question

Muscular tube providing for passage of food and liquid Originates at edge of ___ cartilage Enters abdomen via __ __ Terminates at ___ of stomach

answer

cricoid, esophageal hiatus, cardia

question

Esophagus: 3 anatomic areas of narrowing ____ constriction ____ (aortobronchial constriction) ___ constriction

answer

Pharyngoesophageal Thoracic Diaphragmatic

question

Outer muscle later of esophagus: inner:

answer

longitudinal circular

question

Cervical esophagus Primarily ___ muscle

answer

striated

question

At junction of upper ⅓ and & lower ⅔ of esophagus, 50% of fibers are ___ muscle At diaphragmatic hiatus, all muscle is ___ muscle

answer

smooth

question

Arterial supply of the esophagus

answer

Cervical: inferior thyroid a Thoracic: bronchial a, branches off aorta Diaphragmatic and abdominal: L inferior phrenic and left gastric

question

Venous drainage of esophagus:

answer

Cervical: inferior thyroid vein Thoracic: BAH Bronchial v. azygos v. hemiazygos v. Abdominal: L gastric v.

question

Progression of venous drainage blood shunted with cirrhosis

answer

coronary v (l gastric)--> azygos system--> superior vena cava

question

Mucosal lining os esophagus

answer

squamous epithelium (scattered mucous glands) lacks serosa (does not heal well after injury or anastomosis)

question

Muscles of pharynx

answer

Superior constrictor Middle constrictor Inferior constrictor Thyropharyngeus m. Cricopharyngeus m. Generates high-pressure zone that marks the position of UES & esophageal introitus

question

Generates high-pressure zone that marks the position of UES & esophageal introits main component of UES

answer

cricopharyngeus m (an inferior constrictor)

question

is the LES a true sphincter

answer

no There is a distinct high pressure zone in distal thoracic & abdominal esophagus Maintained under tonic contraction except with swallowing

question

steps of swallowing

answer

1. elevation of tongue 2. posterior movement of tongue 3. elevation of soft palate 4. elevation of hyoid 5. elevation of larynx 6. tilting of epiglottis covers opening of larynx

question

Lower esophageal sphincter (LES) (cont)- Sphincter-like function related to crus of esophageal hiatus which contributes to resting pressure of LES Benefit lost with sliding hiatal hernia

answer

true

question

With gastroesophageal reflux (GERD) Decreased ___ of LES Decreased __ of LES Related to ___ displacement ie, GE junction lies more cephalad

answer

pressure length cephalad

question

Imaging Used in patients with esophageal cancer

answer

EUS Defines depth of penetration of tumor Identifies enlarged periesophageal lymph nodes

question

Gold standard for diagnosing & quantifying acid reflux

answer

24 hour pH monitoring

question

Used to assess presence of metastatic disease in patients with esophageal cancer

answer

CT and PET

question

Used to stage esophageal cancer, especially when liver metastases or extensive lymphadenopathy are suspected

answer

Laparoscopy & thoracoscopy-

question

Results from progressive degeneration of ganglion cells in myenteric plexus in esophageal wall Leads to failure of relaxation of LES

answer

achalasia

question

Achalasia is dysphagia for what?

answer

solids and liquids

question

infectious dz involved in achalasia

answer

chaga's dz (Trypanosoma cruzi)

question

the chest pain in achalasia is secondary to....

answer

esophageal distension

question

what might I see on endoscopy eval of achalasia

answer

dilated esophagus and residual material (May result in esophageal candidiasis 2o to stasis)

question

Achalasia may result in what secondary to stasis?

answer

esophageal candidiasis

question

What might I see on barium esophagogram in achalasia?

answer

Dilation of esophagus Narrow gastroesophageal junction (GEJ) Aperistalsis Poor emptying of barium

question

Nonsurgical tx of achalasia

answer

Meds: nitroglycerin, CCBs, botox Dilation

question

surgical tx of achalasia:

answer

laparoscopic heller myotomy (+ partial fundoplication)

question

Achalasia surgery: Myotomy extends proximally ___ cm above GEJ & distally __ cm onto gastric wall

answer

6, 2

question

False diverticula Consist of mucosa & submucosa only Caused by elevated intraluminal pressure 2o to abnormal motility

answer

Pulsion diverticula

question

Result from external inflammatory lymph nodes adhering to esophagus contract & pull on esophagus during healing process outpouching forms from esophageal wall

answer

traction diverticula

question

traction or pulsion are true diverticula?

answer

traction

question

Killian's triangle- Natural area of weakness between oblique fibers of ___ & ___ muscles

answer

thyropharyngeus and cricopharyngeus

question

pharyngoesophagel or zenkers diverticulum: true or false?

