Esophagus Flashcards
Three areas of esophageal narrowing are?
cricopharyngeus muscle
aortic notch
GEJ
Why are the three areas of esophageal narrowing important?
these are where foreign objects that are swallowed tend to be lodged
swallowed corrosive liquids also tend to cause damage here because of slower passage of material here
Opening of esophagus and ending of pharynx is collared around what muscle?
cricopharyngeus mc
Where do the recurrent laryngeal nerves lie in relation to the esophagus?
lie in the right and left grooves between trachea and esophagus
Length of esophagus?
cervical 5 cm
thoracic is 20 cm
abdominal 2cm
Muscles of the esophagus?
outer longitudinal layer
inner circular layer
Muscles of upper esophagus vs lower esophagus?
upper 1/3–> striated
lower 2/3—> smooth (most esophageal motility d/o involve the smooth part of esophagus)
Blood supply of esophagus?
cervical part—> from inferior thyroid A (from subclavian)
thoracic part—> bronchial arteries (1 right sided bronchial artery and 2 left sided most commonly); also get 2 esophageal branches from aorta
abdominal part–> ascending branch of left gastric A and inferior phrenic a
Right and left recurrent laryngeal nerves turn where?
R–> underneath right subclavian A
L–> underneath aortic arch
Venous drainage of esophagus?
cervical–> inferior thyroid vein
thoracic–> azygous, hemi-azygous, bronchial veins
abdominal–> coronary veins
PSNS innvervation of the esophagus?
vagus n
Swallowing is what type of act?
reflexive
What happens when we swallow food?
tongue moves bolus in posterior oropharynx
soft palate is elevated
hyoid bone elevated
epiglottis covers larynx
Describe the course of the esophagus?
cervical esophagus begins as midline structure; then deviates to the left of trachea as passes thru thoracic inlet
at level of carina it deviates to the right to accomadate aortic arch
then deviates to left as it enters diaphragm at T11
At what level does esophagus enter diaphragm
T11
What’s Killian’s triangle?
point of weakness in cervical esophagus
transition point between thyropharyngeus and cricopharyngeus muscle
What m. is responsible for generating the high pressure in the UES?
circopharyngeus
How do we distinguish esophagus from other alimentary organs?
lacks a serosa
What’s a Z line?
point where squamous tissue of esophagus transitions to columnar epithelium of stomach
Musculature of the esophagus?
has outer longitudinal fibers
has inner circular m fibers
upper 1/3–> striated skeletal muscle
lower 2/3–> smooth muscle fibers
How can we identify the GEJ?
squamo-columnar Z line junction helps identify it
transition from smooth esophageal lining to ruggael folds of stomach also helps identify it
the gastro-esophageal fat pad also helps delineate the GEJ
Cervical esophagus supplied by what artery?
inferior thyroid artery–> from thyrocervical trunk–> from L/R subclavians
What’s blood supply of circopharyngeus m, which marks the upper portion of the cervical esophagus?
superior thyroid artery
Blood supply of thoracic esophagus?
4-6 branches directly off the aorta
esophageal branches off of R/L bronchial arteries
Abdominal esophagus receives its blood supply from?
left gastric A
paired inferior phrenic arteries
R/L recurrent laryngeal nerves arise from?
vagus
R/L recurrent laryngeal nerve loop where?
R—> under R-subclavian
L—> under aortic arch
What n innervates the cricopharyngeus m?
recurrent laryngeal n
What are the resting pressures of the UES vs the LES?
UES–> has a steady state of tone at 60 mmHg, prevents steady air flow into esophagus
LES–> avg is 24 mmHg, remains elevated enough to prevent reflux of stomach content
What are the three types of esophageal peristalsis?
primary–> progressive, generate pressures of 40-80 mmHg, generated by voluntary swallowing
secondary–> progressive, but are generated from distention or irritation of esophagus (clears esophagus from material that was left behind after primary peristalsis)
tertiary–> non-progressive, non-peristaltic, cause esophageal spasms b/c they represent uncoordinated esophageal contraction
Intrinsic innervation of esophagus provided by ?
