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Absite Review > Fiser Ch 29: Esophagus > Flashcards

Fiser Ch 29: Esophagus Flashcards

1
Q

layers of the esophagus

A

mucosa (squamous epithelium)
submucosa
muscularis propria (longitudinal muscle layer)
NO SEROSA

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2
Q

blood supply of the esophagus: cervical, thoracic, abdominal

A

cervical: inferior thyroid aa
thoracic: directly from aorta
abdominal: left gastric and inferior phrenic aa

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3
Q

normal UES pressure at rest

A

60 mmHg

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4
Q

normal LES pressure at rest

A

15mmHg

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5
Q

what nerve mediates relaxation of LES?

A

vagus

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6
Q

surgical approach: cervical esophagus

A

left thoracotomy

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7
Q

surgical approach: upper 2/3 thoracic esophagus

A

right thoracotomy

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8
Q

surgical approach: lower 1/3 of esophagus

A

left thoracotomy

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9
Q

treatment of Zenker’s diverticulum?

A

cricopharyngeal myotomy via left cervical incision

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10
Q

whats plummer vinson syndrome?

A
  • due to iron deficient anemia
  • causes upper esophageal webs
    tx: dilation, fe, screen for oral ca
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11
Q

location of zenkers diverticulum vs traction diverticulum?

A

zenkers: cervical esophagus and posterior
traction: mid esophagus and lateral

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12
Q

what an epiphrenic diverticulum? tx?

A
  • rare, associated w esophageal motility disorders (achalasia)
  • distal esophagus
    tx: if symptomatic-
    diverticulectomy and esophageal myotomy on opposite side
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13
Q

what is achalasia and cause?

A
  • lack of peristalsis and failure of LES to relax

- 2/2 autoimmune distruction of neuronal ganglion cells in muscle wall

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14
Q

treatment of achalasia?

A

balloon dilation of LES + nitrates and CCBs initially, then heller myotomy if fails

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15
Q

what is a heller myotomy?

A

left (achalasia) or right (DES, nutcracker) thoracotomy, myotomy of lower esophagus only (achalasia) or upper and lower (DES, nutcracker) + partial nissen fundoplication

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16
Q

what is diffuse esophageal spasm?

A

frequent strong non-peristaltic unorganized contractions, LES relaxes normally

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17
Q

tx of diffuse esophageal spasm?

A

CCBs, trazodone, heller myotomy if fails (myotomy of both UPPER and LOWER

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18
Q

what is nutcracker esophagus?

A

high amplitude peristaltic contractions (>180mmHg), LES relaxes normally

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19
Q

best test to diagnose GERD?

A

pH probe

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20
Q

steps of nissen fundoplication

A
  1. divide short gastrics
  2. pull esophagus into the chest
  3. approximate crura
  4. 270 (partial) or 360 degree gastric fundus
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21
Q

what is a belsey fundoplication?

A

same as nissen but approach is through the chest

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22
Q

key maneuver for dissection during nissen?

A

finding the right crura

23
Q

key maneuver for wrap during nissen

A

finding the left crura

24
Q

what is a collis gastroplasty?

A

not enough esophagus to pull down into abdomen for nissen fundo so staple off stomach cardia and create a neoesophagus

25
Q

treatment of dysphagia following nissen?

A

most likely nissen is too tight which generally resolves on its own, clear liquids for 1 week and if still there then dilation

26
Q

Four different types of hiatal hernias

A

type I: sliding hernia from dilation of hiatus, GE jxn rises above diaphragm
type II: paraesophageal, hole in the diaphragm alongside esophagus, normal GE jxn
type III: combined type I and II
type IV: entire stomach in the chest plus another organ

27
Q

management of high grade dysplasia of barrett’s?

A
  1. Esophagectomy OR

2. EGD surveillance every 3 months, 4 quadrant bx very 1cm for entire length of dysplasia

28
Q

surveillance of pt w uncomplicated barrett’s

A

EGD every year for lifetime

29
Q

esophageal cancer: best test to evaluate for resectability?

A

CT chest abd abdomen

30
Q

esophageal cancer pathology different types

A
  1. Adenocarcinoma: most common, lower 1/3, likely to met to liver
  2. Squamous cell: upp 2/3, likely to met to lung
31
Q

neoadjuvant chemo for esophageal ca? indication?

A

5FU and cisplatin, for T2 tumors+

32
Q

margins for esophagectomy for esophageal cancer?

A

6-8cm

33
Q

primary blood supply to stomach after replacing esophagus in esophagectomy?

A

right gastroepiploic artery

34
Q

incisions for transhiatal approach esophagectomy and where is anastomosis?

A

neck and abdomen, cervical leak from esophageal anastomosis (cause of mortality)

35
Q

incisions for Ivor Lewis approach esophagectomy, where is anastomosis?

A

abdominal incision and right thoracotomy, get an intrathoracic anastomosis

36
Q

incisions for a 3-hole esophagectomy?

A

abdominal, neck and thoracotomy

37
Q

most common benign esophageal tumor

A

leiomyoma, in the muscularis propria, mostly in lower 2/3 of esophagus (smooth muscle)

38
Q

when do you remove an esophageal leiomyoma?

A

> 5cm or symptomatic, extra-mucosal nucleation via thoracotomy

39
Q

where are esophageal polyps mostly found?

A

cervical esophagus

40
Q

management of caustic esophageal perforations?

A

esophagectomy

41
Q

best test to evaluate for esophageal perforation?

A

gastrograffin swallow

42
Q

criteria for non-surgical management of esophageal perforation?

A
  1. Contained perforation by contrast
  2. Self draining
  3. No systemic effects
43
Q

Management of non-contained esophageal perforation

A

If <24hrs and minimal contamination: primary repair with drains, muscle flaps
If >24hrs or extensive contamination:
neck- drains
chest - resection (esophagectomy), or exclusion and diversion

44
Q

where is esophageal perforation often found in Boerhaave’s syndome?

A

left lateral wall of esophagus, 3-5cm above GE junction

45
Q

what is hartmann’s sign?

A

mediastinal crunching on auscultation, seen in esophageal perforation likely from Boerhaave’s syndrome

46
Q 
Describe fundoplication:
Thal:
Belsey:
Dor:
Lind:
Toupet:
A 
Thal: 270* anterior
Belsey: 270* anterior transthoracic
Dor: 180*-200* anterior
Lind: 300* posterior
Toupet: 270* posterior
47
Q

surveillance of Barett’s esophagus without dysplasia?

A

once daily PPI and EGD every 3-5 years w 4 quadrant biopsies every 2cm

48
Q

what is a demeester score and what is considered abnormal?

A

Demeester score: result of 24 hour pH monitoring, composite of percent total time pH <4 in different positions, number and duration of episodes, a score >14.72 is abnormal

49
Q

what is esophageal impedence used for?

A

for non-acid reflux (aka bile reflux), measures an electrical current

50
Q

What is the origin of the thoracic duct?

A

cisterna chyli at L1-2

51
Q

where does the thoracic duct cross midline??

A

right to left at T4-5

52
Q

where does the thoracic duct insert?

A

left subclavian vein with the internal jugular vein

53
Q

what does the thoracic duct carry?

A

chylomicrons and long chain fatty acids

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