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QUESTION NOTES > ESOPHAGUS > Flashcards

ESOPHAGUS Flashcards

1
Q

What type of hiatal hernia can be managed medically?

A

Type I (II-IV need surgical repair always)

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2
Q

Most common benign tumor of esophagus

A

esophageal leiomyoma (smooth muscle cells)

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3
Q

Types of achalasia (failed peristalsis)

A
  1. no pressure of esophagus; 100% failed peristalsis
  2. panesophageal pressurization
  3. premature esophageal contractions
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4
Q

MC site spontaneous esophageal perf

A

distal esophagus at L-posterior aspect ~2-3cm above GE jxn (natural weak spot)

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5
Q

Imaging to stage esophageal CA

A

endoscopic US -> depth of tumor penetration, can also identify LN mets

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6
Q

Which sxs of GERD do not improve after Nissen?

A

atypical sxs: cough, laryngitis, aspiration

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7
Q

Ideal results for paraesophageal hernia repair?

A

GE jxn AND 2+ cm distal esophagus must lie in abdomen wo tension

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8
Q

esophageal SCC more prev in …? esophageal adeno more prev in..?

A 
SCC = blacks
adeno = whites
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9
Q

MCC gastric outlet obstruction

A

gastric adenocarcinoma

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10
Q

Dx gastrinoma

A
  1. Gastrin >1000pg/mL, or
  2. Secretin stim test (baseline gastrin, give 2u/kg secretin as bolus, then measure gastrin q5min for 30 min – if increase gastrin >200pg/ml above baseline, then dx)
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11
Q

Steps to repair esophageal perf

A
  1. Extension of myotomy - to expose full length of mucosal injury
  2. Debridement of nonviable tissue
  3. +/- creation of intercostal flap to reinforce repair
  4. Repair mucosa and muscle in separate layers
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12
Q

Primary location esophageal SCC

A

middle third esophagus

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13
Q

Primary location esophageal adenocarcinoma

A

lower third esophagus

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14
Q

Mgmt of >24hrs esophageal perf

A

divide cardia -> resect disease esophagus -> esophagostomy + gastrostomy + feeding-J + mediastinal drainage -> delayed reconstruction

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15
Q

For superficial esophageal neoplasm lesions <2cm, prefer…? for staging.

A

endoscopic mucosal resection > EUS

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16
Q

Tx scleroderma esophagus

A

PPI (bc major sxs reflux)

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17
Q

Endoscopic surveillance recommendation after severe alkalotic caustic injury

A

15-20 years post-injury (risk esophageal SCC 2%)

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18
Q

Most important pathophysiologic explanation for esophageal perf?

A

absence of serosal layer

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19
Q

Blood supply to esophagus

A

cervical -> inferior thyroid
thoracic -> aorta
abdominal -> left gastric + inferior phrenic arteries

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20
Q

What muscle comprises upper esophageal sphincter? Innervated by?

A

cricopharyngeus muscle; superior laryngeal nerve

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21
Q

Borders of Killian’s triangle

A

superior to cricopharyngeus + inferior to inferior constrictor muscles

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22
Q

Abx coverage for esophageal perf

A

GNR, oral flora, anaerobes, fungus* = ampicillin, ceftriaxone, flagyl, fluconazole

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23
Q

If repairing esophageal perf after EGD dilation for achalasia, must also do what…?

A

contralateral myotomy to relieve achalasia

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24
Q

Manometry: achalasia

A

high/normal LES basal pressure + incomplete LES relaxation + hypotonic/atonic peristalsis

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25
Q

Extent of Heller myotomy

A

6cm up esophagus + 2cm onto stomach

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26
Q

Manometry: isolated hypertensive LES

A

high basal LES pressure + complete LES relaxation + normal peristalsis

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27
Q

Mgmt Zenker’s diverticulum

A

> 3cm -> endoscopic division of UES

<3cm -> open myotomy of cricopharyngeus muscle via left neck incision +/- division of sphincter

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28
Q

Thoracic diverticulum… think?

A

association with inflammatory process (TB, malignancy) -> traction diverticulum (true)

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29
Q

If low-grade dysplasia of Barrett’s… surveillance?

