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Fiser Chaper 29. ESOPHAGUS Flashcards

1
Q

Esophagus wall layers

A

Mucosa: squamous epithelium

Submucosa

Muscularis propria: longitudinal muscle layer

(no serosa)

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2
Q

Upper 1/3 and lower 2/3 esophagus

A

Upper 1/3: striated muscle

Lower 2/3: smooth muscle

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3
Q

Esophagus blood supply

A

Cervical: inferior thyroid artery

Thoracic esophagus: directly off aorta

Abdominal: left gastric and inferior phrenic arteries

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4
Q

Esophagus venous drainage

A

Hemi-azygous and azygous veins

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5
Q

Esophagus lymphatic drainage

A

Upper 2/3 drains cephalad

Lower 1/3 caudad

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6
Q

Right and left vagus nerve

A

Right travels on posterior portion of stomach as it exits chest; becomes celiac plexus; has criminal nerve of Grassi which can cause persistently high acid levels postop if left undivided after vagotomy

Left vagus travels on anterior portion of stomach; goes to liver and biliary tree

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7
Q

Thoracic duct

A

Travels from R to L at T4-5 as it ascends mediastinum; inserts into L subclavian vein

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8
Q

Where does thoracic duct enter into?

A

L subclavian vein

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9
Q

UES and LEs

A

UES: Cricopharyngeus (circular muscle which prevents air swallowing), 15cm from incisors, gets RLN innervation, most common site of esophageal perf (usually occurs with EGD); aspiration with brainstem stroke is due to failure of cricopharyngeus to relax

LES: anatomic zone of high pressure, NOT an anatomis sphincter; 40cm from incisors, relaxation mediated by inhibitory neurons, normal contracted at resting state (prevents reflux)

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10
Q

Normal UES and LES pressure

A

UES: 60mmHg at rest, 15mmHg with food bolus

LES: 15mmHgb at rest, 0mmHg with food bolus

Both are normally contracted between meals

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11
Q

Anatomic areas of esophageal narrowing (and perf)

A
  • Cricopharyngeus muscle
  • Compression by left mainstem bronchus and aortic arch
  • Diaphragm
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12
Q

Swallowing stages

A

CNS initates swallow

  1. Primary peristalsis: food boluw and wallow initiation
  2. Secondary peristalsis: incomplete emptying and esophageal distension, propagating waes
  3. tertiary peristalsis: non-propagating, non-peristalsis (dysfunction)
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13
Q

Swallowing mechanism

A

Soft palate occludes nasopharynx

Larynx rises and airway opening is blocked by epiglottis

Cricopharyngeus relaxes

Pharyngeal contraction moves food into esophagus

LES relaxes soon after initiation of swallow (vagus mediated)

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14
Q

Surgical approach for different regions of esophagus

A

Cervical: Left

Upper 2/3 thoracic: Right (avoids aorta)

Lower 1/3 thoracic: Left

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15
Q

Hiccoughs causes

A

Gastric distension, temperature changes, EtOH, tobacco

Reflex arc: vagus, phrenic, sympathetic chain T6-12

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16
Q

Esophageal dysfunction primary/secondary

A

Primary: achalasia, DES, nutracker

Secondary: GERD (most common), scleroderma

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17
Q

Best test for heartburn

A

Endoscopy

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18
Q

Best test for dysphagia or odynophagia

A

Barium swallow (better at picking up masses)

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19
Q

Meat impaction dx and tx

A

EGD

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20
Q

Pharyngoesophageal disorders

A

trouble in transferring food from mouth to esophagus

Most commonly neuromuscular disease (MG, muscular dystrophy, stroke)

Liquids worse than solids

Plummer-Vinson syndrome

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21
Q

Upper esophageal web; IDA

A

Plummer-Vinson syndrome

Tx: dilation, Fe, need to screen for oral Ca

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22
Q

Upper esophageal dysphagia, choking hallitosis

A

Zenker’s diverticulum: caused by increased pressure during swallowing

Is a false diverticulum located posteriorly, located between pharyngeal constrictors and cricopharyngeus

Caused by failure of cricopharyngeus to relax

Dx: barium swallow, manometry, risk for perforation with EGD

Tx: Cricopharyngeal myotomy; can also resect or suspend (removal not necessary); via L cervical incision, leave drains, POD1 esophagogram

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23
Q

Regurgitation of undigested food, dysphagia, in some with recent inflammation/granulomatous disease/tumor

A

Traction diverticulum

True diverticulum, usually lies lateral and in mid-esophagus

Tx: Excision and primary closure if symptomatic, may need palliative therapy (XRT) if due to invasive ca; leave alone if symptomatic

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24
Q

Asymptomatic or dysphagia and regurgitation, found to have diverticulum and achalasia

A

Epiphrenic diverticulum

Rare, associated with esophageal motility disorders like achalasia

Most commonly in distal 10cm of esophagus

D: Esophagram and manomery

Tx: Diverticulectomy and esophageal myotomy on side OPPOSITE the diverticulectomy if symptomatic

