narrowest point of diaphragm
Cricopharyngeus
Contained esophageal perforations treatment
observation and abx ok
Barrett’s histologic change
squamous to columnar cells with Goblet cells
LES resting pressure
10-20 mm Hg
UES resting pressure
50-70 mm Hg
Surgical esophagomyotomy steps
Incise 6.5 cm of longitudinal then circular muscle fibers of distal esophagus and 2.5 cm of proximal gastric muscle fibers
Mallory Weiss syndrome
linear tear of gastroesophageal mucosa
Blood supply to the gastric conduit after esophagectomy
R gastroepiploic artery
Principles of partial fundoplication (Dor - anterior, Toupet - posterior)
Restore an intra-abdominal segment of distal esophagus
Accentuate the angle of His
Create a long anterior mucosal valve at GEJ
Esophageal cancer T stages
o T1: 1A: invades lamina propria or muscularis mucosa 1B: invades submucosa o T2: invades muscularis propria o T3: invades adventitia o T4: invades surrounding structures T4a: resectable (invades pleura/pericardium, etc) T4b: unresectable
Tx of esophageal CA >5 cm from cricopharyngeus + resectable
esophagectomy
Tx of esophageal CA <5 cm from cricopharyngeus
definitive chemoradiation
T1a tumors tx
endoscopic mucosal resection +/- ablation
T1b (no nodes) tx
upfront esophagectomy
T2 or greater OR any positive LN tx
neoadjuvant + esophagectomy
Unresectable disease or distant mets tx
chemoradiation only
Layers of the esophagus
Mucosa
Submucosa
Muscularis propria
NO SEROSA
Blood supply of the esophagus
Cervical portion: inferior thyroid artery
Thoracic portion: straight from aorta
Abdominal portion: L gastric and inferior phrenic arteries
UES is made of? Innervated by?
Cricopharyngeus muscle
Superior laryngeal nerve
Tx of Barretts with high grade dysplasia?
Endoscopic treatment: radiofrequency ablation vs endoscopic mucosal resection
Radiofrequency ablation preferred for long segment Barretts
EMR best for lesions < 2 cm - resect down to submucosa
Esophageal varices treatment
Prophylactic antibiotics for 7 days
Started on octreotide and/or vaso - reduces portal blood flow and thus reduces portal pressure
Endoscopic therapy: sclerotherapy or variceal banding
Techniques of transthoracic heller myotomy
Patient positioned in right lateral decubitus position
Enter the pleural space in the 7th intercostal space
Incise the inferior pulmonary ligament
Retract the lung medially and cephalad
Incise the mediastinal pleura
Encircle the esophagus with a penrose drain
Identify both vagus nerves
Perform esophagomyotomy
Manometry findings of scleroderma
Low amplitude
Simultaneous contractions with normal or low LES pressures
Most common complication following fundoplication
Dysphagia
MC cause is post-op edema - self limiting and resolves within 6-8 weeks
If dysphagia persists beyond this time frame, further investigation is indicated
Hormones that increase LES pressure
Gastrin
Motilin
Hormones that decrease LES pressure
CCK Estrogen/progesterone Glucagon Somatostatin Secretin
Manometry findings of achalasia
Hypertonic LES, failure of LES to relax with a food bolus
Aperistalsis