Auerbach’s plexus–> between muscle layers
Meissner’s plexus–> submucosal layer
What causes esophageal diverticula to form?
due to primary motor disturbances of the UES and LES
Where do we commonly see esophageal diverticula form?
pharyngoesophageal (Zenker’s)
mid-esophageal (parabronchial)
epiphrenic (sub-diaphragmatic)
What is the difference between a true and false diverticulum?
true divertic—> involves all layers of esophagus
false divertic—> only mucosa and submucosa only
What are pulsion vs traction diverticulum?
pulsion—> false diverticula (caused by increased intraluminal pressures )
traction—> true (due to external inflammatory mediastinal lymph nodes adhered to esophagus, and as they heal they contract and pull the esophagus in the process)
***Zenker’s and epiphrenic diverticula are pulsion diverticula
What is a pharyngo-esophageal diverticulum?
Zenker’s
false diverticula;pulsion; due to elevated intra-luminal pressures
What is the most common esophageal divertic?
Zenker’s
Who gets Zenker’s and where do they get it?
men in 70s
get it at Killian’s triangle; junction between thyropharyngeus and cricopharyngeus
**MC location is left-posterior
What’s cricopharyngeal achalasia?
Zenkers’s
Most serious complication from a Zenker’s?
aspiration pneumonia
lung abscess
Why do we need lateral views to visualize a Zenker’s?
usually protrudes posteriorly, in pre-tracheal space
Tx for Zenker;s?
surgical vs endoscopy is gold standard–> can do diverticulectomy vs diverticulopexy–>done via incision on left neck
in all cases a myotomy is performed on thyropharyngeus and cricopharyngeus
(open left cervical incision was done in the past)
When do you perform a diverticulectomy vs diverticulopexy for Zenker’s?
old frail pts, who won’t heal well–> diverticulopexy via left cervical incision
in most pts with good tissue, healthy, and >5 cm—> diverticulectomy done
***monitor for 2-3 days, NPO
What’s the Dohlman procedure?
endoscopic approach to repair of Zenker’s
done in pts with diverticula between 2-5 cm
doesn’t remove the pouch
wides opening of pouch and divides the cricopharyngeus
What kind of diverticula are epiphrenic diverticula?
false, pulsion
usually found in distal esophagus
**more common right side and have a wide opening
What are some causes of achalasia?
idiopathic
infectious/neurogenic
(stress, trauma, weight reduction, Chagas dx)
Pathophysiology of achalasia?
failure of LES to relax on pharyngeal swallowing
increased esophageal pressure
esophageal dilatation
loss of progressive peristalsis
What is the risk of Ca with achalasia?
over a 20 year period, a pt will have 8% chance of developing ca
squamous cell ca most common (air-fluid levels in esophagus causes mucosal irritation and induce metaplasia)
Sxs of achalasia?
dysphagia–> begins with liquids, progresses to solids
regurgitation
weight loss
Esophagram shows a dilated esophagus with distal narrowing/tapering referred to as a bird’s beak appearance;
achalasia
Gold standard for diagnosing achalasia?
manometry
Surgical tx for achalasia?
modified laparoscopic heller myotomy
Barium esophagram showing a corck-screw esophagus indicates what?
Diffuse esophageal spasm
Surgical tx for DES?
long myotomy, extending proximally and down to LES
Dor fundoplication done to prevent healing of myotomy and prevent reflux
This hypermotility disorder is associated with the most pain, results in high amp contractions;
nutcracker esophagus
In this esophageal hypermotility d/o, pressures as high as 400 mgHg of pressure can be seen;
nutcracker esophagus
Tx for nutcracker esophagus?
medical (CCBs, nitrates, anti-spasmodics)
avoidance of coffee, cold and hot foods
Barrett’s esophagus?
normal stratified squamous epithelium of distal esophagus turns into gastric columnar epithelium in response to acid reflux
What factor responsible for Barrett’s?
chronic GERD
What is the risk of developing esophageal ca in Barrett’s?
40-fold increase in developing esophageal Ca
For all pt’s with barret’s esophagus, what is recommended annually?
endoscopy
**for pts with low grade dysplasia–> endoscopy Q 6 months
What do we do for people with high grade dysplasia Barrett/s?
resection
What congenital anatomic vascular variant can cause compression of esophagus and cause a so -called vascular ring?
when right subclavian artery comes off of the descending aorta and travels behind the esophagus
What’s a pulmonary artery sling?
