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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
treatment of dysphagia following nissen?
most likely nissen is too tight which generally resolves on its own, clear liquids for 1 week and if still there then dilation
26
Four different types of hiatal hernias
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
management of high grade dysplasia of barrett's?
1. Esophagectomy OR | 2. EGD surveillance every 3 months, 4 quadrant bx very 1cm for entire length of dysplasia
28
surveillance of pt w uncomplicated barrett's
EGD every year for lifetime
29
esophageal cancer: best test to evaluate for resectability?
CT chest abd abdomen
30
esophageal cancer pathology different types
1. Adenocarcinoma: most common, lower 1/3, likely to met to liver 2. Squamous cell: upp 2/3, likely to met to lung
31
neoadjuvant chemo for esophageal ca? indication?
5FU and cisplatin, for T2 tumors+
32
margins for esophagectomy for esophageal cancer?
6-8cm
33
primary blood supply to stomach after replacing esophagus in esophagectomy?
right gastroepiploic artery
34
incisions for transhiatal approach esophagectomy and where is anastomosis?
neck and abdomen, cervical leak from esophageal anastomosis (cause of mortality)
35
incisions for Ivor Lewis approach esophagectomy, where is anastomosis?
abdominal incision and right thoracotomy, get an intrathoracic anastomosis
36
incisions for a 3-hole esophagectomy?
abdominal, neck and thoracotomy
37
most common benign esophageal tumor
leiomyoma, in the muscularis propria, mostly in lower 2/3 of esophagus (smooth muscle)
38
when do you remove an esophageal leiomyoma?
>5cm or symptomatic, extra-mucosal nucleation via thoracotomy
39
where are esophageal polyps mostly found?
cervical esophagus
40
management of caustic esophageal perforations?
esophagectomy
41
best test to evaluate for esophageal perforation?
gastrograffin swallow
42
criteria for non-surgical management of esophageal perforation?
1. Contained perforation by contrast 2. Self draining 3. No systemic effects
43
Management of non-contained esophageal perforation
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
where is esophageal perforation often found in Boerhaave's syndome?
left lateral wall of esophagus, 3-5cm above GE junction
45
what is hartmann's sign?
mediastinal crunching on auscultation, seen in esophageal perforation likely from Boerhaave's syndrome
46
``` Describe fundoplication: Thal: Belsey: Dor: Lind: Toupet: ```
``` Thal: 270* anterior Belsey: 270* anterior transthoracic Dor: 180*-200* anterior Lind: 300* posterior Toupet: 270* posterior ```
47
surveillance of Barett's esophagus without dysplasia?
once daily PPI and EGD every 3-5 years w 4 quadrant biopsies every 2cm
48
what is a demeester score and what is considered abnormal?
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
what is esophageal impedence used for?
for non-acid reflux (aka bile reflux), measures an electrical current
50
What is the origin of the thoracic duct?
cisterna chyli at L1-2
51
where does the thoracic duct cross midline??
right to left at T4-5
52
where does the thoracic duct insert?
left subclavian vein with the internal jugular vein
53
what does the thoracic duct carry?
chylomicrons and long chain fatty acids

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