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25
Dysphagia, regurgitation, weight loss, respiratory symptoms
Achalasia Caused by lack of peristalsis and failure of LES to relax after food bolus Secondary to neuronal degeneration in muscle wall Dx: Manometry shows increased LES pressure and incomplete LES relaxation, with NO peristalsis Can get tortuous dilated esophagus and epiphrenic diverticula; bird's beak appearance Tx: Balloon dilatation of LES is effective in 80%; nitrates and CCBs; If medical tx and dilation fail, Heller myotomty (L thoracotomy, myotomy of lower esophagus ONLY, also partial Nissen) T cruzi can produce similar symptoms
26
Chest pain, dysphagia, psychiatric history, manometry shows frequent strong non-peristaltic unorganized contractions and LES relaxes normally
DES Tx: CCB, nitrates; Heller myotomy ifthose fail (myotomy of UPPER AND LOWER esophagus); surgery usually less effective than for achalasia
27
Chest pain and dysphagia, manometry shows high-amplitude PERISTALTIC contractions and LES relaxes normally
Nutcracker esophagus Tx: CCB, nitrates; Heller myotomy if those fail (myotomy of UPPE AND LOWER esophagus); surgery usually less effective than for achalasia
28
Dysphagia and loss of LES tone with massive reflux and strictures
Scleroderma: fibrous replacement of smooth muscle Tx: Esophagectomy usual if severe
29
Normal anatomic protection from GERD
Competent LES, normal esophageal body, and normal gastric reservoir
30
Causes of GERD
Increased acid exposure to esophagus from loss of gastroesophageal barrier
31
GERD symptoms
Heartburn 30-60 minutes after meals, worse with lying down Can also have asthma symptoms (cough), choking, aspiration
32
GERD workup
Make sure patient does not have another cause for pain (check for unusual symptoms) Unusual symptoms: dysphagia/odynophagia (tumors), bloating (aerophagia and delayed gastric emptying, dx GES), epigastric pain (PUD or tumor)
33
GERD tx
Empirically with PPI, 99% effective Failure of PPI despite 3-4 weeks of escalating doses: need diagnostic studies
34
GERD dx studies
pH probe (best test), manometry (resting LES < 6 mmHg), endoscopy, histology
35
GERD surgical indications
Failure of medical tx, avoidance of lifetime meds, young patients
36
Surgical tx of GERD
Nissen fundoplication: divide short gastrics, pull esophagus into abdomen, approximate crura, 270 (partial) or 360 degree gastric fundus wrap
37
What is the phrenoesophageal membrane made of?
Its an extension of the transversalis fascia
38
Key maneuver for Nissen wrap
identification of the L crura
39
Complications of Nissen wrap
Injury to spleen, diaphragm, esophagus, or pneumothoraz
40
Belsey anti-reflux
Approach through chest
41
Collis gastroplasty
When not enough esophagus exists to pull down into abdomen, can staple along stomach cardia and create a neo-esophagus
42
MCC dysphagia after Nissen
Wrap too tight
43
Hiatal hernia types
I: Sliding hernia from dilation of hiatus (most common); often associated with GERD II: Paraesophageal; hole in diaphragm alongside esophagus, normal GEJ, symptoms of chest pain, dysphagia, early satiety. Usually need repair due to high risk of incarceration; may want to avoid repair in the elderly and frail. In repair STILL NEED NISSEN as diaphragm repair can affect LES and also helps anchor stomach III: combined IV: entire stomach in chest plus another organ (colon, spleen)
44
Schatzki's ring
Almost all have an associaed sliding hiatal hernia Symptoms of dysphagia Tx: dilatation of ring and PPI usually sufficent; do NOT resect
45
Barrett's esophagus
Squamous metaplasia to columnar epithelium Occurs with long-standing exposure to gastric reflux Cancer risk is 50x higher (adenocarcinoma) Ucomplicated Barrett's can be treated like GERD (PPI or Nissen): surgery will decrease esophagitis and further metaplasia but will NOT prevent malignancy or cause regression of columnar lining. Need careful follow up with EGD for lifetime, even after Nissen Severe Barrett's dysplasia is an indication for esophagectomy
46
Esophageal cancer characteristics
Almost always malignant with early invasion of nodes Spreads quickly along submucosal lymphatic channels Symptoms are dysphagia especially to solids, and weight loss Risk factors are EtOH, tobacco, caustic injury, nitrosamines Dx: esophagram (best test for dysphagia)
47
Signs of unresectable esophageal cancer
CT chest and abdomen is the best single test for resectability Hoarseness (RLN invasion) Horner's syndrome (brachial plexus invasion) Phrenic nerve invasion Malignant pleural effusion Malignant fistula Airway invasion Vertebral invasion Supravlavicular or celiac nodes (M1 disease; nodal disease outside area of resection)
48
