Esophagus

Question 1

Layers of the esophagus? Muscle types? Blood supply to cervical esophagus? Abdominal esophagus?

Answer 1

Mucosa (squamous), submucosa, muscular propia (longitudinal muscle layer), no serosa – upper 1/3 has striated muscle, lower 2/3 has smooth muscle; cervical esophagus supplied by inferior thyroid artery, abdominal esophagus by left gastric and inferior phrenic arteries

Question 2

Course of the recurrent laryngeal nerve (R/L)? thoracic duct?

Answer 2

Right RLN around R subclavian artery, L RLN around aortic arch, thoracic duct travels from R to L at T4/T5 as it ascends mediastinum, empties into L subclavian vein

Question 3

Most common site of esophageal perforation for EGD?

Answer 3

Cricopharyngeus muscle (innervated by RLN)

Question 4

Plummer-Vinson syndrome?

Answer 4

upper esophageal webs iron deficiency anemia; tx w/ esophageal dilation and Fe, screen for oral Ca

Question 5

Zenker’s diverticulum: pathophysiology, which muscles involved, dx, tx

Answer 5

False diverticulum (located posteriorly between pharyngeal constrictors and cricopharyngeus) caused by failure of cricopharyngeus to relax, dx w/ barium swallow studies, manometry (EGD high risk), tx w/ cricopharyngeal myotomy (Zenker’s either resected or suspended)

Question 6

Traction diverticulum: pathophysiology, tx

Answer 6

true diverticulum, usually lateral, due to inflammation, granulomatous disease, tumor, tx w/ excision/primary closure if symptomatic

Question 7

Epiphrenic diverticulum: pathophysiology, tx

Answer 7

rare, associated w/ esophageal dysmotility disorders, most common in distal 10 cm of esophagus, most asymptomatic, dx w/ esophageal and manometry – tx w/ diverticulectomy and esophageal myotomy

Question 8

Achalasia manometry findings?

Answer 8

1. High LES pressure, 2. incomplete LES relaxation, 3. aperistalsis

Question 9

Diffuse esophageal spasm manometry findings?

Answer 9

Frequent strong non-peristaltic unorganized contractions, LES relaxes normally

Question 10

Nutcracker esophagus manometry findings?

Answer 10

High amplitude peristaltic contractions, LES relaxes normally

Question 11

Hiatal hernia types?

Answer 11

I sliding hernia (often assoc. w/ GERD), II paraesophageal, adjacent to the esophagus, III combined, IV entire stomach in chest plus another organ

Question 12

Most common site of esophageal adenocarcinoma metastasis?

Answer 12

Liver

Question 13

Most common site of esophageal squamous carcinoma metastasis?

Answer 13

Lung

Question 14

What does alkali caustic ingestion cause? Acidic caustic ingestion? Tx?

Answer 14

Alkali causes deep liquefaction necrosis (especially liquid, eg Drano), acidic causes coagulation necrosis (mostly causes gastric injury), r/o free perforation, EGD up to site of injury (do not want to cause iatrogenic perforation)

Question 15

Esophageal perforation most common locations? Iatrogenic? Spontaneous?

Answer 15

If iatrogenic, usually cervical esophagus near cricopharyngeus muscle, if spontaneous, usually near left lateral wall of the esophagus 3-5 cm above GE junction

Question 16

Palmarplantar keratoderma: what to watch out for

Answer 16

Tylosis, rhbdf2 gene. Esophageal cancer, autosomal dominant

Question 17

Squamous cell ca of head neck, esophagus, pancytopenia

Answer 17

Fanconi anemia

Question 18

Dysphasia, well circumscribed 6cm mass in wall of mid esophagus - dx, tx, pitfalls

Answer 18

Esophageal leiomyoma. Do not biopsy. Characteristic ct / swallow findings, if symptomatic or >5cm. vats or thoracotomy for enucleation. Mid R, distal L.

Question 19

How to access esophagus surgically?

Answer 19

Cervical via L neck, mid via R chest, distal via L chest