Esophagus - Benign And Malignant Disorders

Front 1

the cervical esophagus obtains blood supply from where?

Back 1

inferior thyroid arteries and veins.

Front 2

what are some anatomic landmarks that the esophagus passes in the chest?

Back 2

just to the left and posterior to the trachea, splits the tracheal bifucation at the carina, then runs posterior to the left atrium

Front 3

what is the blood supply of the thoracic esophagus?

Back 3

bronchial arteries (upper portion) and the branches of the thoracic aorta (midportion) and drains into the hemiazygos and azygos veins

inferiorly: left gastric a/v and inferior phrenic arteries

Front 4

where does lymph from the esophagus drain?

Back 4

Cervical esoph: cervical and upper paratracheal nodes

Lower thoracic and abdominal esophagus drains preferentially into the retrocardiac and celiac nodes.

Front 5

what are the three layers of the esophagus?

Back 5

mucosa is made of squamous epithelium overlying a lamina propria and a muscularis mucosa

lamina propria = submucosa is elastic and fibrous layer (strongest)

muscularis - 2 layers longitudinal and circular
upper 1/3 is skeletal. lower third is smooth muscle

*no serosa layer (no outer layer to confine spread of disease

Front 6

what three muscles are involved in the upper esophageal sphincter? what is the innervation?

Back 6

lower pharyngeal constrictor
cricopharyngeus
cervical esophageal muscle

innervated by Nucleus Ambiguus.

Front 7

what is the resting pressure of the UES? what opens it?

Back 7

60-100 mm Hg

muscle relaxation, then supra and infra hyoid musculature pulls the sphincter open.

Front 8

whats the rate of peristalsis?

Back 8

3-4 cm/sec

Front 9

what biochemicals open the LES?

Back 9

nitric oxide and VIP (vasoactive intestinal peptide)

Front 10

what accounts for normal physiologic reflux?

Back 10

transient LES relaxations. not associated with swallowing. unknown etiology. may be triggered by gastric distension

Front 11

what are signs of a hiatal hernia?

Back 11

refluxing with cough or bending.

the 'pinchcock' action of the diaphragmatic crus is lost with increased abdominal pressure when the LES is above the crus.

Front 12

what is achalasia?
how does achalasia present?
what do you order to work it up?

Back 12

disorder of motility,+/_ increased pressure of the LES, fails to relax. Due to loss of Auerbach's plexus (no NO or VIP released)

rare, dysphagia to solids and liquids, and regurgitation (75%), weight loss in some, but some adapt with food changes. reflux sx from fermenting food in 50%

work up with manometry (key test) - absence of peristalsis with elevated LES.
barium or fluoro - dilated sigmoid esophagus, birds beak
Endoscopy to r/o tumor. Achalasia is also a risk factor for tumor.

Front 13

how do you treat achalasia?

Back 13

Calcium channel blocker to dilate muscle. Helps about 10 % of patients

Botox injection to LES, endoscopic, usually doesn't work beyond 2.5 years (only 30% still benefit). Use in elderly who cannot tolerate dilation

dilation of LES. success is about 70-80% of pts, usually works for 10 years. Perf rate is 5% (needs open repair) may need reflux meds.

Heller myotomy- laparoscopic, with partial fundoplication. Treatment of choice when expertise is available and patient can tolerate surgery. Good results. Need to be followed with endoscopy to monitor for cancer

Front 14

what is pseudoachalasia or secondary achalasia?

Back 14

when a tumor (ex of the cardia) compresses and infiltrates the esophagus. looks like achalasia on barium swallow and manometry. suspect it in pt's over 60 or with risk factors for cancer. order CT or endoscopic US to r/o tumor

Front 15

where do esophageal diverticula typically occur?

Back 15

above the UES (Zenker's) or LES.

protrusion of mucosa and submucosa through muscularis

Front 16

How does a Zenkers or Pharyngoesophageal diverticulum present? what muscles are involved? what side does it deviate to?

Back 16

dysphagia, regurgitation, gurgling, halitosis.

inferior pharyngeal constrictor and cricopharyngeus (Killian's triangle).

as diverticulum grows, deviates to the left.

Front 17

what tests do you want?

Back 17

barium shows diverticulum.

consider ambulatory manometry - shows UES motility and might show low tone in LES

Front 18

how do zenker's form?

Back 18

form from poorly coordinated muscle movement that increases pressure right above the LES, usually CP spasm. Usually associated with GERD (30-50%)

Front 19

what does an increase in pain and hematemesis make you concerned for?

Back 19

SCC. rare but reported.

Front 20

How do you treat Zenkers?

Back 20

open vs endoscopic approach

for < 2 cm, myotomy is sufficient.

greater than 2 cm - myotomy , excision of pouch, and incision in 3 cm of pharyngeal wall.

endoscopic approach is best between 3-6 cm (2 ok per desilva - but you worry about not getting distal enough in the sac due to limitations on the end of the stapler)

Front 21

what's the prognosis?

Back 21

90% of people get better with surgical treatment. Some people need PPI or fundoplication for reflux

Front 22

what causes an epiphrenic diverticula? sx? work up? treatment?

