EsophagusEsophagus

STATE OF THE ARTSTATE OF THE ART

AnatomyAnatomy

Squamous epithelium, circular inner Squamous epithelium, circular inner muscle layer, outer longitudinal muscle layer, outer longitudinal muscle layermuscle layer

NO SEROSANO SEROSA Upper esophagus: striated muscleUpper esophagus: striated muscle Lower esophagus: smooth muscleLower esophagus: smooth muscle

3 3 Narrowings?Narrowings?

Lies in midline, with a deviation to the LEFT in the lower portion of neck and upper portion of thorax

Returns to midline in midportion of thorax near bifurcation of the trachea

Surgical Approach: Cervical Left, Upper Thoracic Right, Lower Thoracic Left

1. Cricopharyngeus Muscle – circular muscle, prevents air swallowing

Luminal diameter 1.5 cm

Narrowest point

MC site of perforation

Aspiration with brainstem stroke- failure of UES to relax

2. Indentation of the anterior and left lateral esophageal wall d/t crossing of the left main stem bronchus and aortic arch

3. Hiatus of diaphragm – gastroesophageal sphincter mechanism

ABSITE:

Cervical Esophagus is supplied by?

Abdominal Esophagus supplied by:

Left gastric a. & Inferior phrenic a.

Swallowing StagesSwallowing Stages

CNS initiates swallowCNS initiates swallow Normal esophagus pressures Normal esophagus pressures

with food bolus 70-120 with food bolus 70-120 mmHgmmHg

Primary peristasis-Primary peristasis- occurs occurs with food bolus and swallow with food bolus and swallow initiationinitiation

Secondary peristalsis-Secondary peristalsis- occurs occurs with incomplete emptying with incomplete emptying and esophageal distention, and esophageal distention, propogating wavespropogating waves

Tertiary peristalsis-Tertiary peristalsis- nonpropating, nonperistalsing nonpropating, nonperistalsing (dysfunctional)(dysfunctional)

UES and LES are normally UES and LES are normally contracted b/w mealscontracted b/w meals

LES normal pressure at rest LES normal pressure at rest 10-20mmHg10-20mmHg

Contracted at resting state- Contracted at resting state- prevents refluxprevents reflux

Soft palate Soft palate occludes occludes nasopharynxnasopharynx

Larynx rises and Larynx rises and airway opening airway opening is blocked by is blocked by epiglottisepiglottis

Cricopharyngeus Cricopharyngeus relaxesrelaxes

Pharyngeal Pharyngeal contraction contraction moves food into moves food into esophagusesophagus

LES relaxes soon LES relaxes soon after initiation of after initiation of swallowswallow

Esophageal Functional TestsEsophageal Functional Tests

Cineradiologic studiesCineradiologic studies EndoscopyEndoscopy Endoscopic ultrasonographyEndoscopic ultrasonography Endoscopic mucosal resection (EMR)Endoscopic mucosal resection (EMR) pH monitoringpH monitoring Detection of bilirubin in the stomach Detection of bilirubin in the stomach

and esophagusand esophagus Esophageal impedance Esophageal impedance

Cineradiology of the Cineradiology of the

EsophagusEsophagus General indications for a video-General indications for a video-

esophagram are the following:   esophagram are the following:    Globus sensationGlobus sensation

  Dysphagia  Dysphagia  Regurgitation  Regurgitation  Gastroesophageal reflux disease  Gastroesophageal reflux disease  Noncardiac chest pain  Noncardiac chest pain  Esophageal neoplasm  Esophageal neoplasm  Suspected postoperative complications  Suspected postoperative complications

EndoscopyEndoscopy A.A.      Upper abdominal symptoms that persist despite an appropriate trial   Upper abdominal symptoms that persist despite an appropriate trial of therapyof therapy    B.B.    Upper abdominal symptoms associated with other symptoms or     Upper abdominal symptoms associated with other symptoms or signs suggesting serious organic disease (e.g., anorexia and weight loss) signs suggesting serious organic disease (e.g., anorexia and weight loss) or in patients older than 45 yearsor in patients older than 45 years    C.C.    Dysphagia, odynophagia, aspiration, unexplained laryngeal     Dysphagia, odynophagia, aspiration, unexplained laryngeal symptoms, unexplained chronic cough, or asthmasymptoms, unexplained chronic cough, or asthma    D.D.        Esophageal reflux symptoms that are persistent or recurrent despite Esophageal reflux symptoms that are persistent or recurrent despite appropriate therapyappropriate therapy    E.E.    Other diseases in which the presence of upper GI pathology might     Other diseases in which the presence of upper GI pathology might modify other planned management (e.g., patients who have a history of modify other planned management (e.g., patients who have a history of ulcer or GI bleeding who are scheduled for organ transplantation, long-ulcer or GI bleeding who are scheduled for organ transplantation, long-term anticoagulation or chronic nonsteroidal anti-inflammatory drug term anticoagulation or chronic nonsteroidal anti-inflammatory drug therapy for arthritis, and those with cancer of the head and neck)therapy for arthritis, and those with cancer of the head and neck)    F.F.    For confirmation and specific histologic diagnosis of radiologically     For confirmation and specific histologic diagnosis of radiologically demonstrated ulcers, strictures, and neoplastic lesionsdemonstrated ulcers, strictures, and neoplastic lesions    G.G.        Upper gastrointestinal bleedingUpper gastrointestinal bleeding    H.H.    To assess acute injury after caustic ingestion    To assess acute injury after caustic ingestion    I.I.    Removal of foreign bodies    Removal of foreign bodies    J.J.    Removal of selected polypoid lesions    Removal of selected polypoid lesions    K.K.    Placement of feeding or drainage tubes (per oral, percutaneous     Placement of feeding or drainage tubes (per oral, percutaneous endoscopic gastrostomy, percutaneous endoscopic jejunostomy)endoscopic gastrostomy, percutaneous endoscopic jejunostomy)    L.L.    Dilatation of stenotic lesions (e.g., with transendoscopic balloon     Dilatation of stenotic lesions (e.g., with transendoscopic balloon dilators or dilatation systems employing guidewires)dilators or dilatation systems employing guidewires)    M.M.    Palliative treatment of stenosing neoplasms (e.g., laser, multipolar     Palliative treatment of stenosing neoplasms (e.g., laser, multipolar electrocoagulation, stent placement)electrocoagulation, stent placement)

Grade I valve: A ridge of tissue 3 to 4 cm long on the lesser curve is closely applied to the endoscope.

Grade II valve: The ridge is less well defined than in grade I, and it opens occasionally with respiration but closes promptly.

Grade III valve: The ridge is barely present, and there is often failure to close around the endoscope. It is nearly always accompanied by a hiatal hernia and esophagitis.

Grade IV valve: There is no muscular ridge. The gastroesophageal junction remains open all the time, and the squamous epithelium can often be seen from this retroflexed position. A hiatal hernia is always present.

