Esophagus Flashcards
1
Q
Esophagus develops during gestation
A
4th week
2
Q
Failure of separation of dorsal foregut from laryngotracheobronchial tree during development
A
TEF fistula
3
Q
Failure of recanalization of tubular lumen
A
Esophageal atresia, web, stenosis
4
Q
5-6cm
Extends from cricopharyngeus (C6) to thoracic inlet (T1)
A
Cervical esophagus
5
Q
15cm From TO (T1) to esophagea hiatus of diaphragm (T10)
A
Thoracic esophagus
6
Q
Short 5-6cm
Absent in patients with hiatal hernia or esophageal shortening from chronic inflammation
A
Abdominal esophagus
7
Q
Cricopharyngeus (UES) innveration
A
recurrent laryngeal nerve
8
Q
Functional zone not an anatomic structure
A
LES
9
Q
Anatomic sites of esophageal narrowing
Most common sites of foreign body impaction
A
Aortic arch
left main stem Bronchus
Cricopharyngeus
Diaphragm
10
Q
Esophageal wall layers
A
Mucosa
Submucosa
Muscularis
11
Q
Esoohagus lacks this layer so healing is poor after insult
A
Serosa
12
Q
Mucosa of esopahgus
A
Non keratinizing SSE
13
Q
Muscularis layer is divided into
A
Outer longitudinal
Inner circular
14
Q
Upper 1/3 of esophageal muscle
Lower 2/3
A
striated
smooth
15
Q
Esophageal landmark by endoscopic distance from incisor
UES
Thoracic inlet
Aortic arch/LMB
LES/GEJ
A
UES 15cm
TI 18cm
Aortic arch/LMB 25cm
LES/GEJ 40cm
16
Q
Upper 1/3 of esophagus blood supply
A
Inferior thyroid artery
17
Q
Middle 1/3 esophagus blood supply
A
Descending thoracic aorta
Bronchial arteries
18
Q
Lower 1/3 esophagus blood supply
A
Left gastric artery
Inferior phrenic artery
19
Q
Parasympathetic inn to esophagus
A
Vagus nerve
20
Q
Innervates cricopharyngeus and cervical region
A
recurrent laryngeal nerve
21
Q
sympathetic fibers for the esophagus arise from
A
Cervical
Thoracic chain ganglia
22
Q
Contains nonsegmented network of lymphatics
A
Submucosa
Upper 2/3 cephalad drain
Lower caudad
23
Q
Site of cricopharyngeal weakness
Most common location to find pseudodiverticula or iatrogenic perforation
A
Killian’s triangle
24
Q
35 y/o female
progressive heartburn, regurgitation of undigested food
barium swallow: bird beak tapering of distal esoph
manometry reveals:
A
Achalasia
Lack of peristalsis
Failure of LES relaxation
25
Strongest layer of esophagus
| Primary importance for surgical repair
submucosa
26
Most common esophageal motility disorder
25-60 years equal distribution
Aperistalsis
Failure of LES relaxation during swallowing
Not a primary disorder but neural degeneration
Achalasia
27
Patients with achalasia present with
Progressive dysphagia to solids and liquids
Heartburn, chest paun
Regurgitation of undigested food
Techniques to ameliorate dysphagia by maintaining upright, keeping arms elevated over head, consuming liquid
28
Achalasia dx: finding
Barium swallow: bird beak with dilation if proximal segment
29
Dx mandatory to rule out obstructing mass or stricture
Esophagoscopy
30
Manometry in achalasia reveals
lack of peristalsis and failure LES relxation
| resting LES pressure may be normal or high
31
UES pressure (resting)
50-70
32
UES pressure (bolus)
12-14
33
LES pressure (resting)
10-20
34
Medical management of achalasia
Nitrates
Ca ch blocker
Botox
35
Symptomatic improvement but recurrence is high and risk of perforation at 5% in achalasia repair
Pneumatic dilation
36
Definitive therapy: achalasia
Heller myotomy
37
Long standing severe achalasia
| Dilated and non functional esophagus called
sigmoid esophagus
tx: esophagectomy
38
smooth muscle degeneration
LES failure
