Fiser Chaper 29. ESOPHAGUS Flashcards Preview

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1

Esophagus wall layers

Mucosa: squamous epithelium

Submucosa

Muscularis propria: longitudinal muscle layer

(no serosa)

2

Upper 1/3 and lower 2/3 esophagus

Upper 1/3: striated muscle

Lower 2/3: smooth muscle

3

Esophagus blood supply

Cervical: inferior thyroid artery

Thoracic esophagus: directly off aorta

Abdominal: left gastric and inferior phrenic arteries

4

Esophagus venous drainage

Hemi-azygous and azygous veins

5

Esophagus lymphatic drainage

Upper 2/3 drains cephalad

Lower 1/3 caudad

6

Right and left vagus nerve

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

7

Thoracic duct

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

8

Where does thoracic duct enter into?

L subclavian vein

9

UES and LEs

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)

10

Normal UES and LES pressure

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

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

Both are normally contracted between meals

11

Anatomic areas of esophageal narrowing (and perf)

- Cricopharyngeus muscle

- Compression by left mainstem bronchus and aortic arch

- Diaphragm

12

Swallowing stages

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)

13

Swallowing mechanism

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)

14

Surgical approach for different regions of esophagus

Cervical: Left

Upper 2/3 thoracic: Right (avoids aorta)

Lower 1/3 thoracic: Left

15

Hiccoughs causes

Gastric distension, temperature changes, EtOH, tobacco

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

16

Esophageal dysfunction primary/secondary

Primary: achalasia, DES, nutracker

Secondary: GERD (most common), scleroderma

17

Best test for heartburn

Endoscopy

18

Best test for dysphagia or odynophagia

Barium swallow (better at picking up masses)

19

Meat impaction dx and tx

EGD

20

Pharyngoesophageal disorders

trouble in transferring food from mouth to esophagus

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

Liquids worse than solids

Plummer-Vinson syndrome

21

Upper esophageal web; IDA

Plummer-Vinson syndrome

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

22

Upper esophageal dysphagia, choking hallitosis

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

23

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

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

24

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

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

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