Hill's endoscopic grading of the retroflexed view of the cardia.

Endoscopic UltrasonographyEndoscopic Ultrasonography Combines endoscopy and 5–12 Combines endoscopy and 5–12

MHz frequency ultrasonography MHz frequency ultrasonography to evaluate the different layers to evaluate the different layers of the esophageal wall and of the esophageal wall and adjacent structures outside the adjacent structures outside the wall. wall.

The presence of nodal The presence of nodal metastases increases with the metastases increases with the depth of tumor invasion. depth of tumor invasion.

If the tumor is confined to the If the tumor is confined to the mucosa, nodal metastases are mucosa, nodal metastases are unlikely, but they are likely to be unlikely, but they are likely to be present in nearly 90% of patients present in nearly 90% of patients who have disease eroding who have disease eroding through the wall. through the wall.

Mostly used at centers dedicated to Mostly used at centers dedicated to the treatment of esophageal cancer.the treatment of esophageal cancer.

A more practical method of A more practical method of assessing the depth of early tumors assessing the depth of early tumors is by endoscopic mucosal resection is by endoscopic mucosal resection

Esophageal pH Esophageal pH MeasurementsMeasurements

Indications for pH MonitoringIndications for pH Monitoring     1.1.    Symptomatic patients with normal    Symptomatic patients with normal endoscopy for surgical considerationendoscopy for surgical consideration

    2.2.    Failed antireflux surgery evaluation    Failed antireflux surgery evaluation    3.3.    Symptoms refractory to proton     Symptoms refractory to proton pump pump

inhibitor therapyinhibitor therapy    4.4.    Chest pain evaluation    Chest pain evaluation    5.5.    Otorhinolaryngolic symptoms    Otorhinolaryngolic symptoms    6.6.    Nonallergic asthma and chronic     Nonallergic asthma and chronic

undiagnosed coughundiagnosed cough

Therapeutic pH studiesTherapeutic pH studies

pH studies are the only means to pH studies are the only means to determine whether acid reflux has determine whether acid reflux has been controlled or not. been controlled or not.

The pH probe may be used in The pH probe may be used in combination with an impedance study, combination with an impedance study, which will assess reflux whether the which will assess reflux whether the refluxate is acid or not.refluxate is acid or not.

Such studies are becoming more Such studies are becoming more important in the management of important in the management of Barrett's esophagus when control of all Barrett's esophagus when control of all reflux may be an important issue.reflux may be an important issue.

Bilitec MonitoringBilitec Monitoring Bilirubin concentration in a solution Bilirubin concentration in a solution

can be directly measured by can be directly measured by spectrophotometry, based on specific spectrophotometry, based on specific absorption at a wavelength of 453 nm. absorption at a wavelength of 453 nm. Measurement of bilirubin in the Measurement of bilirubin in the stomach and esophagus is an indirect stomach and esophagus is an indirect method of measuring bile, a frequent method of measuring bile, a frequent constituent of the refluxate in constituent of the refluxate in gastroesophageal reflux gastroesophageal reflux

Impedance TestingImpedance Testing

Esophageal impedance is a measure Esophageal impedance is a measure of the resistance to electrical of the resistance to electrical conductivity of the esophagus and its conductivity of the esophagus and its contents and is used to measure contents and is used to measure bolus transport. bolus transport.

Impedance is inversely proportional Impedance is inversely proportional to electrical conductivityto electrical conductivity

Clinical UsesClinical Uses

1.1.    Measurement of all types of gastroesophageal     Measurement of all types of gastroesophageal reflux (i.e., acid and nonacid refluxates, liquid or gas reflux (i.e., acid and nonacid refluxates, liquid or gas and mixed refluxatesand mixed refluxates    2.2.    Assessment of high gastroesophageal reflux    Assessment of high gastroesophageal reflux    3.3.    Measurement of swallow function by bolus     Measurement of swallow function by bolus transporttransport    4.4.    Assessment of patients for GERD therapy (i.e.,     Assessment of patients for GERD therapy (i.e., suitability for endoscopic or operative antireflux suitability for endoscopic or operative antireflux procedure)procedure)    5.5.    Identification of patients “at risk” for 360-    Identification of patients “at risk” for 360-degree fundoplication because of poor bolus degree fundoplication because of poor bolus transporttransport    6.6.    Assessment of patients with dysphagia, IEM,     Assessment of patients with dysphagia, IEM, and precordial chest painand precordial chest pain    7.7.    Assessment of recurrent symptoms after     Assessment of recurrent symptoms after antireflux surgeryantireflux surgery

Clinical Application of Esophageal Clinical Application of Esophageal

Function TestsFunction Tests Gastroesophageal Reflux Disease:Gastroesophageal Reflux Disease: Contemplating antireflux surgery complete Contemplating antireflux surgery complete

the investigation of patients with suspected the investigation of patients with suspected GERD by doing:GERD by doing:– video-esophagram, endoscopy with biopsies, video-esophagram, endoscopy with biopsies,

manometry, and pH measurementsmanometry, and pH measurements Failure to appreciate fully the physiology of Failure to appreciate fully the physiology of

the patient's deficit may result in the patient's deficit may result in inappropriate surgery (e.g., fundoplication for inappropriate surgery (e.g., fundoplication for achalasia, 360-degree fundoplication for achalasia, 360-degree fundoplication for scleroderma). scleroderma).

Clinical Application of Esophageal Clinical Application of Esophageal

Function TestsFunction Tests DysphagiaDysphagia

A video-esophagram is the appropriate first A video-esophagram is the appropriate first investigation for patients with dysphagia. investigation for patients with dysphagia.

Detect causes of dysphagia that are not evident Detect causes of dysphagia that are not evident on endoscopy alone:on endoscopy alone:– such as a cricopharyngeal barsuch as a cricopharyngeal bar– small Zenker diverticulumsmall Zenker diverticulum– small epiphrenic diverticulasmall epiphrenic diverticula– early achalasiaearly achalasia

Road map of obstructing lesions such as strictures Road map of obstructing lesions such as strictures and cancers and allow for the preparation of the and cancers and allow for the preparation of the patient should dilatation be necessary. patient should dilatation be necessary.

Undiagnosed Chest Pain Undiagnosed Chest Pain Chest pain may also be related to a motility Chest pain may also be related to a motility

disorder or GERD, and a video-esophagram, disorder or GERD, and a video-esophagram, endoscopy, manometry, and pH testing are endoscopy, manometry, and pH testing are recommended.recommended.

Undiagnosed Laryngitis, Chronic Cough and Undiagnosed Laryngitis, Chronic Cough and Nonallergic Asthma Nonallergic Asthma

These symptoms may be related to These symptoms may be related to gastroesophageal reflux, sometimes in gastroesophageal reflux, sometimes in association with a motility deficit, and a full association with a motility deficit, and a full investigation as for GERD is recommended. A investigation as for GERD is recommended. A dual pH probe is used for pH assessment.dual pH probe is used for pH assessment.

