Oesophagus Flashcards
What are the causes of perforating oesophageal injury?
1. iatrogenic-60% with endoscopy 2. Trauma-25% with stab and gunshot wounds 3. Spontaneous-15% -Boerhave syndrome 4. Caustic injuries 5. Barotrauma
What is Boerhaave syndrome?
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)
What is the clinical picture of these patients?
- Hoarseness
- Pleuritic chest pain
- 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
What is the management of perforations if you see this patient in the ward?
- 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
What are the 2 chemicals we ingest?
- Acids-battery acid and worse in stomach
2. Alkali-cleaning detergents and worse in the oesophagus
What is a complication of caustic injury?
It can cause strictures(healing by fibrosis)
What is the clinical presentation of patients with caustic injuries?
- drooling because its too painful to swallow
- History of ingestion
- stridor and bronchospasm
- inflammatory markers like tachycardia, fever
- burn marks to the lips, mouth
What is the initial management for caustic injuries?
- Nil by mouth
- IV fluids
- IV antibiotics
- Analgesia
- Refer for endoscopy
What is the definitive management for caustic injuries?
- mild damage-discharge after endoscopy
- moderate damage- conservative management after endoscopy
- severe damage- laparotomy for possible necrosis resection and stent placement for 6 weeks to prevent stricture formation
- Chest xray t look for perforation into mediastinum
When a middle aged individual arrives with sudden GERD, what should you exclude first?
carcinoma!
What are the causes of GERD?
- increased abdominal pressure
- decreased lower oesophageal sphincter function
- loss of the angle of his(angle between the oesophaus and the fundus)
- absence of a segment of oesophagus in the abdomen
- Poor oesophageal contractions(clearance mechanism) common in scleroderma
What do 80% of adults with GERD have?
A hiatus hernia
What are the indications for surgery?
- Patient does not want to be on lifelong PPI treatment
- Lung/aspiration complications
- volume reflux with regurgitation
- columnar metalsia (barrets oesophagus)
- failed treatment on conservative management
What is the surgery we do for GERD?
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
What is achalasia?
It is a rare neurological condition that causes decreased lowere oesophageal relaxation due to the loss of ganglionic cells in Auberchs plexus
What are secondary conditions that can cause achalsia?
-scleroderma and Chaga’s disease
What are the symptoms of achalasia?
- weight loss
- dysphagia
- regugitation
- commonly diagnosed in 25-60 year olds
What is the treatment of achalasia?
Medical: botulinim injection, pharmacotherapy and balloon dilatation
Surgical: Hellers myotomy
What is the CT appearance of diffuse oesophageal spasm?
- corkscrew appearance with sliding hiatus hernia
What is the appearance on CT of achalasia?
birds beak
What is diffuse oesophageal spasm?
- It is when there diffuse premature contractions of the distal esophagus usually presenting with dysphagia or odynophagia and anxiety
surgical repair is a esophagotomy
What are the 3 types of oesophageal diverticuli?
- Zenkers
- Mid-oesophageal
- epiphrenic diverticulum
What is Zenkers diverticulum?
It is when there is an outpouching above the upper oesophageal sphincter(cricopharyngeal muscle) and the mucosa/submucosa comes out posteriorly and downward
How do we manage Zenker’s?
<2cm a myotomy is done
2-5cm a diverticulopexy is done and the Zenker’s attached upwards
>5cm a diverticulotomy is done
What is the clinical picture of someone with Zenkers?
- dysphagia and hallitosis, lump in throat, regurgitation
What causes mid-oesophageal diverticuli?
fibrosis from TB lymph nodes
What is epiphrenic diverticuli?
It is diverticuli that is located at the lower 1/3 of the esophagus associated with achalasia and GERD
What type of benign tumour occurs in the oesophagus?
leimyoma
What are the top 3 types of carcinoma of the gastrointestinal system?
- colorectal
- hepatocellular
- oesophageal
What are the two common types of cancers of the oesophagus?
- squamous cell caused by alcohol and smoking
2. adenocarcinoma caused by obesity and GERD
What are the predisposing factors/risk factors that lead to malignancy in the oesophagus?
- Dietary
molybedunum deficiency in the soil of the Transkei
micronutrient deficiencies:vitamin A, B12, E
nitrosamine rich foods like pickled, salted foods and meats - smoking and alchol
- previous chemical burns
- GERD especially barrets metaplasia
- obesity
What are the symptoms of oesophageal cancer?
- dysphagia( first solids then liquids) and weight loss
- coughing
- anaemia
- chest pain
- hoarseness-involvement of the recurrent laryngeal nerve
- swollen neck LN-virchows trosier
What special investigations can you do for oesophageal carcinoma?
- contrast swalow is first to see the concentric stricture pattern and possible tracheo-oesophageal fistula
- endoscopy with biopsy for histology
What are the 3 questions you should ask before deciding on management?
- The health status of the person-will they survive the operation
- Is the tumour resectable?
- Are there mets?
What is the survival rate after the oesophageal resection?
60% 5 year survival rate
What can we do for palliative patients?
- stent that goes through the tumour-SEMS(self expanding metal stent)
- chemotherapy and radiotherapy
- Laser or cryo destruction of the tumour
The patients typically live for 6 months