answer

false

question

should I do an endoscopy if I suspect esophageal diverticula

answer

no instrument could enter and cause perforation

question

evaluation of zenkers diverticulum

answer

barium esophagogram +lateral view

question

zenkers tx

answer

Cricopharyngeal myotomy with diverticulectomy

question

evaluation of mid esophageal diverticula

answer

barium esophagogram and esophageal manometry

question

Tx of mid esophageal diverticula: traction (true)

answer

tx of underlying infectious process and diverticulopexy

question

Tx of mid esophageal diverticula:motor abnormality (false)

answer

diverticulopexy with long esophagomyotomy and partial fundoplication

question

epiphrenic diverticula are true or false

answer

false (often related to motility disorder)

question

Evaluation of epiphrenic diverticula:

answer

CXR Esophagogram Manometry Endoscopy

question

What might CXR show if I have epiphrenic diverticula

answer

air fluid level in posterior mediastinum

question

Tx of epiphrenic diverticula

answer

Diverticulopexy or diverticulectomy Myotomy extending from diverticulum onto the LES Partial fundoplication

question

what kind of hernia might contribute to GERD

answer

type 1 sliding hiatal hernia (Gastroesophageal junction (GEJ) is displaced above diaphragm Pinchcock action of esophageal crua is lost A hiatal hernia is neither necessary or sufficient to make dx of GERD)

question

Eval of GERD:

answer

endoscopy barium swallow manometry pH monitoring

question

Indications for surgery in GERD pt:

answer

young pt who requires chronic PPIs regurg is persisting despite therapy respiratory symptoms vocal cord damage barrett

question

Tx of GERD if hiatal hernia is present?

answer

replace GEJ below diaphragm --360-dgree wrap (Nissen fundoplication)

question

Dx of Barrett Esophagus:

answer

Endoscopy Shows columnar epithelium extending above GEJ

question

tx of BE metaplasia:

answer

PPIs vs antireflux procedure (Fundoplication may promote regression of metaplasia to normal mucosa Must continue surveillance endoscopy every 12-24 months)

question

BE tx: low grade dysplasia

answer

Endoscopic eradication: (radio frequency ablation) or endoscopic surveillance q 6-12 mos

question

BE tx: high grade dysplasia

answer

Endoscopic eradication: Endoscopic mucosal resection of visible mucosal irregularities Endoscopic radio frequency ablation Esophagectomy: special circumstances...

question

Types of hiatal Hernia: GEJ moves above diaphragm

answer

1

question

Types of hiatal Hernia: Gastric fundus herniates alongside esophagus into mediastinum

answer

II

question

Types of hiatal Hernia: GEJ & stomach herniate into mediastinum

answer

III

question

Types of hiatal Hernia: Intrathoracic stomach along with an associated viscera, eg., colon, small bowel, or spleen

answer

IV

question

Sliding hiatal hernia tx:

answer

presence does not indicate tx... if associated with gerd may be indicated based on severity of symptoms

question

eval of paraesophageal hernias t II, III, IV

answer

endoscopy, barium, manometry

question

Tx of paraesophageal types 2,3,4 operative:

answer

Usually done via laparoscopic approach Procedure includes Return of herniated stomach & other viscera to abdominal cavity Repair enlarged esophageal hiatus Fundoplication

question

most common benign tumor of esophagus

answer

leiomyoma

question

Eval of benign tumors of esophagus

answer

Endoscopy Barium esophagogram Endoscopic ultrasound Chest CT

question

tx of leiomyoma of esophagus

answer

surgical enucleation

question

> 60% of new esophageal cancers in USA* Risk factors include GERD, Barrett's esophagus, smoking, & obesity*

answer

adenocarcinoma

question

In 1970's, most common type of esophageal cancer Risk factors: Smoking, alcohol

answer

squamous cell carcinoma

question

Carcinoma of esophagus..hoarseness is a symptoms what nerves are involved here?

answer

R or L recurrent laryngeal nerve

question

spontaneous vomiting cause of esophageal perforation

answer

Boerhaave Syndrome

question

Tx of early esophageal cancer

answer

Endoscopic mucosal resection or radiofrequency ablation Need strict endoscopic follow-up

question

TX: Invasive cancer with no spread of tumor to adjacent structures, no distant metastases, & patient is fit from cardiopulmonary point of view

answer

esophagectomy

question

Esophageal cancer: locally advanced dz

answer

neoadjuvant therapy (radiotherapy and chemo) followed by surgery

question

esophageal perforation: you should do repair in first 24 hours

answer

if you want ur pt to survive

question

Most common location for instrument perforation of the esophagus where can it occur in thoracic esophagus?

answer

cervical esophagus areas of constriction--- -----level of left main bronchus and aortic arch and diaphragmatic hiatus

question

spontaneous esophageal perforation occurs where?

answer

left posterolateral wall of esophagus 3-5 cm proximal to GE junction

question

imaging studies for esophageal perforation?

answer

soft tissue radiographs (with concern of cervical perf) CXR barium with water soluble contrast CT of chest and or abdomen if barium non dx

question

tx of esophageal perforation

answer

IV fluids & broad spectrum antibiotics Urinary catheter ---With thoracic perforation Secure airway ---With thoracic perforation CXR & water-soluble esophagogram Surgery

question

surgical tx of eso perf: cervical< 24

answer

primary repair and drainage small: external drainage only

question

surgical tx of eso perf: thoracic <24 hours

answer

Primary repair with pleural flap, muscle flap or Nissen fundoplication External drainage Chest tube With distal obstruction, resection With achalasia: Heller myotomy

question

Esophageal perf: >24 hours

answer

Resect diseased portion of esophagus Close distal end of esophagus Perform temporary cervical esophagostomy Place gastrostomy tube Place feeding jejunostomy tube External drainage

question

eval of mallory weiss syndrome

answer

esophagogastroscopy

question

Longitudinal tear in mucosa & submucosa near GE junction associated with bout of forceful vomiting

answer

mallory weiss syndrome

question

tx of mallory weiss syndrome

answer

Place NGT to decompress stomach Administer antiemetic In majority of patients, bleeding will stop spontaneously If patient still has significant bleeding at endoscopy- Endoscopic therapy (electrocautery) may be helpful May require surgery

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