Esophagus

Question 1

Anatomic location of esophagus

Answer 1

Pharynx to stomach- goes down/left, then right, then left again to connect to stomach.
Posterior border- vertebral column and thoracic duct
Anterior- trachea
Lateral- pleura
Left- Aorta

Question 2

Nerves of esophagus (on outside)

Answer 2

Vagus nerve makes a plexus around it, condenses to form 2 trunks on the lateral esophagus. Trunks rotate- left trunk goes anterior, right trunk goes posterior

Question 3

Layers of the esophagus

Answer 3

Mucosa (squamous epithelium, becomes columnar near GE jn)
Submucosa (contains meissner plexus)
2 muscular layers (longitudinal and circular) with Auerbach’s plexus in bt
Esophagus does NOT have a serosa as the outermost layer like other GI stuff.

Question 4

Arterial supply to esophagus

Answer 4

Upper esophagus- superior and inferior thyroid arteries

Lower- intercostal arteries, left gastric, phrenic arteries

Question 5

Venous drainage of esophagus

Answer 5

Upper esophagus- to inferior thyroid vein and vertebral veins
Mid and lower- to azygous, hemiazygous, left gastric veins

Question 6

In what pts do esophageal submucosal veins become enlarged? and what happens?

Answer 6

In pts w portal HTN

It can cause varices and life-threatening bleeding

Question 7

Where do lymphatics from the esophagus drain into?

Answer 7

cervical, mediastinal, celiac, gastric nodes

Question 8

Innervation of the esophagus

Answer 8

Vagus
Cervical sympathetic ganglion
Splanchnic ganglion
Celiac ganglion

Question 9

T/F there is not a true sphincter in the lower esophagus

Answer 9

True! LES- no such thing. Gastric reflux prevented by increased tone.

Question 10

T/F esophageal neoplasms are usually not malignant

Answer 10

False. They are almost always malignant.

Question 11

What are the benign lesions of the esophagus

Answer 11

Benign lesions only account for 1%. They are leiomyomas, hemangiomas, cysts, polyps.
99% are malignant.

Question 12

What kind of esophageal cancer is most common?

Answer 12

In USA- adenocarcinoma

In the world- squamous cell

Question 13

Pathogenesis of esophageal ca (lifestyle)

Answer 13

Mucosal insult- hot liquids, burns from acid/base ingestion, radiation-induced esophagitis, reflux esophagitis
Alch, cig, nitrosamines, malnutrition
Barret’s esophagus
Plummer-Vinson

Question 14

HPE of esophageal adenocarcinoma

Answer 14

Progressive dysphagia to solids
esp in older male w hx of GERD.
Usu no other sx, appear well.

Question 15

HPE of esophageal squamous cell carcinoma

Answer 15

Heavy alch/tobacco use

Usu px w more pronounced sx (dysphagia to solids) dt more advanced dz

Question 16

Dx Eval for esophageal lesions

Answer 16

Barium esophagogram- inital study for new dysphagia
Def Dx- tsu confirm by flexible esophagoscopy w biopsy.
EUS to determine stage
Mets- CT/PET

Question 17

T/F the esophageal dz is usu locally invasive or metastatic on px

Answer 17

True bc there is no serosa to keep it contained

Question 18

Rx for esophageal ca

Answer 18

rad, chemo, surg

if contained local dz- esophaectomy

Question 19

Why does achalasia occur?

Answer 19

No peristalsis + LES doesn’t relax w swallowing.

Probably a problem w Auerbach’s plexus (which is in bt the muscular layers)

Question 20

What is the most common esophageal motility disorder?

Answer 20

achalasia

Question 21

HPE of achalasia

Answer 21

Dysphagia
Regurgitation (non-sour, bc didn’t get to stomach) esp w recumbent position
Hx of pneumonia (aspiration)

Question 22

Dx Eval for achalasia

Answer 22

Esophagography- shows distal narrowing. Also, must do this to r/o ca! and look for strictures
Dynamic video img- abn peristalsis
bird’s beak and/or prox dilaton

Question 23

Rx for achalasia

Answer 23

Surgery- esophagomyotomy (heller myotomy) via laproscopy. partial fundoplication also performed often in addition to reduce post-op gerd
Can also use botox but doesn’t really work for long.
Can also use pneumatic balloon dilatation of LES, but not as good as surg

Question 24

When does esophageal perforation usually occur?

Answer 24

Iatrogenic, after instrumentation

Can also be from foreign bodies, penetrating trauma

Question 25

What is Boerhaave syndrome?

Answer 25

Spontaneous esophageal rupture after vom

Question 26

HPE esophageal perf

Answer 26

recent instrumentation, recent vom (boerhaave).
epigastric abd pain, shoulder pain
subcutanous emphysema
abd tenderness/distention
if delayed dx- sepsis (fever, tachy, hypotension)
Hydropneumothorax

Question 27

Dx eval for esophageal perf

Answer 27

CXR- shows pleural effusion, hydropneumothorax, mediastinal emphysema
Esophageal contrast study- shows location of perf
If needed, flexible endoscopy
Throacentesis- empyema

Question 28

Rx for esophageal perf

Answer 28

immediate exploratory throacotomy and repair of perf
drain w chest tubes post-op
if small lacerations, can give abx and observe

Question 29

T/F if esophageal perforation is not treated immediately, there is very high mortality

Answer 29

True. >50% if not treated in 24hrs