Esophagus Benign Disease Flashcards
Most common site and cause of esophageal perforation:
Cricopharyngeus muscle, iatrogenic
Management of esophageal perforation:
(1) Treatment of contamination with broad-spectrum antibiotics and antifungals. (2) Wide local drainage. (3) Source control with covered esophageal stents or VATS. (4) Enteric feeding access with G or J tubes.
Best initial test for suspected esophageal perforation:
Gastrografin esophagram
Recommended first test in any patient presenting with esophageal dysphagia:
Barium esophagram
Indications for a barium esophagram:
Regurgitation, globus sensation, dysphagia, GERD, noncardiac chest pain, esophageal neoplasm
What characteristics of the esophagus help determine if a lower esophageal sphincter is mechanically defective?
Pressure <6 mm Hg, total length <2 cm, abdominal length <1 cm
What is the definition of a hypertensive lower esophageal sphincter?
LES with a sphincter pressure above the ninety-fifth percentile of normal
What are the manometric characteristics of achalasia?
Hypertensive LES resting pressure, incomplete or nonrelaxing LES, aperistalsis of the esophageal body, esophageal pressurization, and elevated lower esophageal baseline pressure
What is the gold standard for the diagnosis of achalasia?
Esophageal manometry
What is the presumed pathogenesis of achalasia?
Primary destruction of nerves to the LES with secondary degeneration of the neuromuscular function of the body of the esophagus from idiopathic or infectious neurogenic degeneration
What is the classic triad of presenting symptoms for achalasia?
Dysphagia, regurgitation, weight loss
What is the most common esophageal carcinoma identified with achalasia?
Squamous cell carcinoma
Standard surgical treatment for achalasia:
Heller myotomy
What are the classic manometry findings with diffuse esophageal spasm?
Simultaneous, multipeaked contractions of high amplitude (>120 mm Hg) or long duration (>2.5 seconds)
Indications for surgery in a patient with diffuse esophageal spasm:
Incapacitating chest pain or dysphagia after failure of medical and endoscopic therapy or presence of a pulsion diverticulum of the thoracic esophagus
If indicated, what surgical procedure should be performed in patients with diffuse esophageal spasm?
Long esophagomyotomy with the proximal extent high enough to include the entire length of the abnormal motility as determined by manometric measurements and the distal extent of the myotomy down onto the LES, with or without extension onto the stomach through a left thoracotomy or a left video-assisted technique; Dor fundoplication can be performed to provide protection from reflux and prevent healing of the myotomy site.
What is the gold standard for the diagnosis of nutcracker esophagus?
Manometry demonstrating high-amplitude peristaltic contractions with normal relaxation of LES. Peristaltic esophageal contractions 2 standard deviations above the normal values on manometric tracings (amplitudes >400 mm Hg)
Treatment of nutcracker esophagus:
Medical (calcium channel blockers, nitrates, and antispasmodics) for temporary relief during acute spasms; avoidance of caffeine, cold, and hot foods
Manometric findings with hypertensive LES:
Elevated LES pressure (>26 mm Hg) and normal relaxation of the LES
Treatment of hypertensive LES:
Initially endoscopically with Botox injections and hydrostatic balloon dilation; surgery indicated in symptomatic patients who fail interventional treatments
If indicated, what is the operation of choice for hypertensive LES?
Laparoscopic modified Heller esophagomyotomy with a partial antireflux procedure (Dor, Toupet) in patients with normal esophageal motility
What is the manometric definition of ineffective esophageal motility?
The sum total of the number of low-amplitude contractions (<30 mm Hg) and nontransmitted contractions exceeds 30% of wet swallows
Best treatment for ineffective esophageal motility:
Prevention with effective treatment of GERD; altered motility is irreversible
Treatment for a patient with Barrett esophagus with no dysplasia?