ManometryManometry

Used to evaluate the resting Used to evaluate the resting pressures in the esophageal body pressures in the esophageal body and upper and lower sphincters and and upper and lower sphincters and the response to swallowing the response to swallowing

DiagnosticDiagnostic     1.1.        Motility disordersMotility disorders: achalasia, hypertensive lower : achalasia, hypertensive lower

esophageal sphincter, nutcracker esophagus, inadequate esophageal sphincter, nutcracker esophagus, inadequate esophageal motility (IEM; includes scleroderma and diffuse esophageal motility (IEM; includes scleroderma and diffuse esophageal spasm), nonspecific esophageal motor disorderesophageal spasm), nonspecific esophageal motor disorder    2.2.        DysphagiaDysphagia: assessment of the cause of functional : assessment of the cause of functional obstructionobstruction    3.3.        Chest painChest pain: assessment of the cause and relation to : assessment of the cause and relation to gastroesophageal refluxgastroesophageal reflux    4.4.        Respiratory disordersRespiratory disorders (especially chronic cough): a (especially chronic cough): a motility disorder may be associated with gastroesophageal motility disorder may be associated with gastroesophageal reflux responsible for the coughreflux responsible for the cough

Preoperative AssessmentPreoperative Assessment     1.1.    Verify the correct diagnosis and suitability for surgery.    Verify the correct diagnosis and suitability for surgery.

    2.2.    Avoid postoperative dysphagia.    Avoid postoperative dysphagia.

Postoperative AssessmentPostoperative Assessment     1.1.    Assessment of the response to surgery.    Assessment of the response to surgery.

    2.2.    Confirmation of the effect of treatment on the lower     Confirmation of the effect of treatment on the lower esophageal sphincter (e.g., for achalasia).esophageal sphincter (e.g., for achalasia).    3.3.    Assess the cause of failed surgery.    Assess the cause of failed surgery.

Hypertensive Lower Hypertensive Lower Esophageal SphincterEsophageal Sphincter

A hypertensive LES has a sphincter A hypertensive LES has a sphincter pressure above the 95th percentile of pressure above the 95th percentile of normalnormal

This is the second most common motility This is the second most common motility disorderdisorder

Elevated basal pressure of the LES with Elevated basal pressure of the LES with normal relaxation and normal propulsion normal relaxation and normal propulsion in the esophageal bodyin the esophageal body

AchalasiaAchalasia The most common motility disorder in which the LES The most common motility disorder in which the LES

does not relax adequately and in which there is does not relax adequately and in which there is absent peristalsis in the esophageal body. absent peristalsis in the esophageal body.

The LES in achalasia is hypertensive in approximately The LES in achalasia is hypertensive in approximately 50% of patients and characteristically fails to relax 50% of patients and characteristically fails to relax adequately.adequately.

Secondary to neuronal degeneration in muscle wallSecondary to neuronal degeneration in muscle wall There is pressurization (intrathoracic pressures that There is pressurization (intrathoracic pressures that

are normally negative become positive) in are normally negative become positive) in approximately 60% of studies.approximately 60% of studies.

The most diagnostic feature of achalasia is absence The most diagnostic feature of achalasia is absence of peristalsis in 100% of swallow responsesof peristalsis in 100% of swallow responses

Dysphagia, regurgitation, weight loss, respiratory sxDysphagia, regurgitation, weight loss, respiratory sx

Hypertensive LES resting pressure

Incomplete or nonrelaxing LES

Aperistalsis of the esophageal body

Esophageal pressurization: elevated lower esophageal baseline pressure

Tx: goal - eliminate the outflow obstruction afforded Tx: goal - eliminate the outflow obstruction afforded by a nonrelaxing sphincter, relieve dysphagia, and by a nonrelaxing sphincter, relieve dysphagia, and maintain a barrier against gastroesophageal reflux maintain a barrier against gastroesophageal reflux when possiblewhen possible

Nonsurgical treatment includes:Nonsurgical treatment includes:– calcium channel blockers and nitratescalcium channel blockers and nitrates– injection of botulinum toxin into the LESinjection of botulinum toxin into the LES– large-caliber (30–40 mm) pneumatic dilatation of the LES.large-caliber (30–40 mm) pneumatic dilatation of the LES.

Surgical treatment includes division of the muscle Surgical treatment includes division of the muscle fibers of the LES and proximal cardiafibers of the LES and proximal cardia– Heller myotomyHeller myotomy, consists of a single, anterior, , consists of a single, anterior,

longitudinal myotomy and has become the standard longitudinal myotomy and has become the standard operative techniqueoperative technique

– Anterior partial fundoplication of the Dor type is the most Anterior partial fundoplication of the Dor type is the most commonly performed antireflux barrier created following commonly performed antireflux barrier created following myotomy for achalasia – 90 or 180myotomy for achalasia – 90 or 180

– Posterior (Toupet) partial fundoplication - 270Posterior (Toupet) partial fundoplication - 270

Esophageal manometry findings with Esophageal manometry findings with distal esophageal cancer can mimic distal esophageal cancer can mimic achalasia, underscoring the achalasia, underscoring the importance of endoscopy for all pts importance of endoscopy for all pts with dysphagia. Untreated achalasia with dysphagia. Untreated achalasia carries a 2-4% risk of esophageal carries a 2-4% risk of esophageal cancer.cancer.

Primary Esophageal Motility DisordersPrimary Esophageal Motility Disorders– AchalasiaAchalasia– "vigorous" achalasia"vigorous" achalasia– Diffuse and segmental esophageal spasmDiffuse and segmental esophageal spasm– Nutcracker esophagusNutcracker esophagus– Hypertensive lower esophageal sphincterHypertensive lower esophageal sphincter– Nonspecific esophageal motility disordersNonspecific esophageal motility disorders

Secondary Esophageal Motility DisordersSecondary Esophageal Motility Disorders– Collagen vascular diseases: progressive systemic Collagen vascular diseases: progressive systemic

sclerosis, polymyositis and dermatomyositis, sclerosis, polymyositis and dermatomyositis, mixed connective tissue disease, systemic lupus mixed connective tissue disease, systemic lupus erythematosuserythematosus

– Chronic idiopathic intestinal pseudo-obstructionChronic idiopathic intestinal pseudo-obstruction– Neuromuscular diseasesNeuromuscular diseases– Endocrine and metastatic disordersEndocrine and metastatic disorders

Hypercontractile Hypercontractile Esophagus (“Nutcracker Esophagus (“Nutcracker

Esophagus”)Esophagus”) Definition: The mean height of Definition: The mean height of

swallow responses in either of the swallow responses in either of the two distal channels exceeds the two distal channels exceeds the upper limit of normal (180 mm Hg) or upper limit of normal (180 mm Hg) or the duration of swallow responses the duration of swallow responses exceeds 7 seconds in patients who exceeds 7 seconds in patients who have either chest pain or dysphagiahave either chest pain or dysphagia

Mean peristaltic amplitude (10 wet swallows) in distal esophagus 180 mm Hg

Increased mean duration of contractions (>7.0 s)

Normal peristaltic sequence

Ineffective Esophageal Ineffective Esophageal Motility (IEM)Motility (IEM)

Definition: A distinct manometric entity Definition: A distinct manometric entity characterized by a hypocontractile characterized by a hypocontractile esophagus in which the distal esophagus in which the distal esophageal amplitudes are <30 mm Hg esophageal amplitudes are <30 mm Hg or the contractions are nontransmitted or the contractions are nontransmitted in >30% of the wet swallows. in >30% of the wet swallows.

