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MBBS Surgery > Esophagus > Flashcards

Esophagus Flashcards

1
Q

Causes of oropharyngeal dysphagia

A

Neuromuscular

  • Central: stroke, brain stem tumour, PD
  • Peripheral: Motor neuron dz (ALS), peripheral neuropathy, MG, myopathies - myotonic dystrophy, polymyositis, dermatomyositis
  • Post infection: poliomyelitis, syphillis

Mechanical

  • intraluminal: eso web, pharyngeal pouch (Zenker divert)
  • luminal: tumour, abscess
  • extraluminal: anterior mediastinal masses - 4Ts
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2
Q

Oesophageal dysphagia differentials

A

Neuromuscular:

  • pri motility disorder: achalasia, spastic motility - diffuse eso spasm, nutcracker esophagus, hypertensive LES
  • sec motility disorder: scleroderma, multiple sclerosis, Sjögren syndrome, DM

Mechanical

  • intra-luminal: lower eso rings, eso web (Plummer vinson), FB
  • luminal: tumour, strictures (reflux esophagitis, radiation, caustic ingestion, malignant), eosinophilic esophagitis
  • extra-luminal: anterior med masses, bronchogenic CA, vascular ab (thoracic aortic aneurysm, LA dilatation)
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3
Q

Causes of anterior mediastinal masses

A

thymus, thyroid, teratoma, terrible lymphoma

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4
Q

What is CREST syndrome

A 
calcinosis
raynauld
esophageal spasm
sclerodactyly
telangiectasia
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5
Q

Plummer vinson syndrome

  • triad
  • a.w
  • cx
A

triad of

  • post cricoid dysphagia
  • fe deficiency anemia
  • cervical oesophageal webs

a/w

  • glossitis
  • angular chelitis
  • koilonychia
  • splenomegaly
  • enlarged thyroid

risk of eso CA, pharyngeal SCC

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6
Q

Achalasia triad

A
  • aperistalsis of eso (alt in ganglia of Auerbach plexus)
  • increased LES tone/ pressure (hypertensive LES)
  • failure of LES to relax with swallowing
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7
Q

Causes of achalasia

A

Pri: idiopathic
Sec: diabetic autonomic neuropathy, lesions of dorsal motor nuclei (polio, sx ablation), chagas dz
Pseudo: Ca

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8
Q

Tx of achalasia

A

Med:
- CCB (nifedipine) and nitrates (nitroglycerine)
- endoscopic injection of botulinum toxin
Endo:
- per oral endoscopic myotomy
- pneumatic balloon dilatation
Sx:
- lap Heller esophagomyotomy with anterior fundoplication

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9
Q

RF for GERD

A
  • hiatal hernia
  • increased ab pressure: pregnancy, masses, chronic cough, ascites
  • dec LES pressure: smoking, alcohol, caffeine, alpha blockers, nitrates, ccb, bb, antiAch
  • delayed gastric emptying: lying down after meal
  • eso motility disorder: scleroderma
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10
Q

Scoring to diagnose GERD on ph probe

A

De Meester score >14.72 indicates reflux

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11
Q

Mamometry findings suggestive of reflux risk

A

pressure <6mmhg
overall length <2cm
abdominal length <1cm

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12
Q

Severity grading of esophagitis

A

Los Angeles Classification

Savary Miller Classification

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13
Q

When to do OGD for pt with GERD

A
  • progressive symptoms despite medical therapy
  • recurrent symptoms despite endoscopic/ sx therapy
  • dysphagia, odynophagia
  • LOW, LOA
  • regurgitation
  • UGBIT, anemia
  • found a mass on imaging
  • screen for Barrett (use narrow-band imaging on OGD)
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14
Q

Non sx mgx of GERD

A

Lifestyle:

  • stop smoking, alcohol, chocolate
  • stop medications that decrease LES pressure
  • lose weight, avoid tight garments
  • don’t lie down after meals, sleep at an angle
  • eat small frequent meals

Meds:

  • acid suppression: antacids, PPI, H2 receptor antagonists
  • pro kinetics to increase gastric clearance: metoclopramide
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15
Q

when to do sx for GERD

A
  • med therapy failing, recurrent progressive symptoms
  • severe GERD with cx: barret, erosive esophagitis
  • poor compliance to med
  • manometric evidence of defective LES
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16
Q

Types of sx for GERD

A

fundoplication (wrap funds ard GEJ)

  • 360: nissen
  • partial: anterior 90, anterior 180, posterior 270 (toupet)
17
Q

Cx of Nissen fundoplication

A 
GA risks
Intra op risks: hemorrhage, perforation
Post op:
- infection
- dumping syndrome
- gas bloat syndrome
- too loose: recurrent symptom
- too tight: dysphagia
- slipped nissen: wrap slides down, GEJ retract into chest
18
Q

What is Barretts?

A

intestinal metaplasia: esophageal stratified squamous epithelium converted to mucus secreting columnar epithelium with goblet cells above z line

19
Q

how will you mgx Barrett esophagus

A
  1. tx underlying reflux
    - GERD mgx
  2. endoscopic surveillance - freq depends on severity
    a. length of segment: Prague classification C,M
    b. deg of dysplasia: Seattle protocol - 4quad biopsy every 2cm
    c. other RF: gender, smoking
  3. tx by biopsy grading
  4. intestinal metaplasia - 0% (OGD every 2 yr)
  5. low grade dysplasia (ablation)
  6. high grade dysplasia
    - nodule: EMR > ablate
    - no nodule > ablate
  7. malignancy - CRT>sx

haloradiofrequency ablation

20
Q

RF for oesophageal SCC

A 
alcohol, smoking
caustic injuries
nitrosamine ingestion
achalasia
others: PV syndrome, Tylosis (AD), eso diverticula and webs

non mod: age>60, male, fam hx

21
Q

RF for oesophageal adenoCA

A

chronic GERD
barrett esophagus
obesity
smoking

non mod: age>60, male, fam hx

22
Q

esophageal SCC vs adenoCA

A

SCC: anywhere, typically middle 3rd

  • CA in situ > invasive progression
  • lymphatics (widespread tumour infiltration beyond apparent margins)

AdenoCA: distal 3rd
- b/g chronic GERD, barrett

23
Q

layers of GI wall

A

mucosal - epithelium, lamina propria, muscularis mucosa
submucosal - meissner plexus
muscularis propria - circular muscle, Auerbach (myenteric) plexus), longitudinal muscle
adventicia/ serosa

24
Q

Curative tx for oesophageal cx

A

localised: endoscopic mucosal resection

higher stage tumour:

  1. neoadjuvant CT/RT
  2. sx
    - trans thoracic: Ivor lewis (intra thoracic anas)/ mc keown (cervical anas)
    - trans hiatal (cervical anas)
25
Q

Cx of esophagectomy

A
  • GA risks
  • CVS risks: post esophagectomy AF, AMI, DVT
  • pul risk: atelectasis, pneumonia, ARDS
  • eso anastomotic cx: leak with mediastinitis, strictures, conduit ischemia
  • gastric outlet obstruction
  • other local traumatic cx: chylothorax, Recurrent LN
26
Q

palliative mgx of oesophageal cancer

A

CT/ RT
nutritional support: PEG, jejunostomy tube
endoscopic:
- intraluminal stents (cx: ulceration, migration, ca growth proximal to stent, obstruction by food)
(stent is a CI for RT - risk of stent migration)

  • laser technique
    photodynamic therapy: injection of photosensitive agent activated by low power laser lights resulting in selective tumour necrosis

MBBS Surgery (18 decks)

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