A

repeat EGD w/ biopsy 6-mo + high-dose PPI (40-80 daily)

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30
Q

Dx esophageal CA (3)

A
  1. EGD w/ biopsy
  2. staging with PET/CT
  3. endoscopic US vs. EMR for T-stage and nodes

+/- FNA of suspicious nodes

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31
Q

T-stage esophageal CA

A 
T1A = lamina propria or muscularis mucosa (inner)
T1B = submucosa (risk lymphatic spread!)
T2 = muscularis propria
T3 = adventitia (outer)
T4 = surrounding structures (A = resectable; B = not)
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32
Q

N-stage esophageal CA

A 
N1 = 1-2
N2 = 3-6
N3 = 7+
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33
Q

Mgmt >T1 esophageal CA

A

neoadjuvant CRT + surgery

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34
Q

Mgmt cervical vs. thoracic esophageal CA

A

cervical (<5cm from cricopharyngeus) -> definitive CRT (unresectable bc surgery has too high morbidity)

thoracic (>5cm) -> esophagectomy if resectable

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35
Q

Mgmt high-grade + T1A

A

endoscopic mucosal resection +/- ablation

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36
Q

Mgmt high-grade + T1B

A

neoadjuvant CRT + esophagectomy

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37
Q

Low-grade + T1B

A

esophagectomy (no neoadjuvant)

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38
Q

What is definitive CRT for esophageal CA?

A

5-FU + taxane

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39
Q

Iver-Lewis esophagectomy

A

transthoracic approach = lap + R-thoracotomy (better for distal tumors); anastamosis in thorax

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40
Q

Transhiatal esophagectomy

A

lap + L-cervical incision; anastamosis in neck; long-term survival equal to transthoracic

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41
Q

Areas of esophageal narrowing (aka. most vulnerable areas for injury)

A
  1. cricopharyngeus muscle
  2. aortic arch
  3. L-mainstem bronchus
  4. LES
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42
Q

Primary blood supply to gastric conduit after esophagectomy

A

R-gastroepiploic artery

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43
Q

Dysphagia + palmoplantar keratoderma… think?

A

Tylosis (AD chr 17q25)

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44
Q

SCC head/neck/esophagus + pancytopenia… think?

A

Fanconi’s anemia

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45
Q

Screening for tylosis; risk?

A

annual EGD starting at age 20 (40-90% risk esophageal SCC by age 70)

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46
Q

If advance esophageal CA, but need feeding tube access…?

A

J-tube (avoid G-tube bc want to preserve gastric conduit)

47
Q

Tx esophageal leiomyoma

A

If >5cm or symptomatic -> thoracotomy + enucleate; otherwise endoscopic

48
Q

hx GERD, dysphagia, narrow ring above GE jxn… think?

A

Schatzki ring

49
Q

Course of thoracic duct

A

lymphatic duct originates in abdomen -> cisterna chyli path that passes up through aortic hiatus and diaphragm -> runs btwn thoracic aorta + azygous vein -> crosses over T5 (R->L) -> drains into confluence of IJ and L-subclav

50
Q

MC location of Mallory Weiss tear

A

lesser curvature of stomach (at point of GE jxn) - NOT esophagus

51
Q

Do you biopsy esophageal leiomyoma?

A

NO - dx via imaging. biopsy would complicate excision.

52
Q

Right vagus travels where in relation to esophagus… supplies…?

A

posterior esophagus -> celiac plexus

53
Q

Left vagus travels where in relation to esophagus… supplies…?

A

anterior esophagus -> hepatic branches to liver and biliary tree

54
Q

Findings scleroderma on manometry

A

low amplitude, simultaneous contractions with normal/low LES pressure (+reflux)

55
Q

Indications for emergent endoscopy 2/2 foreign body (3)

A
  • esophageal obstruction (aka. unable to handle oral secretions)
  • disk battery in esophagus
  • sharp-pointed object in esophagus
56
Q

Indications urgent (within 24 hr) endoscopy 2/2 foreign body (5)

A
  • not-sharp objects in esophagus
  • esophageal food impaction wo complete obstruction
  • sharp objects in stomach/duodenum
  • objects >6cm at/above prox duodenum
  • magnets within endoscopic reach
57
Q

Indications non-urgent endoscopy (5)