IEM incorporates scleroderma of the IEM incorporates scleroderma of the esophagus and end-stage reflux esophagus and end-stage reflux disease disease

Decreased or absent amplitude of esophageal peristalsis (<30 mm Hg)

Increased number of nontransmitted contractions

Treatment should be directed at the GERD symptoms, and as Treatment should be directed at the GERD symptoms, and as dysphagia becomes a problem, the therapy should be dysphagia becomes a problem, the therapy should be directed toward the anatomic abnormality (peptic stricture, directed toward the anatomic abnormality (peptic stricture, tumor)tumor)

Surgical antireflux procedures are offered to patients with Surgical antireflux procedures are offered to patients with severe or refractory GERD; these should be partial severe or refractory GERD; these should be partial fundoplication wraps such as the Dor or Toupet techniques fundoplication wraps such as the Dor or Toupet techniques

Patients with better access through the left chest are offered Patients with better access through the left chest are offered Belsey Mark IV fundoplicationBelsey Mark IV fundoplication

Care is taken not to make the wrap too tight because this Care is taken not to make the wrap too tight because this would cause a functional obstruction; thus these repairs are would cause a functional obstruction; thus these repairs are performed over a 50-F Maloney dilatorperformed over a 50-F Maloney dilator

Finally, esophagectomy should be considered only in the most Finally, esophagectomy should be considered only in the most extreme cases in which patients have failed a prior antireflux extreme cases in which patients have failed a prior antireflux procedure and continue to have persistent severe symptoms procedure and continue to have persistent severe symptoms or develop secondary problems such as undilatable strictures or develop secondary problems such as undilatable strictures or cancer or cancer

SclerodermaScleroderma

smooth muscle atrophy and collagen deposition smooth muscle atrophy and collagen deposition

normal peristalsis in the proximal striated esophagusnormal peristalsis in the proximal striated esophagus

absent peristalsis in the distal smooth muscle portionabsent peristalsis in the distal smooth muscle portion

Diffuse Esophageal Diffuse Esophageal SpasmSpasm

Definition: Definition: – symptoms of substernal chest pain, dysphagia, or symptoms of substernal chest pain, dysphagia, or

bothboth– the radiographic appearance of localized the radiographic appearance of localized

nonprogressive waves (tertiary contractions)nonprogressive waves (tertiary contractions)– increased incidence of nonperistaltic contractions increased incidence of nonperistaltic contractions

recorded by intraluminal manometryrecorded by intraluminal manometry

Because the abnormal contractions are Because the abnormal contractions are usually seen in the distal esophagus, Castell usually seen in the distal esophagus, Castell has suggested that the term “distal has suggested that the term “distal esophageal spasm” is more appropriateesophageal spasm” is more appropriate

Disorder relates more to uncoordinated Disorder relates more to uncoordinated contractions than to high-pressure contractions than to high-pressure contractions.contractions.

Simultaneous (nonperistaltic contractions) (>20% of wet swallows)Repetitive and multi-peaked contractionsSpontaneous contractionsIntermittent normal peristalsisContractions may be of increased amplitude and duration

Smooth-muscle relaxation:Smooth-muscle relaxation:– NitratesNitrates– calcium-channel blockerscalcium-channel blockers– phosphodiesterase inhibitorsphosphodiesterase inhibitors

Tricyclic antidepressants and Tricyclic antidepressants and serotonin reuptake inhibitorsserotonin reuptake inhibitors

BotoxBotox Heller myotomy (transect circular Heller myotomy (transect circular

layer of upper and lower esophagus)layer of upper and lower esophagus)

Causes of Esophageal PerforationCauses of Esophageal Perforation     1.1.        Iatrogenic - MCC  Iatrogenic - MCC    

a.a. Intraluminal Intraluminal i.i.   Esophagoscopy, particularly with dilatation   Esophagoscopy, particularly with dilatation

    ii.ii.  Endoscopic or transesophageal ultrasound  Endoscopic or transesophageal ultrasound    iii.iii.  Endoscopic antireflux procedures  Endoscopic antireflux procedures    iv.iv.  Endoscopic mucosal resection or ablation  Endoscopic mucosal resection or ablation    v.v.    Esophageal intubation with a tube (nasogastric, Sengstaken–Blakemore) or     Esophageal intubation with a tube (nasogastric, Sengstaken–Blakemore) or bougie (for antireflux surgery or dilatation)bougie (for antireflux surgery or dilatation)    vi.vi.  Misplaced endotracheal tube during intubation  Misplaced endotracheal tube during intubation

     b.b. Extraluminal Extraluminal      i.i.  Intraoperative injury during neck, mediastinal, thoracic, or upper abdominal   Intraoperative injury during neck, mediastinal, thoracic, or upper abdominal

proceduresprocedures    ii.ii.  Radiation therapy for esophageal tumor  Radiation therapy for esophageal tumor

    2.2.    Trauma       Trauma    a.a.    Penetrating or blunt injury    Penetrating or blunt injury

    b.b.    Barotrauma (seizure, weightlifting, postemetic or Boerhaave's syndrome)    Barotrauma (seizure, weightlifting, postemetic or Boerhaave's syndrome)    c.c.    Foreign body or caustic ingestion       Foreign body or caustic ingestion    i.i.  Fish bones  Fish bones    ii.ii.  Food or solid objects (coins, nails, pins)  Food or solid objects (coins, nails, pins)    iii.iii.  Acid or alkaline material  Acid or alkaline material

    3.3.    Malignancy    Malignancy    4.4.    Inflammation       Inflammation   

a.a. Crohn's disease of the esophagus Crohn's disease of the esophagus      b.b. Gastroesophageal reflux and ulceration Gastroesophageal reflux and ulceration    5.5.    Infection    Infection

Intrathoracic esophageal perforation Intrathoracic esophageal perforation lethal lethal– Negative intrathoracic pressure sucks esophageal Negative intrathoracic pressure sucks esophageal

and gastric contents out of the site of perforation and gastric contents out of the site of perforation and into the mediastinumand into the mediastinum

Cervical perforation typically presents with Cervical perforation typically presents with neck tenderness, odynophagia, and neck tenderness, odynophagia, and subcutaneous emphysemasubcutaneous emphysema

Most commonly, the perforation is in the Most commonly, the perforation is in the distal esophagus toward the left chest. A left-distal esophagus toward the left chest. A left-sided pleural effusion or hydropneumothorax sided pleural effusion or hydropneumothorax may be present by the time patients present may be present by the time patients present for evaluation and should be an indication of for evaluation and should be an indication of the correct diagnosis the correct diagnosis

The initial test in most circumstances should be a water-The initial test in most circumstances should be a water-soluble (gastrograffin) contrast swallow. soluble (gastrograffin) contrast swallow.