disordered peristalsis of distal esophagus
esophageal dysmotility in 80% women 40-50
sparing of:
Scleroderma
proximal striated
39
Scleroderma s and sx
severe reflux esophagitis
dysphagia
scleroderma (calcinosis, Raynaud, esophageal dysmo, sclerodactyly, skin change, telangiectasia, renal impairment, pulmonary HTN)
40
Scleroderma dx: finding
Barium: dilated esophagus with DISTAL NARROWING
Manometry: dysmotility, aperistalsis of distal esophagus with inc LES
41
Medical mx of scleroderma
Sx
H2 blocker
PPI
HOB elevation
severe with loss of function (fundoplicariob and gastroplasty)
42
Primary motility disorder
Disordered high amplitude motility
Substernal chest pain radiating to neck or upper ex
Dysphagia with solid and liquid
Diffuse esophageal spasm
43
DES dx: finding
Barium: corkscrew esophagus and segmentation
Manometry: frequent, high amp, simultaneous contraction (>/= 20% of 10 simultaneous waveform)
LES normal
44
DES medical mx
nitrate
Ca ch blocker
Botox
45
Most common primary motility disorder
Chest pain, dysphagia
Manometry: continuous, high amp (>/=2 SD above normal) peristalsis
Nutcracker esophagus
Tx:
Nitrate
Ca ch blocker
Sx: Heller if nonrefractory
46
Found at Killian’s triangle as a result of discoordination of UES relaxation and swallowing
Pharyngoesophageal
| Zenker’s or Pulsion diverticulum
47
Either pulsion (motility disorder) or traction bec of extra esophageal disease such as cancer or granulomatous infection
Middle esophageal diverticula
48
Most commonly by motility d/o, achalasia
Associated with GERD
Within 10cm of GEJ
Epiphrenic diverticula
49
```
Regurgitation
Halitosis
Aspiration
Chest pain
Dysphagia
Asymptomatic
```
Diverticulum
50
Diverticulum dx
Barium
Manometry and pH studies: motility disorder with reflux
Esophagoscopy to rule out mechanical obstruction
51
Sx for diverticula
Diverticulectomy with myotomy
| Transoral stapled repair
52
Congenital incomplete recanalization but may be acquired
Trans or mucosal and submucosal
Asymptomatic but sometimes dysphagia with solid food
Associated with GERD or IDA (Plummer Vinson)
Esophageal web, ring
53
Ring at the GEJ due to GERD
Schatzki’s ring
54
Majority of paraesophageal hernias are
Type I sliding hiatal
55
Ulcer in sliding hiatal hernia
Lesser curve
Chronic blood loss but rarely with perforation
Cameron’s ulcer
56
Borchardt’s triad
Severe chest pain
Painful retching without emesis
Inability to pass NGT
incarcerated paraesophageal hernia
57
```
Incidenta on upper endoscopy or CT
Bowel sounds on chest
CXR air fluid level in chest
Coiled intrathoracic NGT
Barium swallow is dx
```
Esophageal hernia
58
Chest
Contains GEJ with or without fundus
No volvulus
Type I Sliding Hiatal
59
Abdomen
Contains fundus
Organoaxial volvulus
Type II rolling paraesophageal
60
Chest
Contains GEJ, fundus, body
Organoaxial and mesoaxial volvulus
Type III mixed paraesophageal
61
Chest
Contains GEJ, fundus abdominal organ
Organoaxial or mesoaxial volvulus
Type IV mixed paraesophageal
62
Chest pain and paraesophageal hernia is emergency surgery bec of
risk of incarceration or strangulation
63
Sliding hernia sx
Elective
64
Preferred surgery for chronic hernia
Transthoracic
65
Classic teaching for asymptomatic paraesophageal hernia
surgical repair for all
66
Paraesophageal hernia repairs must be
hernia reduction
Sac excision
Tension free closure of crural defect
67
Longitudinal mucosal tear near GEJ due to repeated retching and high intraluminal pressure
Common in alcoholics
Dx:
Mallory Weis tear
Endoscopy
68