A
  • coins in esophagus may be observed for 12-24hrs if asymptomatic
  • blunt objects >2.5cm in stomach
  • disk or cylindrical batteries in stomach wo signs GI injury may be observed up to 48hrs (unless >2cm)
  • blunt objects that fail to pass stomach 3-4wks
  • blunt objects distal to duodenum that remain in same location >1wk
58
Q

Mgmt Barrett esophagus w/ high-grade dysplasia

A

radiofrequency ablation* vs. endoscopic mucosal resection

59
Q

Mgmt proximal vs. distal esophageal adenoCA with complete clinical response after chemorad

A

proximal -> observation

distal (high recurrence) -> surveillance -> obs + salvage esophagectomy vs. neoadjuvant + radial esophagectomy

60
Q

If progressive disease despite neoadjuvant for esophageal adenoCA?

A

palliative chemoRx or surgery

61
Q

What should you do after neoadjuvant for esophageal or rectal CA?

A

restaging for consideration of surgical intervention vs. surveillance

62
Q

normal LES pressure

A

10-15 mmHg

63
Q

Acidic substances cause what kind of necrosis?

A

coagulative

64
Q

Alkaline agents cause what kind of necrosis?

A

liquefactive - can produce injury outside of esophagus, to mediastinum

65
Q

When endoscopy for caustic agent ingestion?

A

within 24 hours once pt stable

66
Q

Grade of caustic ingestion injury (Zargar): endoscopic vs. pathologic findings

A

1: edema, erythema, exudate // little or no loss of mucosa
2: ulcer and/or hemorrhage // injury to submucosa or muscle layer
3: transmural ulceration with focal vs. extensive necrosis // injury through entire wall
4: penetration and/or perf

67
Q

What grade of caustic ingestion injury requires IV Abx?

68
Q

Adult with esophageal food impaction… concern for?

A

underlying pathology (MC eosinophilic esophagitis, tumor, Schatzski rings, peptic stricture)

69
Q

Mgmt esophageal food impaction

A

flexible endoscopy + biopsy

70
Q

When consider esophageal stenting for iatrogenic perf?

A

consider in all pts with perf from upper endo - particularly useful in presence of maligancy

71
Q

C/I esophageal stenting for iatrogenic perf

A
  • tear >6cm
  • delayed presentation (>24hr) bc tissue necrosis
    relative: difficult to place stent in proximal esophagus + at distal/GE junction
72
Q

Compared with pts Tx surgery alone for esophageal CA, those Tx with neoadjuvant CRT are more likely to have increased…

A

chylothroax

73
Q

Most likely cause of food bolus impaction in otherwise healthy adult

A

Eosinophilic esophagitis

74
Q

EGD finding: eosinophilic esophagitis

A

multiple concentric rings or white exudate

75
Q

Compared to total fundiplication, partial has lower rates of…?

A
  • dysphagia

- gas-related symptoms

76
Q

Compared to partial fundiplication, total is more effective at…?

A

controlling post-operative reflux symptoms

77
Q

POEM divides what muscle fibers of lower esophagus and stomach vs. Heller myotomy? Results?

A

POEM: only circular muscles (lowers incidence of GERD vs. Heller myotomy wo fundiplication)
Heller: circular and longitudinal muscle layers

78
Q

Pt after alkali ingestion, with circumferential ulceration at proximal esophagus… next step for evaluation?

A

CT C/P - as effective as endoscopy in assessment of depth of injury (do NOT do endoscopy past point of circumferential injury) - also alkali tend to have low risk stomach perf

79
Q

Pt with failed Nissen (recurrent GERD) + shortened esophagus 2/2 transmural esophagitis + obese… best procedure to repair?

A

Belsey Mark IV - thoracic approach + can free up the esophagus for tension-free return of terminal esophagus to abdomen

80
Q

Ligation of thoracic duct performed in what type of esophagectomy?

A

Iver-Lewis esophagectomy bc possible chyle leak after extensive thoracic lymphadenectomy

81
Q

What part of transhiatal esophagectomy is done under direct visualization? what is done blind?

A

distal third - good for distal tumors. but limited and blind thoracic lymphadenopathy

82
Q

UGI finding for diffuse esophageal spasm

A

corkscrew appearance

83
Q

Epiphrenic diverticula due to …?