RIGHT LATERAL DECUBITUS:RIGHT LATERAL DECUBITUS:– The study should be done in the right lateral decubitus position to avoid rapid The study should be done in the right lateral decubitus position to avoid rapid

transit of contrast into the stomach, and if no leak is seen with gastrograffin, then transit of contrast into the stomach, and if no leak is seen with gastrograffin, then thin barium should be used because this may show a small leak missed by thin barium should be used because this may show a small leak missed by gastrograffin.gastrograffin.

CT CHEST:CT CHEST:– If the diagnosis remains unclear, a CT scan of the chest should be done If the diagnosis remains unclear, a CT scan of the chest should be done

immediately after the contrast swallow because even very small leaks will be immediately after the contrast swallow because even very small leaks will be apparent with the resolution offered by a CT scan.apparent with the resolution offered by a CT scan.

UPPER ENDOSCOPYUPPER ENDOSCOPY::– flexible endoscopy should be performed in most patients with flexible endoscopy should be performed in most patients with

perforations distal to the cervical esophagus.perforations distal to the cervical esophagus.– Small mucosal tears or perforations can be detected with the Small mucosal tears or perforations can be detected with the

excellent visualization offered by modern endoscopes. excellent visualization offered by modern endoscopes. – Look for slight fluttering of the mucosa during air insufflation as Look for slight fluttering of the mucosa during air insufflation as

a clue to the location of the injury. a clue to the location of the injury. – Concerns regarding making the hole larger are unfounded Concerns regarding making the hole larger are unfounded

because the size of the hole is irrelevant in terms of prognosisbecause the size of the hole is irrelevant in terms of prognosis

TreatmentTreatment– Aggressive fluid resuscitationAggressive fluid resuscitation– Broad-spectrum antibioticsBroad-spectrum antibiotics– In patients on chronic acid-suppression In patients on chronic acid-suppression

medications, antifungal therapy is also medications, antifungal therapy is also appropriateappropriate

– A nasogastric tube to decompress the stomach A nasogastric tube to decompress the stomach is important but must be placed carefully; it may is important but must be placed carefully; it may be best inserted immediately after the contrast be best inserted immediately after the contrast swallow with the aid of fluoroscopy or during the swallow with the aid of fluoroscopy or during the endoscopic evaluation of the esophagus. endoscopic evaluation of the esophagus.

– A chest tube should be placed to drain an A chest tube should be placed to drain an associated pleural effusion or associated pleural effusion or hydropneumothorax.hydropneumothorax.

A 42 year old man reports that while A 42 year old man reports that while eating a large piece of meat, he began eating a large piece of meat, he began retching, vomiting and developed retching, vomiting and developed severe chest pain. He is now in the ER severe chest pain. He is now in the ER with crepitus, (Hamman’s sign or with crepitus, (Hamman’s sign or Mediastinal crunch) tachypnea, Mediastinal crunch) tachypnea, tachycardia, and a chest X-ray with tachycardia, and a chest X-ray with widening of the mediastinum and a left widening of the mediastinum and a left pleural effusion. What is the next step pleural effusion. What is the next step in management? in management?

A left thoracotomy and primary A left thoracotomy and primary repair of the ruptured esophagus is repair of the ruptured esophagus is indicated. Sudden-onset of crepitus indicated. Sudden-onset of crepitus following an episode of retching is a following an episode of retching is a classic presentation of Boerhaave’s classic presentation of Boerhaave’s syndrome.syndrome.

Boerhaave’s SyndromeBoerhaave’s Syndrome

Spontaneous perforation of the Spontaneous perforation of the esophagus typically follows large esophagus typically follows large intake of food, followed by violent intake of food, followed by violent retching and vomitingretching and vomitingThe most common site of rupture is 3-The most common site of rupture is 3-5 cm above the GEJ on the left 5 cm above the GEJ on the left posterolateral aspectposterolateral aspectThe 2nd most common site is the mid-The 2nd most common site is the mid-thoracic esophgus on the right side at thoracic esophgus on the right side at the level of the azygos veinthe level of the azygos vein

LATE RUPTURELATE RUPTURE

resect the perforated siteresect the perforated site

spitz fistula (exteriorize proximal)spitz fistula (exteriorize proximal)

close the distal endclose the distal end

mediastinal external drainagemediastinal external drainage

feeding jejunostomyfeeding jejunostomy

delayed reconstruction with colon or jejunal delayed reconstruction with colon or jejunal interpositioninterposition

A 29 year old man presents with A 29 year old man presents with dysphagia and an UGI series which dysphagia and an UGI series which demonstrates a stricture. What is demonstrates a stricture. What is the most likely etiology of his the most likely etiology of his esophageal stricture?esophageal stricture?

In general, chemical injury from In general, chemical injury from exposure to gastric juice, medication, exposure to gastric juice, medication, or caustic agents is the most or caustic agents is the most common cause of esophageal common cause of esophageal stricture in young people.stricture in young people.

Esophageal StricturesEsophageal Strictures

Caused by reflux of gastroduodenal contents, Caused by reflux of gastroduodenal contents, medications, or caustic agents (bleach, medications, or caustic agents (bleach, ammonia, lye)ammonia, lye)

medication induced strictures typically occur medication induced strictures typically occur in the mid-esophagusin the mid-esophagus

Peptic strictures usually occur in the distal Peptic strictures usually occur in the distal esophagusesophagus

caustic strictures can involve the entire caustic strictures can involve the entire esophagus, or segments at any level.esophagus, or segments at any level.

Management of strictures depends Management of strictures depends on location, pliability, and length of on location, pliability, and length of the stricture.the stricture.

pliable, unfixed, short strictures are often dilatedpliable, unfixed, short strictures are often dilated

fixed strictures may require surgerfixed strictures may require surgery y

A 74 year old male A 74 year old male presents with presents with dysphagia, gurgling dysphagia, gurgling sounds in his neck, sounds in his neck, and regurgitation of and regurgitation of undigested food. undigested food. What is the most What is the most likely diagnosis?likely diagnosis?

This pt most likely has a Zenker’s This pt most likely has a Zenker’s diverticulum, but because of his age, diverticulum, but because of his age, cancer remains the “must R/O cancer remains the “must R/O diagnosis”.diagnosis”.