Back 22

motility disorder, elevated pressures above the diaphragm result in diverticulum of mucosa/sub through the muscularis.

achalasia is the most common cause.

sx dysphagia, chest pain, regurgitation

w/u: CXR shows a/f level
Barium - outlines diverticulum
Manometry shows underlying motility disorder

tx: open the muscle with partial fundoplication. laparoscopic is successful in 80-90% of cases.

Front 23

how does eosinophilic esophagitis present?

Back 23

food impactions and chest pain. in absence of with with controlled reflux. h/o atopy. currently diagnosis of exclusion.

usually airborne alloantigens. swallowed. eosinophilic infiltration of the esophagus. improved with food elimination diets.

Front 24

what are the diagnostic features of EE on esophagoscopy?

Back 24

1. Trachealization of the esoph - rings
2. longitudinal furrows
3. mucosal friability and irritation
4. multicentric white patches
5. strictures
6. absence of hiatal hernia that would more strongly suggest GERD.

Front 25

microscopic evidence of EE on biopsy?

Back 25

> 15 eos' per HPF (not very commonly seen in GERD. if on PPI and still see this, strongly suggestive of EE)

Front 26

what is the best test for atopy in EE patients?

Back 26

SPT

Front 27

how do you treat EE?

Back 27

avoid offending foods (immunotherapy)
PPI
topical glucocorticoids

...difficult to treat with relapsing course

Front 28

how do motility disorders contribute to GERD?

Back 28

reduced peristalsis means more severe reflux and less acid clearance.

hiatal hernias contribute too.

Front 29

Is response to a PPI an acceptable test for GERD?

Back 29

yes.

Front 30

what are the two mechanisms for GERD induced respiratory symptoms?

Back 30

Vagal reflux arc resulting in bronchoconstriction

microaspiration into the tracheobronchial tree.

Front 31

does normal manometry rule out GERD? why do we use it?

Back 31

no. 40% of patients with normal test results still have it.

it's needed to place the pH probe 5 cm above the LES. the other probe is 20 cm above the LES

Front 32

whats the sensitivity of pH testing? when should it be ordered?

Back 32

92% sensitive and specific.

- in patients that don't respond to PPI
- prior to PPI therapy
- rebound symptoms when PPI is removed
- atypical symptoms (if should consider other diagnoses)

Front 33

what is Barret's esophagus? what is the rate of occurrence in GERD patients.? what kind of cancer can it lead do?

Back 33

metaplastic changes from squamous to columnar epithelium. (intestinal type epithelium with goblet cells)

seen in 12% of patients with GERD

goes from metaplasia, to low, then high grade dysplasia, to adenocarcinoma

Front 34

what does a nissen accomplish?

Back 34

increases the resting pressure and length of the LES.

90% success in patients with typical symptoms
70-90% for atypical symptoms

Front 35

what characteristics make a good candidate for nissen?

Back 35

good response to PPI's
high amounts of refluxate (with voice changes or laryngeal swelling)

patients with barret's.
-even with acid control, bile still contributes to metaplastic changes
- patients with barrets are more likely to have low LES pressure
- evidence suggests surgery can prevent progression to cancer

Front 36

what degree of barrets has been shown to regress?

Back 36

in < 3 cm segments, 15-50% regress.

Front 37

when does barret's need to be resected?

Back 37

high grade dysplasia can be resected, has a 30% incidence of having invasive carcinoma (possibly lower %). Can also continue to monitor.

if they choose to monitor or unfit for surgery, q3 month endoscopy with multiple biopsies.

if young and fit for OR, esophagectomy is treatment of choice. goal is to get cancer out before it invades muscle or spreads to nodes.

Front 38

what are the options if a patient cannot tolerate a big surgery?

Back 38

radiofrequency ablation (RFA) or submucosa resection

can also be used for T1a disease as well as high grade barrets

Front 39

how many deaths per year in the US are atributed to esophageal cancer?

Back 39

10,000+

Front 40

what is plummer vinson syndrome?

Back 40

postcricoid dysphagia, upper esophageal webs, and iron deficiency anemia

Front 41

what are the biggest risk factors for esophageal cancer? who is your typical patient?

Back 41

smoking and etoh for SCC
GERD and obesity for adenocarcinoma

60-70 yo male

presents with dysphagia to solids first.
odynophagia
weightloss

Front 42

when esophageal cancer invades surrounding structures, where does it go?

Back 42

tracheobronchial tree, aorta, RLN

tends to go to paraesophageal nodes.

mets to liver and lung

Front 43

what tests do you order?

Back 43

barium shows an irregular intraluminal mass

esophagoscopy for exam and bx.
bronch to rule out invasion into the next lumen

CT's vs PET depending on stage of disease
Bone scan for new onset bone pain

Front 44

when do you operate on esophageal cancer?

Back 44

T3 or less (disease can extend into the adventitia, but not surrounding structures).
No mets
Can tolerate a big surgery

Front 45

what dictates survival from surgery?

Back 45

not type of surgery, but the stage of the disease when treated

this is important because the morbitidty of surgery (respiratory issues, arrythmias, ets) are seen in 30% of patients

Front 46

what role does CRT play?

Back 46

not a big one. no survival benefit from neoadjuvant therapy when added to surgery.

if T4 disease, CRT is palliative to allow the patient to eat.

Dysphagia : treat with stent (good if TEF is present), vs Ng Yag laser resection vs XRT.

Front 47

whats the 5 year survival ?

Back 47

25-30% for all comers.