Acid suppression medication and EGD every 3 to 5 years
Treatment for a patient with Barrett esophagus with low-grade dysplasia:
Acid suppression medication and surveillance endoscopy performed at 6 to 12 months
Recommended treatment for a patient with Barrett esophagus with high-grade dysplasia:
Confirmation of pathology by two experienced pathologists. (1) Esophagectomy or (2) endoscopic mucosal resection with radiofrequency ablation or (3) endoscopic surveillance every 3 months. Choice of treatment will depend on if patient is a surgical candidate.
What is the most common aortic arch anomaly that creates an incomplete vascular ring around the esophagus?
Right subclavian artery arising from the descending aorta and traveling behind the esophagus in its course to the right upper extremity
What is a pulmonary artery sling?
An anomaly of the pulmonary arterial trunk where the left pulmonary artery arises from the right pulmonary artery (instead of the main pulmonary artery trunk) and courses between the trachea and the esophagus with resultant significant anterior compression of the esophagus
What can develop with a long-standing, untreated pulmonary artery sling?
Tracheal stenosis and left pulmonary artery narrowing
Treatment of a pulmonary artery sling:
Open sternotomy with cardiopulmonary bypass and anatomic repositioning of the great vessels
What are the theories regarding the etiology of a Schatzki ring?
A result of reflux esophagitis versus overcontractility of the circular esophageal musculature of the inferior esophageal sphincter combined with the sliding gastric mucosa of a hiatal hernia results in persistent apposition of the 2 mucosal layers and fibrosis of the submucosal layer below
How is the diagnosis of a Schatzki ring made?
Barium esophagram
Treatment for an asymptomatic patient incidentally found to have a Schatzki ring:
No treatment
Treatment for a patient with a Schatzki ring who presents with acute obstruction:
Administration of oral papain (2.5% solution) in 5-mL aliquots every 30 minutes for a total of 4 doses for proteolytic digestion of impacted protein food; intravenous (IV) meperidine (25–50 mg) to encourage spontaneous dislodgment of the impacted food bolus; esophagoscopy with the use of an overtube (rigid or flexible) for extraction
Treatment for a patient with a Schatzki ring who presents with dysphagia:
Disruption of the ring by oral dilation (50-French tapered Maloney bougie) with sequential bougienage dilation as symptoms recur
Indications for surgery in a patient with a Schatzki ring:
Patients who fail bougienage or have intractable reflux, intraoperative bougienage followed by a Nissen fundoplication is recommended, but excision of the ring is not indicated
If indicated, what surgical procedure is performed in a patient with a Schatzki ring?
Intraoperative bougienage followed by Nissen fundoplication without excision of the ring
How is an esophageal web distinguished from a Schatzki ring based on epithelium?
Esophageal web has squamous cell epithelium above and below the web. Schatzki ring is composed of esophageal epithelium above and gastric epithelium below the ring.
What is the treatment for a thin esophageal web?
Membranous disruption through an endoscope or bougie, versus piecemeal excision with biopsy forceps, versus laser lysis, versus balloon dilation
What is the treatment for a thick esophageal web refractory to bougienage?
Surgical mucosal resection via a transcervical or transthoracic approach, longitudinal myotomy created and circumferential excision of the web performed, mucosa is circumferentially reapproximated with interrupted absorbable sutures, and muscle is closed longitudinally
What is the characteristic appearance of a leiomyoma on barium esophagram?
A smooth, well-defined, noncircumferential mass with distinct borders
What is the treatment for a leiomyoma?
Surgical enucleation; observation acceptable in patients with significant comorbidities or with small (<2 cm) asymptomatic tumors
What is a type I hiatal hernia?
Sliding hiatal hernia; simple herniation of GE junction into chest
What is a type II hiatal hernia?
GE junction remains at esophageal hiatus and gastric fundus herniates alongside the esophagus into the chest
What is a type III hiatal hernia?
Combination of type I and type II hiatal hernia; GE junction and gastric fundus/body in chest
What is a type IV hiatal hernia?
Advanced stage of hiatal hernia with entire stomach and other intraabdominal content herniated into the chest
