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2013-10-19 15:15:15

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    • author "me"
    • tags "Absite"
    • description ""
    • fileName "Esophagus"
    • freezingBlueDBID -1.0
    • Where is the Meissner plexus located?
    • In the submucosa
  1. How long is the lower esophageal sphincter?
    2-5cm in length
  2. Lower esophageal sphincter pressure resting pressure zone:
    6-26 mmHg

    • Increased by: gastrin, motilin
    • Decreased by: cholecystokinin, secretin
  3. 3 types of esophageal contraction:
    Primary - propulsive, initiated after swallowing, travel entire length of the esophagus, generate pressures of 40-80 mmHg

    Secondary - propulsive, initiated by presence of food rather than voluntary swallowing

    Tertiary - uncoordinated contractions that are nonperistaltic
  4. Indications for antireflux surgery:
    • Severe esophageal injury
    • Incomplete resolution of symptoms with medical therapy
    • Patient preference against long term pharmacotherapy
    • Complications from a hiatal hernia
  5. Most common finding on reoperation for recurrence of GERD symotoms:
    Herniated fundoplication above the diaphragm (33%)

    • Others:
    • Disrupted wrap (18%)
    • Tight wrap (13%)
    • Slipped wrap onto body of stomach (10%)
  6. Failure rate of antireflux surgery:
    1% per year
  7. Endoscopic techniques to treat esophageal reflux disease:
    • Augment the LES by:
    • Suturing-NDO, Endocinch, Esophyx
    • Radiofrequency energy - Stretta
    • Injection of a polymer - Enteryx (discontinued in 2005 following a
    • death by injection into aorta)
  8. Type I hiatal hernia:
    GE junction is herniated into the chest

    • Aka sliding hiatal hernia
    • Most common type
  9. Type II hiatal hernia
    GE junction is below the diaphragm with the fundus of the stomach herniated into the chest

    • Aka paraesophageal hernia
    • Least common type
  10. Type III hiatal hernia
    Herniation of gastric fundus and body into chest

    Combo of types I & II
  11. Type IV hiatal hernia
    Entire stomach and other intra-abdominal organs are herniated into the chest
  12. Smooth filling defect indistal end of esophagus on barium esophagogram =
    Leiomyoma (aka gastrointestinal stromal tumor)

    Of esophageal neoplasms <1% are benign, 60% of these are leiomyomas - most commonly found in distal 2/3 of esophagus

    On EUS - hypoechoic mass within submucosa or muscularis propria

    Cause = mutation of c-KIT oncogene

    • Remove by enucleation
    • Do not biopsy due to increased risk of perforation
  13. Factors that contribute to failure of the intrinsic antireflux mechanism:
    • Intra-abdominal lower esophageal sphincter length < 1cm
    • LES resting pressure < 6 mmHg
    • Presence of esophageal dysmotility
    • LES total length < 2 cm
    • Low attachment of the phrenoesophageal ligament
  14. Implicated causes of achalasia
    • Severe emotional stress
    • Trypanosoma cruzi infection causing destruction of the myenteric Auerbach plexus
    • Drastic weight loss
  15. Manometry findings for achalasia:
    • LES pressure > 35 mmHg
    • LES fails to relax below 5 mmHg with deglutition
    • Increased esophageal body pressures due to incomplete air evacuation
    • Low amplitude aperistaltic waveforms
  16. Rate of esophageal perforation after endoscopic pneumatic dilation:
  17. Treatment of esophageal perforation:
    • Contained perf in stable pt - NPO & IV Abx
    • Underlying path (achalasia, esophageal ca, stricture) - left thoracotomy, primary repair, myotomy (if achalasia)/esophagectomy (if sigmoid esophagus or megaesophagus), drain placement
  18. Parabronchial diverticulum is:
    A true diverticulum caused by traction on inflammed mediastinal nodes (historically caused by TB, now more often seen with Histoplasmosis infection
  19. Diffuse esophageal spam diagnosis:
    Corkscrew pattern on esophagography

    Manometry - simultaneous multipeaked contractions similar to those seen in achalasia, but with normal receptive relaxation of LES
  20. Diffuse esophageal spam treatment:
    1st line = Pharmacotherapy aimed at smooth muscle relaxation (nitrates, calcium channel blockers, phosphodiesterase inhibitors)

