ABSITE - Esophagus

56 flashcards · Other · by Arielle Thomas

1. What is Achalasia

   A rare disorder in which the lower esophageal sphincter fails to relax properly during swallowing

2. How do you diagnose achalasia?

   High resolution manometry - plot of esophageal peristalsis is generated in response to a 5 mL water swallow and is bounded by the UES and the LES.

3. What are the three metrics that high resolution manometry uses to evaluate esophageal function?

   Distal contractile integral (assessment of the strength of esophageal smooth muscle contraction - incorporates length, amplitude, and duration of the contracting segments) Distal latency - measure of timing of esophageal peristalsis and is measure from the UES relaxation to the deceleration point where the peristalsis transitions to a slower EGJ emptying function Integrated Relaxation pressure - pressure over 4 seconds when EGJ relaxation is expected within a 10 second window after upper esopha…

4. What are the IRP values for the types of achalasias?

   Type 1 - IRP of 10mmHg in teh setting of absent peristalsis Normal achalasia - above 15mmHg Type 2 achalasia any IRP with absent perisoalsis in 20% of swallows with panesophageal pressurization Type III = premature or spastic distal esophageal contracion s in at least 20% of swallows

5. How do you diagnose achalsia

   Diagnosis of achalasia is made by manometry.

6. How do you treat achalasia both surgically and minimally invasively?

   Distal esophageal myotomy combined with partial fundoplication (80% success for type 1, 95% type 2, 60% for type 3) Peroral endoscopic myotomy - submucosal tunnel is created in distal esophagus 10cm from the GE junction and is extended 2cm into cardia (increased GERD)

7. What are the indications for manometry?

   Evaluate esophageal sx, evaluation of peristaltic function before surgery or myotomy, eval of postoperative dysphagia, evaluation of rumination with impedance, eval of scleroderma, eval of peristalsis before bariatric surgery and lung transplant, f/u of achalasia after tx

8. Diffuse esophageal spasm

   A rare disorder where the muscles in the esophagus contract in an uncoordinated manner causing chest pain, dysphagia

9. Manometry findings in DES

   Distal latency - ihibitory myenteric neuron activity after contractions is shorter in patients with DES cuasing an increased state of contractions Normal IRP, but distal latency <4.5seconds in 20% of wet swallows

10. Treatment of DES

    Nitrates, sildenafil tricyclic antidepressants diazepam and lorazepam if above meds aren't controlling sx

11. What is the defintion of nutcracker esophagus

    Patiens with a DCI greater than 8000mmHg in greater than 20% of swallows with normal peristalsis and normal LES relaxation

12. Treatment of nutcracker esophagus

    diltiazem

13. What is ineffective esophageal motility

    DCI of less than 450 mmHg in 50% of swallows

14. What is the step-wise management of GERD?

    trial of PPI if reurrent sx - upper endoscopy with biopsy esophagitis, barretts metaplasia, or peptic stricture are confirmation

15. What makes up the Demeester Score

    Greater than 14.72 is positive Percent total time pH <4 percent upright time pH <4 percent supine time pH<4 number of reflux episodes number of reflux episodes >5 minutes longest reflux episode in minutes

16. Impedance testing

    A test that measures the flow of liquid or gas through the esophagus using resistance between two electrodes. Air is high resistance, liquid is low resistance. It can help diagnose disorders such as ineffective esophageal motility and reflux.

17. What condition has absent contractions?

    scleroderma

18. What are the risk factors for GERD

    obesity, hiatal hernia, pregnancy, delayed gastric emptying, connective tissue disorders

19. What are classic GERD symptoms

    burning chest pain, regurgitation of sour fluid, sensation of lump or tightness in the throat

20. What are atypical GERD sx

    cough, wheezing, horaseness, sore thrat, postnasal drip, dental erosion, recurrent pneumonia, ear pain

21. What are alarm symptoms of GERD

    Dysphagia, early satiety, hematemsis, melena, vomiting, weight loss

22. What are the goals of preoperative testing for GERD surgery

    confirm diagnosis of GERD, rule out other etiologies, define anatomy

23. HOw do you confirm the diagnosis of GERD?

    gold standard : ambulatory pH monitoring Upper endoscopy to show the complications of GERD

24. How do you rule out other etiologies of symptoms

    manometry to rule out achalasia and eval motility gastric scintigraphy to dx gastroparesis and. to have baseline emptying so that postoperatively you won't wonder if you had a vagal nerve injury (only for people you suspect have delayed GE)

25. How do you define anatomy

    Upper GI series to show presence size of hiatal hernia or short esophagus, and CT scan

26. What are the three goals of tx of GERD

    control of symptoms healing of reflux esophagitis prevention. of complications

27. What are the indications. for antireflux surgery

    Failed medication management, patient preference, GERD complications, CI to PPI, lung transplant patient, atypical sx wit documented reflux

28. What are contraindications for ARS

    inability to tolerate surgery, cancer or high grade dysplasia, morbid obesity (consider gastric bypass instead)

29. What are the main types of fundoplication surgeries?

    total wrap (nissen) 180-270 degree posterio fundoplication (Toupet) 180 degree anterior wrap (DOR) Hill - posterior gastropexy added on Belsy procedure - transthoracic posterior plication

30. Where are the ports for a nissen

    supraumbilical 10mm camera port 5mm right lateral liver retractor 10mm operating port 5mm right working port 5mm left lateral assistant port