Esophageal DiverticulumEsophageal Diverticulum

commonly associated with motor commonly associated with motor dysfunction and are usually acquireddysfunction and are usually acquired

PulsionPulsion diverticuladiverticula develop from develop from protrusion of the mucosa and submucosa protrusion of the mucosa and submucosa through a defect in the musculaturethrough a defect in the musculature

TractionTraction diverticuladiverticula result from pulling result from pulling on the esophageal wall by scarred or on the esophageal wall by scarred or inflamed adjacent tissue (typically inflamed adjacent tissue (typically mediastinal lymph nodes)mediastinal lymph nodes)

Zenker’s DiverticulumZenker’s Diverticulum

most common typemost common typea false diverticuluma false diverticulumpulsion typepulsion typemore common in menmore common in menarises in the posterior midline of the neck arises in the posterior midline of the neck above the cricopharyngeus muscle and below above the cricopharyngeus muscle and below the pharyngeal inferior constrictor (i.e. the pharyngeal inferior constrictor (i.e. posteriorposterior))Rx: resection and Rx: resection and cricopharyngeal myotomycricopharyngeal myotomy

Zenker’s itself can either be resected or Zenker’s itself can either be resected or suspended (removal of diverticula not suspended (removal of diverticula not necessary)necessary)

Traction DiverticulumTraction Diverticulum

a “true diverticulum”a “true diverticulum”

usually lies usually lies laterallateral, and is , and is in in midesophagusmidesophagus

due to inflammation, due to inflammation, granulomatous disease, or granulomatous disease, or tumortumor

Rx: excision and primary Rx: excision and primary closure, may need palliative closure, may need palliative therapy if due to invasive therapy if due to invasive CaCa

Epiphrenic DiverticulumEpiphrenic Diverticulum

rare, associated with rare, associated with esophageal motility esophageal motility disordersdisorders

most common in the most common in the distal 10 cmdistal 10 cm

Dx: esophagram and Dx: esophagram and manometrymanometry

Rx: diverticulectomhy Rx: diverticulectomhy and long esophageal and long esophageal myotomy on the side myotomy on the side opposite the opposite the diverticulectomydiverticulectomy

A 43 year old female complains of A 43 year old female complains of frequent heartburn after meals and frequent heartburn after meals and at night. She experiences at night. She experiences predictable chest pain with certain predictable chest pain with certain foods and notes that her pain is foods and notes that her pain is consistently better when she is consistently better when she is upright. What is the next step?upright. What is the next step?

Medical management with an H-2 Medical management with an H-2 blocker or PPI and behavioral blocker or PPI and behavioral modification is the mainstay modification is the mainstay treatment of GERDtreatment of GERD

GERDGERD

substernal burning after meals or at night is the most substernal burning after meals or at night is the most common symptomcommon symptom

Initial management for mild reflux symptoms is Initial management for mild reflux symptoms is conservative:conservative:

Topical agents (antacids) weight reductionTopical agents (antacids) weight reduction

dietary changes (caffeine, ETOH) smoking cessationdietary changes (caffeine, ETOH) smoking cessation

avoid laying down after meals elevation of HOBavoid laying down after meals elevation of HOB

Reassess in 4-6 weeks, if not improved, more Reassess in 4-6 weeks, if not improved, more aggressive medical therapy is indicated.aggressive medical therapy is indicated.

PPI block parietal cell hydrogen pump action, resulting PPI block parietal cell hydrogen pump action, resulting in healing in 80% of pts with erosive esphagitisin healing in 80% of pts with erosive esphagitis

Studies to work-up GERD include the following Studies to work-up GERD include the following options, aimed at assessing both esophagitis and options, aimed at assessing both esophagitis and esophageal function:esophageal function:

EGD with bxEGD with bx

24 hr pH testing24 hr pH testing

esophageal manometryesophageal manometry

Barium swallow under real-time radiographic Barium swallow under real-time radiographic observationobservation

Gastric emptying studyGastric emptying study

Up to 50% of GERD pts do not have gross Up to 50% of GERD pts do not have gross evidence of esophagitis at EGD.evidence of esophagitis at EGD.

Biopsy is essential not only to Biopsy is essential not only to confirm esophagitis, but to rule out confirm esophagitis, but to rule out Barrett’s esophagusBarrett’s esophagusFailure of medical Rx over 1 year Failure of medical Rx over 1 year should be demonstrated before should be demonstrated before recommending surgeryrecommending surgeryStrictures and erosive esophagitis Strictures and erosive esophagitis refractory to medical therapy are refractory to medical therapy are surgical indicationssurgical indications

Surgical Therapy – Five Basic PrinciplesSurgical Therapy – Five Basic Principles

– restore the pressure of the distal esophageal sphincter to restore the pressure of the distal esophageal sphincter to a level twice resting gastric pressure a level twice resting gastric pressure

– length of the distal esophageal sphincter in the positive-length of the distal esophageal sphincter in the positive-pressure environment of the abdomenpressure environment of the abdomen 3cm length with of 1.5-2cm of abdominal esophagus 3cm length with of 1.5-2cm of abdominal esophagus

– reconstructed cardia to relax on deglutitionreconstructed cardia to relax on deglutition use only the fundus of the stomachuse only the fundus of the stomach wrap around the sphincter onlywrap around the sphincter only avoid vagal nervesavoid vagal nerves

– not increase the resistance of the sphincternot increase the resistance of the sphincter constructed over a 60F bougieconstructed over a 60F bougie

– tension free, and approximating the cruratension free, and approximating the crura

Nissen fundoplication:Nissen fundoplication:360 degree wrap of gastric fundus around the distal 360 degree wrap of gastric fundus around the distal esophagus, altering the GEJ and maintaining the esophagus, altering the GEJ and maintaining the distal esophagus in the abdominal cavity.distal esophagus in the abdominal cavity.

Hill gastropexy:Hill gastropexy:restores the GEJ to the abdominal cavity, securing restores the GEJ to the abdominal cavity, securing the gastric cardia to the pre-aortic fasciathe gastric cardia to the pre-aortic fascia

Partial fundoplication:Partial fundoplication:Toupet 270 degree wrap of the fundus at the GEJ, Toupet 270 degree wrap of the fundus at the GEJ, less desirable than a full wrap. less desirable than a full wrap.

Belsey Mark IV:Belsey Mark IV:transthoracic approach to 360 wrap of stomach transthoracic approach to 360 wrap of stomach around distal esophagusaround distal esophagus

Gas bloat is the most common side effect Gas bloat is the most common side effect postfundoplicationpostfundoplication

Pre-Op Evaluation - GERDPre-Op Evaluation - GERD

Esophageal body failureEsophageal body failure– test to see if sufficient power to propel test to see if sufficient power to propel

bolus through a new LESbolus through a new LES– if normal - 360 degree Nissenif normal - 360 degree Nissen– if abnormal - partial fundiplicationif abnormal - partial fundiplication

Belsy Mark IV or ToupetBelsy Mark IV or Toupet

– if stricture - dilate to 60 f bougieif stricture - dilate to 60 f bougie

Esophageal shorteningEsophageal shortening– secondary to repetitive injury - scarring secondary to repetitive injury - scarring

and fibrosisand fibrosis– increase incidence if breakdown & increase incidence if breakdown &

thoracic displacementthoracic displacement– evaluate with endoscopy or esophogramevaluate with endoscopy or esophogram– >5 cm hiatal hernia - short esophagus>5 cm hiatal hernia - short esophagus

transthoracic approach suggestedtransthoracic approach suggested Collis gastroplasty & partial fundiplication Collis gastroplasty & partial fundiplication

A 52 year old male with longstanding A 52 year old male with longstanding reflux and known Barrett’s reflux and known Barrett’s esophagus asks you about his risk of esophagus asks you about his risk of developing esophageal cancer. developing esophageal cancer. Surveillance endoscopic biopsies Surveillance endoscopic biopsies every other year have shown no every other year have shown no dysplasia.dysplasia.