    Surgery = esophagomyotomy from level of aortic arch to the LES
  21. Zenker diverticulum =
    A false diverticulum with the mucosa and submucosa herniating between the oblique mucsle fibers of the thyropharyngeus and cricopharyngeus muscles (Killian triangle)
  22. Treatment of Zenker diverticulum:
    Surgical or endoscopic

    • 3cm or smaller - surgical myotomy
    • > 3 cm - surgical/endoscopic (recovery shorter with endoscopic)
  23. Barrett esophagus =
    Intestinal columnar epithelium replaces esophageal squamous epithelium as a result of inflammation secondary to chronic reflux

    Gastric juice may contain bile salts which are soluble and nonionized in pH range of 2-6.5 & therefore better absorbed by esophageal mucosal cells, causing greatest cell damage.
  24. Barrett esophagus epidemiology:
    Found in 10% of pts with GERD

    > 70% of cases are found in men aged 55-63yo
  25. Barrett esophagus risk for esophageal carcinoma:
    40-fold increased risk

    Requires endoscopic surveillence
  26. Mallory-Weiss tears =
    Linear tears in the esophagohastric mucosa that cause arterial bleeding in pts with repeated emesis

    Dx: by endoscopy

    Tx: bleeding stops spontaneously; endoscopic injection/caughtery, gastrotomy with suture ligation for refractory bleeding
  27. Schatzki rings =
    • Concentric constrictions of the distal end of the esophagus occuring at the squamocolumnar junction resulting in esophageal mucosa above and gastric mucosa below.
    • The ring consists of muscularis mucosa, connective tissue, and submucosal fibrosis.
  28. Treatment of Schatzki rings =
    • Oral dilation
    • Provides 18mo of relief

    Do not excise due to subsequent formation of of strictures
  29. Esophageal cancer epidemiology:
    Most common type worldwide vs. US =
    Male:Female ratio by type =
    Ethnic prediliction:
    Risk Factors:
    6th most common malignancy, incidence 20/100,000 in US

    • Worldwide = squamous cell carcinoma
    • US = adenocarcinoma (70%)

    • M:F
    • Squamous cell = 3:1
    • Adenoca = 15:1

    • Squamous cell - African-American men
    • Adenoca - White men

    • Alcohol/Tobacco = 5-fold increased risk
    • Alcohol & Tobacco = 25-100-fold increased risk
  30. Most important diagnostic tool in esophageal cancer staging =
    • Endoscopic ultrasound
    • Able to get tissue samples from primary lesion & lymph nodes. More sensitive & specific than CT for evaluating celiac lymph nodes

    • Barium esophagography - good first test
    • CT - accurate for M staging, only 57% accurate for T staging
    • PET - good for N & M staging
    • MRI - good for metastatic & T4 lesions
  31. Risk of LN involvement by T stage (tumor depth)
    • T1a intramucosa - 18%
    • T1b submucosa - 55%
    • T2 not beyond muscularis mucosa - 60%
    • T3 involves paraesophageal tissue, not adjacent structures - 80%
    • T4 involves adjacent structures - 100%
  32. Neoadjuvant chemoradiation in esophageal adenocarcinoma results in:
    Complete histologic response in approx 25% of patients

    Radiation limited to 4500cGy to avoid surgical morbidity
  33. Describe transhiatal esophagectomy
    • Incisions on left side of neck and abdomen used instead of a thoracotomy.
    • Esophagus bluntly dissected & tubularized stomach is pulled through the posterior mediastinum to create a cervical esophagogastric anastomosis
    • Blood supply to the gastric conduit is based on the right gastroepiploic artery.
  34. Damage caused by ingestion of alkaline substances:
    Liquifactive necrosis which can cause deep tissue penetration
  35. Treatment of ingestion of alkaline substance
    Within 1hr of ingestion - 1/2 strength vinegar or citrus juice to neutralize

    Endoscopy to grade the burn

    Serial esophagograms to evaluate for stricture formation

    Prevention of long term strictures - Early stent placement or bougie dilation (after reepithelialization confirmed by endoscopy)

    For long-segment strictures - resection with colonic interposition graft