TCV

Question 1

What should you use to rate control a COPD patient with new onset Afib?

Answer 1

Calcium channel blocker like diltiazem or verapamil (NOT BB 2/2 COPD)

Question 2

What are the types of hiatal hernias?

Answer 2

Type I: GE junction slides above the hiatus. Assoc with GERD
Type II: paraesophageal–a bit of stomach goes through hole in diaphragm. Assoc with early satiety, chest pain, dysphagia
Type III: mix of type I and II
Type IV: entire stomach + another organ in chest

Question 3

What serves as blood supply to the conduit in a transhiatal esophagectomy?

Answer 3

the right gastroepiploic artery

Question 4

Where are incisions and anastomoses in different esophagectomy approaches?

Answer 4

THE: abdominal and left cervical incisions, cervical anastomosis
Ivor Lewis: abdominal incision and right thoractomy, thoracic anastomosis
3 hole: all 3 incisions

Question 5

What is the best diagnostic test for atrial myxoma?

Answer 5

Echo

Question 6

Blood supply to cervical esophagus? Thoracic? Abdominal?

Answer 6

Cervical: inferior thyroid off the thyrocervical trunk
Thoracic: directly off aorta
Abdominal: left gastric

Question 7

Path of thoracic duct?

Answer 7

Starts on the right at T12, crosses to the left in the mediastinum (T4-5), and drains into L subclavian vein

Question 8

Describe path of vagus nerves?

Answer 8

Right vagus travels posteriorly to the stomach and becomes the celiac plexus, also gives off the criminal nerve of grassi (will keep acid levels high after vagotomy if not divided). Left vagus travels anteriorly and goes to liver and biliary tree.

Question 9

Another name for upper esophageal sphincter? Innervation?

Answer 9

Crichopharyngeus muscle. Prevents air swallowing. Innervated by recurrent laryngeal nerve.

Question 10

How far from incisors is UES? LES?

Answer 10

UES is 15 cm. LES is 40 cm.

Question 11

What is normal LES pressure at rest?

Answer 11

15 mmHg

Question 12

What are the areas of anatomic esophageal narrowing?

Answer 12

1) Cricopharyngeus muscle (15 cm)
2) L mainstem bronchus and aortic arch (24-26 cm)
3) Diaphragm (40 cm)

Question 13

What mediates relaxation of the LES?

Answer 13

Vagus nerve

Question 14

Surgical approach to different areas of esophagus?

Answer 14

Cervical = left neck
Upper 2/3 thoracic: right (avoids aorta)
Lower 1/3 thoracic: left

Question 15

What is Plummer-Vinson syndrome?

Answer 15

Dysphagia, iron deficiency, esophageal web. Increased risk of SCC of the esophagus and pharynx.

Question 16

What is Zenkers diverticulum?

Answer 16

A false diverticulum proximal to UES, caused by failure of the UES to relax during swallowing. Lies posterior

Question 17

Tx of Zenkers?

Answer 17

cricopharyngeal myotomy via left cervical incision, or endoscopic division of the septum

Question 18

What is epiphrenic diverticulum and what is tx?

Answer 18

in the distal 10 cm of esophagus, assoc with motility disorders. Tx is diverticulectomy and esophageal myotomy on the side opposite the diverticulum

Question 19

Tx for achalasia?

Answer 19

try balloon dilation of LES first + med tx (nitrates, calcium channel blockers), then if that fails do Heller myotomy (left thoracotomy + myotomy of lower 1/3 of esophagus + partial nissen)

Question 20

Manometry findings for achalasia?

Answer 20

increased LES pressure, failure of LES to relax + LACK of peristalsis

Question 21

Manometry of diffuse esophageal spasm?

Answer 21

disorganized, nonperistaltic contractions in >10% of swallows, LES relaxes NORMALLY

Question 22

Tx of DES?

Answer 22

Try medical (Ca channel blockers, nitrates) because surgery is less effective and would need a long myotomy

Question 23

Manometry of nutcracker esophagus?

Answer 23

high amplitude peristaltic contractions, LES relaxes NORMALLY

Question 24

Tx of nutcracker esophagus?

Answer 24

Try medical and avoid surgery bc need a long segment myotomy (upper and lower)

Question 25

Initial tx for GERD?

Answer 25

trial of PPI for 3-4 wks. If no improvement, EGD, pH probe, or manometry (rest LES <6 mmHg)

Question 26

What is normal UES pressure at rest?

Answer 26

60 mmHg

Question 27

What is a Schatzki’s ring and what is it assoc with? tx?

Answer 27

An esophageal ring usually assoc with hiatal hernia. Tx is dilation and PPI.