A pt with Barrett’s esophagus has twice A pt with Barrett’s esophagus has twice the relative risk of developing esophageal the relative risk of developing esophageal cancercancer

a metaplastic degeneration of normal a metaplastic degeneration of normal esophageal lining, in which normal esophageal lining, in which normal squamous epithelium is replaced by squamous epithelium is replaced by metaplastic columnar epithiliummetaplastic columnar epithiliumcarcinogenesis starts with activation of carcinogenesis starts with activation of protooncogenes and disabling of tumor protooncogenes and disabling of tumor suppressor genes (p53)suppressor genes (p53)

traditional Rx is two tiered: GERD traditional Rx is two tiered: GERD control and surveillance endoscopy control and surveillance endoscopy with biopsy every 1-2 yearswith biopsy every 1-2 years

dysplasia is widely regarded as a dysplasia is widely regarded as a precursor for invasive cancer:precursor for invasive cancer:

low grade-Rx PPI, follow up EGDlow grade-Rx PPI, follow up EGD

High grade- considered premalignant, High grade- considered premalignant, Rx with surgical resection.Rx with surgical resection.

Photoablative surgery used for non-Photoablative surgery used for non-operative candidatesoperative candidates

High grade dysplasia should be High grade dysplasia should be considered cancer and requires considered cancer and requires surgical resection.surgical resection.

A 62 year old man with a 40 pack A 62 year old man with a 40 pack year tobacco history and a moderate year tobacco history and a moderate drinking history presents with drinking history presents with progressive dysphagia and a 30 lbs progressive dysphagia and a 30 lbs weight loss. What is the most likely weight loss. What is the most likely diagnosis?diagnosis?

Dysphagia and weight loss are the Dysphagia and weight loss are the most common presenting symptoms most common presenting symptoms of pts with esophageal cancer.of pts with esophageal cancer.

Adenocarcinoma ca is the most common Adenocarcinoma ca is the most common typetype

AdenoCa – most often in lower 1/3 of esophagusAdenoCa – most often in lower 1/3 of esophagus

Squamous – most often in upper 2/3 of esophagusSquamous – most often in upper 2/3 of esophagus

Metastatic spread by rich submucosal Metastatic spread by rich submucosal lymphaticslymphatics

Early direct extension due to lack of serosaEarly direct extension due to lack of serosa

Risk factors: smoking, ETOH, silica, Risk factors: smoking, ETOH, silica, nitrosamines, and Barrett’snitrosamines, and Barrett’s

Unresectability:Unresectability:– Hoarseness, Horner’s syndrome, phrenic nerve Hoarseness, Horner’s syndrome, phrenic nerve

involvement, malignant pleural effusion, involvement, malignant pleural effusion, malignant fistula, airway invasion, vertebral malignant fistula, airway invasion, vertebral invasioninvasion

CI to esophagectomy:CI to esophagectomy:– Nodal disease outside the area of resection (I..e. Nodal disease outside the area of resection (I..e.

SMA or Celiac Nodes)SMA or Celiac Nodes)– Distant mets (I.e. to lung or liver)Distant mets (I.e. to lung or liver)

Curative resectionCurative resection– tumor has not penetrated the esophageal walltumor has not penetrated the esophageal wall– fewer than five positive lymph nodesfewer than five positive lymph nodes– Regional lymph nodes = N1 diseaseRegional lymph nodes = N1 disease– Celiac, Cervical, & Supra-clavicular lymph nodes Celiac, Cervical, & Supra-clavicular lymph nodes

= M1 disease= M1 disease

Esophageal endoluminal ultrasound Esophageal endoluminal ultrasound (EUS) provides the most accurate T (EUS) provides the most accurate T staging, determining wall penetration staging, determining wall penetration and mediastinal invasionand mediastinal invasion

Multidisciplinary treatmentMultidisciplinary treatmentRadiation Rx for Squamous Ca, but is much less Radiation Rx for Squamous Ca, but is much less effective for adenoCaeffective for adenoCa

50% are resectable at presentation, but 75% 50% are resectable at presentation, but 75% resectable following downsizing with preop resectable following downsizing with preop chemoradiationchemoradiation

Bypass and nutritional support may Bypass and nutritional support may be the only options for pts with be the only options for pts with advanced disease or severe advanced disease or severe comorbiditiescomorbidities

Following esophagectomy, the right Following esophagectomy, the right gastroepiploic artery supplies the gastroepiploic artery supplies the reconstructed neo-esophagusreconstructed neo-esophagus

Transhiatal approachTranshiatal approach

Ivor LewisIvor Lewis

3-hole approach3-hole approach

A 72 year old woman presents with A 72 year old woman presents with chest pain two months following a chest pain two months following a laparoscopic paraesophageal hernia laparoscopic paraesophageal hernia repair. A NGT is placed and the tip is repair. A NGT is placed and the tip is visualized in the left chest. Further visualized in the left chest. Further imaging demonstrates a recurrence imaging demonstrates a recurrence of her hernia. What is the next step of her hernia. What is the next step in management?in management?

A Collis lengthening flap and A Collis lengthening flap and paraesophageal hernia repair is paraesophageal hernia repair is required for a recurrence due to required for a recurrence due to tension on the esophagus.tension on the esophagus.

Paraesophageal HerniaParaesophageal Hernia

classification of hernias focuses on the classification of hernias focuses on the relationship of the GEJ to the relationship of the GEJ to the diaphragm:diaphragm:

type 1- GEJ is the lead point of the sliding hiatal type 1- GEJ is the lead point of the sliding hiatal herniahernia

type 2-Angle of His remains intact, so the GEJ remains type 2-Angle of His remains intact, so the GEJ remains in normal position (rare)in normal position (rare)

type 3- GEJ herniated into the thorax with the type 3- GEJ herniated into the thorax with the stomach, but remains caudal to the fundus (most stomach, but remains caudal to the fundus (most common)common)

type 4- type 2 or 3 but with other abdominal organs type 4- type 2 or 3 but with other abdominal organs in the hernia sacin the hernia sac

Organo-axial torsion result when the stomach Organo-axial torsion result when the stomach herniates into the chest with traction from the herniates into the chest with traction from the fixed intra-abdominal duodenum causing the fixed intra-abdominal duodenum causing the stomach to twiststomach to twist

Torsion can cause GI obstruction, vascular Torsion can cause GI obstruction, vascular obstruction with resultant ischemiaobstruction with resultant ischemia

Linear erosions seen in the stomach Linear erosions seen in the stomach (Cameron Ulcers) occur from a mechanical, (Cameron Ulcers) occur from a mechanical, rather than a peptic cause, related to rather than a peptic cause, related to constricting of the rugae in the stomach constricting of the rugae in the stomach through the esophageal hiatus.through the esophageal hiatus.