L-pulm artery comes off of the right pulm artery and causes anterior compression of esophagus
Whats dysphagia lusoria?
aberrant right subclavian artery thats comes off of descending aorta and can cause posterior compress of esophagus
What is a Schatzkis ring?
seen in the GEJ junction
concentric narrowing, makes lower esophagus less distensible
How do we diagnose Schaztkis rings?
barium esophagram
pt is prone, turned slightly to right
Tx for Schatizkis ring?
oral papain or meperidine used to dissolve lodged pieces of food
oral dilation then performed
How do we distinguish esophageal webs from a Shatzkis ring?
webs–> involve mucosa and submucosa, and have squamous type epithelium below and above the web
shtazki ring–> makde of epithelium, and have esophageal mucosa above and gastric mucosa below web
Esophageal webs assc with what syndrome?
plummer vinson syndrome
edentulous, malnourished, middle aged women, glossitis, spoon shaped fingernails, Fe-deficiency anemia
What caustic substance is ingested more commonly acidic or alkali liquids?
alkali –>more damaging
What parts of esophagus are prone to injury more commonly after caustic substance ingestion?
UES
mid-esophagus by aorta
LES
correlate to anatomic narrowings
How do alkaline substance dissolve esophageal tissue?
liquefactive necrosis
***acid ingestions cause coagulative necrosis
Esophageal perforation is a surgical emergency;
early detection and repair; within 24 hrs–> 80-90% survival
> 24 hrs; survival decreases to 50%
Most esophageal perforations occur from what?
EGD
Boarhaves 15%, foreign body ingestion 15%, trauma 10%
Mallory Weiss tear?
mucosal tear of esophagus after vomitus
Boerhavves?
esophageal ruptured after emesis
For suspected esophageal perforation what contrast do we use to image perforation?
BARIUM for thoracic perforations (barium is inert in chest but causes peritonitis in abdomen)
GASTROGRAFFIN for abdominal perforation (can cause life threatening pneumonitis)
Most common perforations seen with Booerhaves are seen where?
above GEJ on left lateral wall of esophagus
Tx of Boorhaves in an unstable pt?
debride devitalized tissue
esophageal diversion or resection
creation of an esophagostomy
wide drainage
placing a feeding gastrostomy or feeding jejunostomy
Most critical variable that determines surgical management for esophageal perf?
degree of inflammation surrounding the perf
less than 24 hrs, tissue is less friable, surgery is recommended
> 24 hrs tissue is more friable
Golden timing for repair of esophageal pers?
within 24 hrs
How do we approach esophageal perforations ?
cervical perfs–>approach on same side of perf
thoracic perforations upper 2/3–> right chest incision
thoracic perforations lower 1/3–> left chest incision
abdominal perforations–> approached from abdomen or left chest
What is a tracheo-esophageal fistula?
it’s an epithelialized tract between trachea and esophagus
How do we treat TEF?
make pt npo, put in a feeding tube (gastrostomy v jejunostomy)
course of IV abx
2nd stage–> ablate the fistula tract
Surgically, how do we remove TEF?
expose the fistula tract via thoracic v cervical incision
segmentel tracheal resection, primary repair of esophagus
place muscle flap between trachea/esophagus
What’s more common; malignant or benign tumors of the esophagus?
malignant tumors more common
***benign tumors make up less than 1 %
What are some common benign esophageal tumors?
60% are leiomyomas
20% are cysts
5% are polyps
Leiomyomas of esophagus?
most common benign lesions
more common in men
seen in distal 2/3 of esophagus 80% of time
**classified as GISTs
Almost all GIST tumors have a ckit oncogene mutation of?
CD117
What medication may be of benefit in leiomyomas of esophagus (GISTs)?
imatinib
tyrosine kinase inhibitor
2nd most common benign lesions of esophagus?
esophageal cysts (congenital vs acquire)
Most esophageal Ca are what type?
squamous cell Ca worldwide
**in US, 70% of diagnosed esophageal ca is adenocarcinoma
Who gets esophageal Ca, males or females?
squamous cell; male to female 3;1 (mostly AA men)
adenocarcinoma; male to female; 15;1 (mostly white men)
Where is squamous cell carcinoma commonly found?
upper and mid esophagus 70% of time
What causes squamous cell carcinoma (commonly found in upper and mid esophagus)?
exposure to envt toxins;
smoking, etoh, nitrosamines, hot liquids, VIt A and zinc deficiencies
caustic ingestion, achalasia, bulimia, plummer vinson, radiation, esophageal diverticula
Most esophageal cancers diagnosed in US and western countries is?
adenocarcinoma
What causes adenocarcinoma?
increasing incidence of GERD
Western diet
use of acid suppression meds
How does GERD lead to adenocarcinoma?
coffee, fats, acidic foods, lead to relaxed LES and increased reflux
to adapt the squamous line distal esophagus transforms to the columnar type tissue of proximal stomach (BARRETTs)
progressive changes from metaplastic barretts to dysplastic changes lead to adenocarcinoma
What are some intrinsic esophageal diseases that are considered pre-malignant?