A

motility disorder (pulsion diverticula)

84
Q

Sensory nerve to gag reflex

A

glossopharyngeal nerve - supplies upper epiglottis

85
Q

Sensory nerve to cough reflex

A

internal branch of superior laryngeal nerve of superior laryngeal nerve - supplies lower epiglottis and larynx above vocal cords

86
Q

Sensory nerve to larynx below vocal cords

A

recurrent laryngeal nerve

87
Q

Motor nerve to intrinsic muscles of larynx (except cricothyroid)

A

recurrent laryngeal nerve

88
Q

Esophageal perf 2/2 cancer… mgmt?

A

if <24hrs - esophagectomy with primary anastomosis

if >24hrs (too much inflam) or unstable - resection and diversion

89
Q

Primary repair can be done for EARLY esophageal perf except…?

A
  • cancer
  • severe peptic strictures
  • caustic injury
  • refractory achalasia
90
Q

If early esophageal free perf + unstable then…?

A

resection and diversion

91
Q

If stable esophageal perf and no cancer… mgmt?

A

eval extent of perf with swallow study - if contained, non-op mgmt (if free, then OR)

92
Q

If free early esophageal perf, no cancer, stable… mgmt?

A

primary repair of perf +/- drain placement +/- flap

93
Q

Esophageal pH monitoring done by two methods…

A
  1. wireless pH monitoring - single probe placed 5cm above LES
  2. intraluminal lube via nasopharyngeal catheter - multiple pH probes along catheter
94
Q

Abnormal DeMeester score

95
Q

How does esophageal impedance study work?

A

low voltage current applied to multiple electrodes within probe to determine direction of bolus transport (ie. bile reflux)

96
Q

Steps of transthoracic heller myotomy (ie. for refractory diffuse esophageal spasm)

A
  • right lateral decub position
  • enter pleural space in 7th intercostal space
  • incise inferior pulm ligament
  • retract lung medially + cephalad
  • incise mediastinal pleura
  • encircle esophagus with penrose drain
  • identify both vagus nerves
  • perform esophagectomy
97
Q

Surveillance and mgmt Barrett’s + no dysplasia

A

serial endoscopies q3-5 years with 4-quad biopsy q2cm + daily PPI (if persists, may do BID)

98
Q

Alcohol associated with esophageal SCC vs. adenoCA?

99
Q

What GI hormones increase LES pressure?

A

gastrin and motilin

100
Q

GERD + stricture… mgmt?

A

Nissen fundoplication +/- Collis gastroplasty for tension-free anastomosis (bc shortened esophagus)

101
Q

How much tension-free anastomosis should be mobilized in abdomen for fundoplication?

A

> 2.5-3 cm

102
Q

Mgmt Zenker’s diverticulum <2cm

A

cricopharyngeal myotomy alone via left neck incision

103
Q

Mgmt Zenker’s diverticulum 2-5cm

A

Dohlman procedure (obliterate sac w/ endoscopic division of distal cricopharyngeus muscle) – requires max neck extension (not for elderly)

104
Q

Mgmt Zenker’s diverticulum >5cm

A

myotomy + resection

105
Q

Mgmt Zenker’s in frail elderly w/ large diverticula

A

diverticulopexy (via incision left neck)

106
Q

For what size Zenker’s diverticulum is surgical vs. endoscopic repair the same result?

107
Q

For what size Zenker’s diverticulum is surgical repair superior to endoscopic?

108
Q

Swallowing center located where in brain?

109
Q

Indications for Toupet fundoplication

A
  • poor esophageal body motility
  • following Heller’s myotomy
  • severe aerophagia (swallow air)
  • inadequate gastric fundus for full wrap (ie. Tubular stomach, previous gastric surgery or splenorrhaphy)
110
Q

Gold standard dx esophageal motility disorders

111
Q

Tx and surveillance of Barrett’s + high-grade dysplasia

A

Ablation + repeat biopsy q3m

112
Q

Surveillance for Barrett’s + low-grade dysplasia

113
Q

When should esophagostomy + feeding tube be placed for esophageal injury?

A

For injuries >24-hrs (if less than, should try to repair primarily)

QUESTION NOTES (28 decks)

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