Asymptomatic paraesophageal Asymptomatic paraesophageal hernias may be electively repaired.hernias may be electively repaired.

Symptomatic paraesophageal hernias Symptomatic paraesophageal hernias should be electively repaired with should be electively repaired with reduction and fixation of stomach in reduction and fixation of stomach in the abdomen (gastropexy or PEG)the abdomen (gastropexy or PEG)

All type II need repair due to high risk All type II need repair due to high risk of incarceratrionof incarceratrion

What is the initial treatment of a pt What is the initial treatment of a pt with an incarcerated paraesophageal with an incarcerated paraesophageal hernia?hernia?

NGT placementNGT placement

A 5 year od boy presents to the ER A 5 year od boy presents to the ER with a recent history of swallowing with a recent history of swallowing “something metal.” X-rays reveal a “something metal.” X-rays reveal a disk battery. What is the next step in disk battery. What is the next step in management?management?

Emergent endoscopic retrieval is Emergent endoscopic retrieval is indicated. Ingested batteries indicated. Ingested batteries become electrically short-circuited by become electrically short-circuited by fluid and tissue. Their discharge fluid and tissue. Their discharge generates heat, causing tissue generates heat, causing tissue damage that may erode the damage that may erode the esophagus, possibly leading to fistula esophagus, possibly leading to fistula formation to the trachea or aorta.formation to the trachea or aorta.

Caustic InjuriesCaustic Injuries

No NG, do NOT induce vomiting, No NG, do NOT induce vomiting, nothing to drinknothing to drink

Alkali – liquefaction necrosis, worse Alkali – liquefaction necrosis, worse than acid, can cause cancerthan acid, can cause cancer

Acid – coagulation necrosisAcid – coagulation necrosis Endoscopy – do NOT use with Endoscopy – do NOT use with

suspected perforation and do NOT go suspected perforation and do NOT go past site of injurypast site of injury

Degree of InjuryDegree of Injury

Primary burn – hyperemiaPrimary burn – hyperemia– Tx: obsv, IVFs, spitting, AbxTx: obsv, IVFs, spitting, Abx

Secondary burn – ulcerations, exudates, Secondary burn – ulcerations, exudates, sloughingsloughing– Tx: prolonged obsv, indications for surgery: Tx: prolonged obsv, indications for surgery:

sepsis, peritonitis, persistent back and chest sepsis, peritonitis, persistent back and chest pain, free air, acidosis, effusion, etcpain, free air, acidosis, effusion, etc

Tertiary burn – deep ulcers, charring, Tertiary burn – deep ulcers, charring, lumen narrowinglumen narrowing– Tx: as above, esophagectomy usually neededTx: as above, esophagectomy usually needed

Immediate TreatmentImmediate Treatment Lye or other alkaliLye or other alkali

– neutralized with half-strength vinegar, lemon juice, or orange juiceneutralized with half-strength vinegar, lemon juice, or orange juice AcidAcid

– neutralized with milk, egg white, or antacidsneutralized with milk, egg white, or antacids– sodium bicarbonate is not used because it generates CO2, which might sodium bicarbonate is not used because it generates CO2, which might

increase the danger of perforationincrease the danger of perforation Emetics are contraindicatedEmetics are contraindicated

– vomiting renews the contact of the caustic substance with the esophagusvomiting renews the contact of the caustic substance with the esophagus

Surgical InterventionSurgical Intervention– complete stenosis in which all attempts have failed to establish a lumencomplete stenosis in which all attempts have failed to establish a lumen– marked irregularity and pocketing on barium swallowmarked irregularity and pocketing on barium swallow– development of a severe periesophageal reaction or mediastinitis with development of a severe periesophageal reaction or mediastinitis with

dilatationdilatation– fistulafistula– inability to dilate or maintain the lumen above a 40F bougieinability to dilate or maintain the lumen above a 40F bougie– a patient who is unwilling or unable to undergo prolonged periods of a patient who is unwilling or unable to undergo prolonged periods of

dilation dilation

Esophageal SubstituteEsophageal Substitute– ColonColon– StomachStomach– Jejunum: free/transfer grafts based on the superior thyroid artery or Jejunum: free/transfer grafts based on the superior thyroid artery or

internal mammary arteryinternal mammary artery

Esophageal Foreign BodiesEsophageal Foreign Bodies

coins most common in childrencoins most common in children

meat bolus most common in adultsmeat bolus most common in adults

rigid or flexible esophagoscopy with or rigid or flexible esophagoscopy with or without fluoroscopy can be diagnosticwithout fluoroscopy can be diagnostic

foreign bodies in adults may be due to foreign bodies in adults may be due to an underlying stricture that should be an underlying stricture that should be ruled out after foreign body removalruled out after foreign body removal

What is the most common benign What is the most common benign tumor of the esophagus?tumor of the esophagus?

Leiomyoma:Leiomyoma:Dx: esophagram, Dx: esophagram, endoscopy needed to R/O endoscopy needed to R/O CaCa

Do not biopsy-can form Do not biopsy-can form scar and make resection scar and make resection difficult.difficult.

Rx: >5 cm or symptomatic- Rx: >5 cm or symptomatic- excision (enucleation) via excision (enucleation) via thoracotomythoracotomy

Mallory-Weiss SyndromeMallory-Weiss Syndrome

Acute upper GI bleed following vomitingAcute upper GI bleed following vomiting cause of UGI bleed - 15%cause of UGI bleed - 15% endoscopy - mucosal tear at GE junctionendoscopy - mucosal tear at GE junction

– associated with diaphragmatic herniaassociated with diaphragmatic hernia treatment - supportivetreatment - supportive

– blakemore tubeblakemore tube– surgery - high gastrotomy oversew liner tearsurgery - high gastrotomy oversew liner tear

Plummer - Vinson SyndromePlummer - Vinson Syndrome

Dysphagia, atrophic oral mucosa, Dysphagia, atrophic oral mucosa, spoon shaped fingers and chronic spoon shaped fingers and chronic anemiaanemia

middle aged femalesmiddle aged females drug induced - ferrous sulfatedrug induced - ferrous sulfate endoscopy - fibrous web below endoscopy - fibrous web below

cricopharyngeouscricopharyngeous treatment - dilatationtreatment - dilatation