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- author "me"
- tags "Absite"
- description ""
- fileName "Esophagus"
- freezingBlueDBID -1.0
- Where is the Meissner plexus located?
- In the submucosa
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How long is the lower esophageal sphincter?
2-5cm in length
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Lower esophageal sphincter pressure resting pressure zone:
6-26 mmHg
- Increased by: gastrin, motilin
- Decreased by: cholecystokinin, secretin
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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
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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
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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%)
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Failure rate of antireflux surgery:
1% per year
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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)
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Type I hiatal hernia:
GE junction is herniated into the chest
- Aka sliding hiatal hernia
- Most common type
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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
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Type III hiatal hernia
Herniation of gastric fundus and body into chest
Combo of types I & II
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Type IV hiatal hernia
Entire stomach and other intra-abdominal organs are herniated into the chest
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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
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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
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Implicated causes of achalasia
- Severe emotional stress
- Trypanosoma cruzi infection causing destruction of the myenteric Auerbach plexus
- Drastic weight loss
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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
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Rate of esophageal perforation after endoscopic pneumatic dilation:
4%
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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
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Parabronchial diverticulum is:
A true diverticulum caused by traction on inflammed mediastinal nodes (historically caused by TB, now more often seen with Histoplasmosis infection
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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
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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
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Zenker diverticulum =
A false diverticulum with the mucosa and submucosa herniating between the oblique mucsle fibers of the thyropharyngeus and cricopharyngeus muscles (Killian triangle)
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Treatment of Zenker diverticulum:
Surgical or endoscopic
- 3cm or smaller - surgical myotomy
- > 3 cm - surgical/endoscopic (recovery shorter with endoscopic)
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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.
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Barrett esophagus epidemiology:
Found in 10% of pts with GERD
> 70% of cases are found in men aged 55-63yo
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Barrett esophagus risk for esophageal carcinoma:
40-fold increased risk
Requires endoscopic surveillence
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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
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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.
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Treatment of Schatzki rings =
- Oral dilation
- Provides 18mo of relief
Do not excise due to subsequent formation of of strictures
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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
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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
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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%
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Neoadjuvant chemoradiation in esophageal adenocarcinoma results in:
Complete histologic response in approx 25% of patients
Radiation limited to 4500cGy to avoid surgical morbidity
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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.
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Damage caused by ingestion of alkaline substances:
Liquifactive necrosis which can cause deep tissue penetration
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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
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