Most common cause of esophageal perforation
iatrogenic
69
Spontaneous rupture of esophagus resulting from inc intraabdominal pressure against closed glottis during bouts of retching
Perforation by malignancy or infection (TB)
Elderly, delibiltated
Esophageal perforation
70
```
Severe chest and back pain
Dyspnea
Dull percussion at left chest
Subcutaneous emphysems
Tachycardia
Hypotension
Severe sepsis with instability
```
Esophageal perforation
71
Esoph perforation dx: finding
CXR: pneumomediastinum, subcutaneous emphysema, left hydropneumothorax, simple effusion
72
Demostrates leak in esophageal rupture
Gastograffin swallow
73
Localizes site of esophageal perforation
Esophagoscopy
74
Esophageal rupture tx
Broad spec antibiotics
NPO
Fluid resuscitation
Drainage of effusion decompression of pneumothorax
75
Esoph perforation operative therapy:
Irrigation and drainage of pleural cavity with primary repair of perforation
Reinforce with intercostal, pleural, pericardial flap
76
Alkali agents cause
liquefactive necrosis
77
Acids cause
coagulation necrosis
78
Caustic injury mx
Dx: flexible esophagoscopy
```
Assess and secure airway
Do not neutralize agent
Observe if asymptomatic
Mildd admit NPO for 1-2 days
Full thickness: NPO, TPN, antibiotic
```
Resect
79
Caustic injury complications
stricture
| SCC
80
58 y/o,M
Hx of GERD
Endoscopy with biopsy: mild dysplasia
Ff up:
Endoscopic surveillance with biopsy every 2 years to monitor dysplasia
81
Premalignant condition by intestinal metaplasia
| Primary risk factor: GERD (5-10)
Barett’s
82
If severe dysplasia is present perform
esophagectomy
83
Resected Barrett’s specimen with severe dysplasia have adenocarcinoma:
20-50%
84
SCC risk factors
```
Tobacco
Alcohol
Achalasia
Alkali injury
Plummer Vinson
```
85
Dx for SCC
Esophagoscopy with biopsy
staging: CT, PET, endoscopic uts
86
Most common esophageal malignancy
Adenocarcinoma
87
Adenocarcinoma rf
GERD
| Barrett’sc
88
Benign lesions and motility disorders appear
smooth narrowing
89
Malignant lesions demonstrate
irregular apple core
| appearance
90
Stage I and IIA sx
| T3NO
Surgery +/- neoadjuvant
91
Stage IIB, III tx
chemoradiation (neoadjuvant) w/
| surgery
92
stage IV tx
palliation: esophageal stent
93
Most common mortality and morbidity in postesophag
Postesohagectomy pneumonia
| pulmo complication
94
Incision: laparotomy, neck
Anastomosis: neck
Transhiatal
95
Incision: laparotomy, right thoracotomy
anastomosis: chest
Ivor-Lewis
96
Incision: left thoracotomy
Anastosmosis: chest
Thoracoabdominal
97
Incision: laparotomy, right thoracotomy, neck
Anastomosis: neck
three hole
98
Worst outcomes occur in leaks from
chest rather neck
99
Majority of patients with esophageal ca present at stage
3
100
Layer essential in anastomotic repair
submucosa
101
Most common site of esophageal perforation during endoscopy
After repeated vomiting
Killian triangle
Distal thoracic esophagus
102
Order of preference of conduit for esophageal reconstruction
Stomach>colon>jejunum
103
45 y/o
progressive dysphagia to solid
first dx?
barium swallow
104
determines resectability of esophageal malignancy
freedom from distant metastases or distal nodal involvement, ability to resect adjacent involved structure
105
80 y/o
dysphagia with aspiration pneumonia
esophageal study contrast agent of choice?
Nonionic H20 soluble agent to minimize risk of pneumonitis
106
Benefits of lap Heller and partial fundoplication vs left thoracoscopic myotomy for achalasia
Dec length of stay
| Dec post op reflux
