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Big Surgery > Oesophagus > Flashcards

Oesophagus Flashcards

1
Q

What are the causes of perforating oesophageal injury?

A 
1. iatrogenic-60%
with endoscopy
2. Trauma-25%
with stab and gunshot wounds
3. Spontaneous-15%
-Boerhave syndrome
4. Caustic injuries
5. Barotrauma
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2
Q

What is Boerhaave syndrome?

A

It is when a person tries to vomit against a closed upper oesophageal sphincter and that leads to increased pressure distally and a full thickness oesopheal perforation on the posterior-lateral side(left)

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3
Q

What is the clinical picture of these patients?

A
  1. Hoarseness
  2. Pleuritic chest pain
  3. Precipitating event

cervical rupture: surgical emphysema, odynophagia
thoracric rupture: peural effusion, crunching heart sounds, deadly mediastinitis(septic shock)
abdominal rupture: acute abdomen and epigastric pain with shoulder pain

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4
Q

What is the management of perforations if you see this patient in the ward?

A
  1. RESUS!
    - IV fluids
    - Antibiotics IV
    - analgesia

primary surgical repair within 24 hours
After 24 hours then we have to do an oesophageal exclusion with cervical esophagostomy, gastrostomy and feeding jejunostomy

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5
Q

What are the 2 chemicals we ingest?

A
  1. Acids-battery acid and worse in stomach

2. Alkali-cleaning detergents and worse in the oesophagus

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6
Q

What is a complication of caustic injury?

A

It can cause strictures(healing by fibrosis)

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7
Q

What is the clinical presentation of patients with caustic injuries?

A
  1. drooling because its too painful to swallow
  2. History of ingestion
  3. stridor and bronchospasm
  4. inflammatory markers like tachycardia, fever
  5. burn marks to the lips, mouth
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8
Q

What is the initial management for caustic injuries?

A
  1. Nil by mouth
  2. IV fluids
  3. IV antibiotics
  4. Analgesia
  5. Refer for endoscopy
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9
Q

What is the definitive management for caustic injuries?

A
  1. mild damage-discharge after endoscopy
  2. moderate damage- conservative management after endoscopy
  3. severe damage- laparotomy for possible necrosis resection and stent placement for 6 weeks to prevent stricture formation
  4. Chest xray t look for perforation into mediastinum
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10
Q

When a middle aged individual arrives with sudden GERD, what should you exclude first?

A

carcinoma!

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11
Q

What are the causes of GERD?

A
  1. increased abdominal pressure
  2. decreased lower oesophageal sphincter function
  3. loss of the angle of his(angle between the oesophaus and the fundus)
  4. absence of a segment of oesophagus in the abdomen
  5. Poor oesophageal contractions(clearance mechanism) common in scleroderma
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12
Q

What do 80% of adults with GERD have?

A

A hiatus hernia

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13
Q

What are the indications for surgery?

A
  1. Patient does not want to be on lifelong PPI treatment
  2. Lung/aspiration complications
  3. volume reflux with regurgitation
  4. columnar metalsia (barrets oesophagus)
  5. failed treatment on conservative management
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14
Q

What is the surgery we do for GERD?

A

Nissen fundoplication where the fundus of the stomach is wrapped 360 degrees around the lower end of the oesophagus and causes increased pressure to prevent reflux
complications: not being able to vomit or belch, flatulence and dysphagia

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15
Q

What is achalasia?

A

It is a rare neurological condition that causes decreased lowere oesophageal relaxation due to the loss of ganglionic cells in Auberchs plexus

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16
Q

What are secondary conditions that can cause achalsia?

A

-scleroderma and Chaga’s disease

17
Q

What are the symptoms of achalasia?

A
  1. weight loss
  2. dysphagia
  3. regugitation
    - commonly diagnosed in 25-60 year olds
18
Q

What is the treatment of achalasia?

A

Medical: botulinim injection, pharmacotherapy and balloon dilatation
Surgical: Hellers myotomy

19
Q

What is the CT appearance of diffuse oesophageal spasm?

A
  1. corkscrew appearance with sliding hiatus hernia
20
Q

What is the appearance on CT of achalasia?

A

birds beak

21
Q

What is diffuse oesophageal spasm?

A
  1. It is when there diffuse premature contractions of the distal esophagus usually presenting with dysphagia or odynophagia and anxiety
    surgical repair is a esophagotomy
22
Q

What are the 3 types of oesophageal diverticuli?

A
  1. Zenkers
  2. Mid-oesophageal
  3. epiphrenic diverticulum
23
Q

What is Zenkers diverticulum?

A

It is when there is an outpouching above the upper oesophageal sphincter(cricopharyngeal muscle) and the mucosa/submucosa comes out posteriorly and downward

24
Q

How do we manage Zenker’s?

A

<2cm a myotomy is done
2-5cm a diverticulopexy is done and the Zenker’s attached upwards
>5cm a diverticulotomy is done

25
Q

What is the clinical picture of someone with Zenkers?

A
  1. dysphagia and hallitosis, lump in throat, regurgitation
26
Q

What causes mid-oesophageal diverticuli?

A

fibrosis from TB lymph nodes

27
Q

What is epiphrenic diverticuli?

A

It is diverticuli that is located at the lower 1/3 of the esophagus associated with achalasia and GERD

28
Q

What type of benign tumour occurs in the oesophagus?

A

leimyoma

29
Q

What are the top 3 types of carcinoma of the gastrointestinal system?

A
  1. colorectal
  2. hepatocellular
  3. oesophageal
30
Q

What are the two common types of cancers of the oesophagus?

A
  1. squamous cell caused by alcohol and smoking

2. adenocarcinoma caused by obesity and GERD

31
Q

What are the predisposing factors/risk factors that lead to malignancy in the oesophagus?

A
  1. Dietary
    molybedunum deficiency in the soil of the Transkei
    micronutrient deficiencies:vitamin A, B12, E
    nitrosamine rich foods like pickled, salted foods and meats
  2. smoking and alchol
  3. previous chemical burns
  4. GERD especially barrets metaplasia
  5. obesity
32
Q

What are the symptoms of oesophageal cancer?

A
  1. dysphagia( first solids then liquids) and weight loss
  2. coughing
  3. anaemia
  4. chest pain
  5. hoarseness-involvement of the recurrent laryngeal nerve
  6. swollen neck LN-virchows trosier
33
Q

What special investigations can you do for oesophageal carcinoma?

A
  1. contrast swalow is first to see the concentric stricture pattern and possible tracheo-oesophageal fistula
  2. endoscopy with biopsy for histology
34
Q

What are the 3 questions you should ask before deciding on management?

A
  1. The health status of the person-will they survive the operation
  2. Is the tumour resectable?
  3. Are there mets?
35
Q

What is the survival rate after the oesophageal resection?

A

60% 5 year survival rate

36
Q

What can we do for palliative patients?

A
  1. stent that goes through the tumour-SEMS(self expanding metal stent)
  2. chemotherapy and radiotherapy
  3. Laser or cryo destruction of the tumour
    The patients typically live for 6 months

Big Surgery (21 decks)

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