Plummer-vinson syndrome; dx of Fe and vitamin deficiency, causes atrophy of esophageal mucosa (assc with increased risk of squamous cell ca)
tylosis–> familial condition, assc with thickening of soles and palms (assc with squamous cell carcinoma)
achalasia–> assc with 16-fold increase in squamous cell ca in late stages of dx
What gene mutation assc with increased risk of esophageal ca?
P53 mutation
Barretts esophagus is assc with 40-fold increase in what esophageal ca?
Barretts
Why does dysphagia present late in the course of esophageal cancers?
b/c the esophagus can distend, 2/3 of the lumen of the esophagus can be obstructed by mass before dysphagia can present
Good first test to start with in someone suspect of having esophageal ca and presenting with dysphagia?
barium esophagram
can show if lesion is intraluminal or intramural, intrinsic or extrinsic
Diagnosis of esophageal Ca is best made by?
endoscopic biopsy
Most critical study for esophageal ca work up?
endoscopic US
TNM staging for esophageal cancer:
T1–> submucosal
T2–>muscularis propria
T3–>adventitia
T4–>surrounding structures
N0–> no nodes
N1–> any nodes
M0–> no mets
M1a–> regional lymph node mets
M1b–> distant lymph node mets
Treatments for squamous cell carcinoma vs adenocarcinoma?
SCC–> more common US, more sensitive to chemo-radiotherapy, are mostly treated non surgically
adenocarcinoma–> more common worldwide, need more aggressive surgical approaches
After caustic agent ingestion, like lye for example, do we do routine surveillance?
15-20 yrs after caustic ingestion
risks of squamous cell carcinoma is 2% after caustic ingestion
Best tx option for high grade dysplasia?
esophagectomy
Why does per-oral endoscopic myotomy have the highest incidence of GERD?
it ablates the LES but does not add an anti-reflux component like a Heller
What’s a Cameron ulcer?
pts with hiatal hernias are prone to developing these due to sliding up GEJ up and down thru the hiatus
What is the first surgical step in someone with a perforated esophagus that you are repairing?
extend the myotomy
Gold standard for diagnosis of achalasia?
esophageal manometry
In pts who have GERD and wound benefit from a fundoplication procedure, but they also have reduced esophageal motility, wht do you do?
can do a partial fundoplication like a Dor, instead of a Nissen
this helps the GERD and doesn’t make the esophageal motility worse
Mid-esophageal perforation, how do you approach it?
right postero-lateral thoracotomy
Perforation of lower third of esophagus, how do you approach?
left postero-lateral thoracotomy
Surgically how do we remove esophageal leiomyomas?
if <5 cm–> endoscopic
if >5 cm–> VATS or laparoscopically
Standard for diagnosis esophageal perf?
esophagraphy with gastrograffin
Traction diverticula are true diverticula and tend to occur where most cmmonly?
mid-esophagus
(pulsion diverticula like zenkers and epiphrenic only involve mucosa and submucosa; false; found in cervical and distal esopagus
Premature contractions in at least 20% of swallows in setting of normal relaxation of LES:
DES
corckscrew appearance on esophagram
tx; initially PPI, CCB initially, botulin injection as second line tx
Mgmt of Barrets:
BE w/out dysplasia; PPI and surveillance 3-5 yrs
BE w/low grade dysplasia–>endoscopic radiofrequency ablation
BE w/high grade dsyplasia–>endoscopic resection followed by radiofrequency ablation, some cases esophagectomy
three types of achalasia based on Chicago classification;
type 1; absent peristalsis, LES not relaxed, normal esophageal pressure
type 2; absent peristalsis, LES not relaxed, pan esophageal increase in presure
type 3; absent peristalsis, LES not relaxed, distal esophagus spastic contractions
What are the margins of a Heller myotomy performed for achalasia?
myotomy 2cm below GE junction
extending 5 cm proximally on esophagus
Predominant sx of achalasia?
dysphagie to solids and liquids both
Tx for Zenkers 2-5 cm?
diverticulopexy w/myotomy
diverticulectom w/myotomy
<2 cm–>diverticulopexy alone, or myotomy alone
Barretts esophagus will predispose to what type of cancer?
adenocarcinoma