31. Steps of the fundoplication

    Dissection of the curra and reduction of hikatal hernia divide pars flaccida (gastrohepatic ligament - watch for replaced left hepatic) Identify right crus and open phrenoesophageal ligament identify left crus and preserve the anterior vagus nerve mobilize the esophagus (3-5cm into abdomen) ligate and divde short gastrics place marking stitch and shoeshine the fundus posterior to the esophagus place 52Fr bougie and stitch the wrap in place (no more than 3cm in length)

32. Describe. the collis gastroplasty

    if you can't get adequate length. ofesophagus you van use a linear stapler tocreate a 4-5cm tube of proximal stomach using a bougie to prevent narrowing of the neoesophagus

33. How long do patient stay on full liquid diet?

    4-6 weeks postoperatively

34. What are the types of wrap failure

    complete disruption, slipped wrap, malpositioned wrap, transhiatal herniation of wrap

35. What can you. do if wrap is too tight

    endoscopic dilation

36. What is gas bloat syndrome

    prevention of patietns from belching due to the wrap and accumulation of gas - epigastric pain, abdominal distension, and inability to belch or vomit with flatus

37. What is the most common cause of failure of wrap and what is the most common technical failure

    Technical failure - misplaced fundo (using body of stomach instead of fundus) failure - herniation of wrap into chest

38. What is barrett esophagus

    Transformation of squamous lined esophagus to icolumnar cells with goblet cells due to exposure to acidic and alkaline gastric juices.

39. What is the risk of progression from HGD to EAC per patient per year?

    6%, there is a 0.1-0.5% rate of neoplastic change if patients have BE

40. What are risk factros for the devlopment of BE?

    Family history, GERD, smoking, obesity, hiatal hernia, white race and male gender, and age greater than 50

41. What is the seattle protocol?

    Standard of care in BE screening and surveillance and detects dysplasia and EAC by obtaining four quadrant biopsy samples at 1-2 cm interval. with pathology reviewed by two pathologists, one with a GI specialization

42. Describe the screening intervals for low grade dysplasia, high grade dysplasia, and BE

    Be - every 3-5 years but can be 1-3 years depending on the length of BE and the initial grade of esophagitis (longer patches and higher grades have higher risks of developing BE) Indefinite - every 3-6 months while optimizing acid suppressive medications Low grade dysplasia - 6-12 months High grade dysplasia - intervention or if no intervention every 3 months

43. What is the management both endoscopically and intervention wise for low grade dysplasia

    6-12 month suriveillance, optiize once daily PPI therapy (can be twice daily if necessary) and antireflux surgery Endoscopic ablative therapy is recommended if dx is persistent

44. What is the management of high grade dysplasia?

    If there are discrete nodules - resect. If lesions larger than 1 cm then endoscopic ultrasound is warranted. Radio frequency ablation at 8 week intervals can be used if HGD or adenoca at the mucosal level only T1a without lymphovascular invasion until completely eradicated If T1b - esophagectomy with lymphadenectomy

45. What is the surveillance of the esophagus after HGD has been treated with RFA?

    every 3 months for a year, every 6 months the second year and annually after

46. What is the role of esophagectomy in high grade dysplasia?

    if there are poor prognostic factors suche as large size >2cm, lymphovascular invasion, multifocality, inabilityt ocomply with repeat endoscopic surveillance, inability to eradicate or progression of disease, failed techniques. endstage eosphageal function.

47. What is the risk of be in patients with GERD?

    10-15%

48. What are the current screening recommendations from the American College of Gastroenterology?

    SCreening male patients with 5+ years of GERD and two or more risk factors (FH, age >50, white race, central obesity, smoking history)

49. What is endoscopic mucosal resection?

    EMR is the initial treatment modality for patients with nodular BE with and without high risk features

50. What are the complications of EMR?

    Esophageal stricture (up to 40% of patients), bleeding (8%), and perforation (1.3%). if undergoing concomitant RFA there is a higher chance of all.

51. What is endoscopic submucosal dissection and when is it used?

    It allows for coomplete en bloc resection of suspicious lesions and is used for larger lesions >1.5cm. primary indication is resection of nodular lesions within a segment of BE

52. What is argon plasma coagulation and when is it used?

    Uses a beam of argon gas to conduct an electrical current resulting in a noncontact form of thermal electrocoaulation. used for BE that only affects the mucosa.

53. What is radiofrequency ablation and when is it used?

    The most commonly used technique it is performed using a balloon catheter a generator and a fixed amount of thermal energy to do a circumferential or focal burn. circumferential is for BE longer than 2cm and focal is for BE that has tongues and is short segment

54. How long is the esophagus and where are the important narrowings?

    the esophagus is 40cm long from the incisors teeth (oropharynx) and goes from C6 to T11, The first narrowing is 15-17cm the UES and 25cm is where the aorta crosses and 38-40 is the LES.

55. Where can the esophagus best be accessed based on its position?

    left in the cervical and lower throacic. Right thoracic approach for middle thoracic.

56. What muscle makes up the cervical esophageal sphincter? What two conditions make it extremely important?

    The UES is made up of the cricopharyngeal muscle which is the lower part of the inferior constrictor muscle of the hypopharynx. This is important because a tight UES causes a pulsion diverticulum *(zenkers) and it is also the part of the esophagus most liable to perforation.