Types of esophageal cancer
Adenocarcinoma: #1, usually in lower 1/3, liver mets most common Squamous cell carcinoma: usually upper 2/3, lung mets most common
49
Chemo for esophageal cancer
Neoadjuvent CRT may downstage tumorsand make them resectable Chemotx: 5Fu and cisplatin (for node-positive disease or preop to shrink tumors)
50
Esophagectomy mortality rate and cure rate
5% mortality, 20% cure rate
51
Primary blood supply to stomach after replacing esophagus
R gastroepiploic artery (have to divide L gastric and short gastrics)
52
Transhiatal approach esophagectomy
Abdominal and neck incisions; bluntly dissect intrathoracic esophagus; may hae decreased mortality from esophageal leaks with cervical anastomosis
53
Ivor Lewis esophagectmoy
Abdominal incision and R thoracotomy Exposes all of the intrathoracic esophagus Intrathoracic anastomosis
54
3-hole esophagectomy
Abdominal, thoracic, and cervical incisions
55
Esophagectomy types
Transhiatal approach Ivor Lewis 3-Hole Colonic interposition Need pyloromyotomy with these procedures
56
Colonic interposition esophagectomy
May be choice in young patients when you want to preserve gastric function; 3 anastomosis required; blood supply depends on colon marginal vessels
57
Post esophagectomy care
POD7 contrast study to rule out leak Postop strictures: most can be dilated
58
Most common benign esophageal tumor
Leiomyoma Located in muscularis propria Present as dysphagia, with mass usually in lower 2/3 of esophagus (smooth muscle cells) Dx: esophagram, EUS, CT scan to r/o cancer, DO NOT BIOPSY (can form scar and make subsequent resection difficult) Tx: Excise via thoractomy if > 5cm or symptomatic
59
Dysphagia and hematemesis, and found to have esophageal polyps
2nd most common benign tumor of esophagus Usually in cervical esophagus Small lesions can be resected endoscopically; larger lesions need cervical incision
60
Caustic esophageal injury
Alkali or acid Primary, secondary, or tertiary burns NO NG TUBE, DO NOT INDUCE VOMITING, NOTHING TO DRINK
61
Alkali and acid burns
Alkali: deep liquefaction necrosis, especially liquid (Drano), worse than acid and more likely to cause cancer Acid: coagulation necrosis; mostly causes gastric injury
62
Caustic injury workup
CT chest and abdomen to look for free air and perforation Endoscopy to assess lesion: do NOT use with suspected perforation and NOT go past a site of sevre injury Serial exams and plain films required
63
Degrees of esophageal caustic injury
Primary burn: hyperemia, observe and IVF, spiting, abx, NPO 3-4 days, may need future serial dilation for strictures (usually cervial), can also get shortening of esophagus with GERD (tx PPI) Secondary burn: ulcerations, exudates, sloughing, do prolonged observation and IVF, spitting, abx, NPO 3-4 days, future dilation if needed; indication for esophagectomy is sepsis, peritonitis, mediastinitis, free air, mediastinal or stomach wall air, crepitance, contrast extrav, pneumothorax, or large effusion Tertiary burn: deep ulcers, charring, lumen narrowing; esophagectomy usually necessary; alimentary tract NOT restored until after patient recovers from caustic injury CAUSTIC ESOPHAGEAL PERFORATIONS REQUIRE ESOPHAGECTOMY AND ARE NOT REPAIRED DUE TO EXTENSIVE DAMAGE
64
Esophageal perforations MCC
EGD
65
Esophageal perforations most common site
Cervical esophagus near cricopharyngeus muscle (?)
66
Pain, dysphagia, tachycardia
Esophageal perforation Dx: CXR to look for free air, gastrograffin swallow followed by barium swallow
67
Management of esophageal perf
Contained perforation by contrast, self draining, NO systemic effects: IVF, NPO, spit, abx Non-contained: If <24 hr and minimal contamination: primary repair with drains (also need longitudinal myotomy to see full extent of injury and consider intercostal muscle flaps to cover repair) If > 48 hr or extensive contamination: - Neck: Drainage (no resection) - Chest: Resection (esophagectomy and cervical esophagostomy) or exclusion and diversion (cervical esophagostomy, staple across distal esophagus, washout mediastinum, chest tubes - late esophagectomy at time of gastric replacement)
68
Indications for esophagectomy in perforation
Severe intrinsic disease (burned out esophagus from achalasia or cancer) regardless of contained or non contained
69
Forceful vomiting followed by chest pain
Boerhaave's: perforation most likely to occur in L lateral wall of esophagus, 3-5 cm above GEJ Mediastinal crunching on auscultation: Hartmann's sign
70
Highest mortality of all perforations
Boerhaave's syndrome: early diagnosis and treatment improve survival Dx: gastrografin swallow Tx: same as for other esophageal perforations

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