Basic Science Lecture3/8/11

Marcie Dorlon, PGY3

Blood SupplyBlood Supply: Inferior : Inferior thyroid, aortic branches, thyroid, aortic branches, bronchial branches, left bronchial branches, left gastic artery branches, gastic artery branches, inferior phrenic branchesinferior phrenic branches

Venous drainageVenous drainage: inferior : inferior thyroid vein, bronchial veins, thyroid vein, bronchial veins, hemiazygous and azygous hemiazygous and azygous veins, coronary veinveins, coronary vein

Lymphatic DrainageLymphatic Drainage: : submucosal, dense single-submucosal, dense single-plexusplexus

InnervationInnervation: mainly vagus : mainly vagus

•Antireflux mechanisms:Antireflux mechanisms:• mechanically effective LES mechanically effective LES • efficient esophageal clearanceefficient esophageal clearance• adequately functioning gastric reservoiradequately functioning gastric reservoir

•Tests to detect:Tests to detect:• structural abnormalitiesstructural abnormalities• functional abnormalitiesfunctional abnormalities• increased exposure to gastric juiceincreased exposure to gastric juice• duodenogastric function as related to esophageal duodenogastric function as related to esophageal diseasedisease

•Radiographic evaluation (barium swallow)Radiographic evaluation (barium swallow)•endoscopic evaluation (with or without biopsy) endoscopic evaluation (with or without biopsy) •stationary manometry stationary manometry •high-resolution manometryhigh-resolution manometry•esophageal impedance esophageal impedance •esophageal transit scintigraphyesophageal transit scintigraphy•video- and cineradiographyvideo- and cineradiography•24-hour ambulatory pH monitoring24-hour ambulatory pH monitoring•gastric emptying study gastric emptying study •gastric acid analysis gastric acid analysis •cholescintigraphy cholescintigraphy •24-hour gastric pH monitoring24-hour gastric pH monitoring

•Chronic disease often requiring life-long medical txChronic disease often requiring life-long medical tx

•Dx: Lack of universally accepted definitionDx: Lack of universally accepted definition

•Sx: Sx: heartburn heartburn (substernal burning worsened by spicy and fatty (substernal burning worsened by spicy and fatty foods, etoh, coffee, chocolate, etc) and foods, etoh, coffee, chocolate, etc) and regurgitationregurgitation, cough, , cough, hoarseness, asthma, recurrent pneumonia, bronchospasm, hoarseness, asthma, recurrent pneumonia, bronchospasm, dysphagia, odynophagiadysphagia, odynophagia

•Complications: esophagitis, stricture, Barrett’s esophagus Complications: esophagitis, stricture, Barrett’s esophagus (metaplasia), adenocarcinoma (neoplasia), repetitive aspiration and (metaplasia), adenocarcinoma (neoplasia), repetitive aspiration and pulmonary fibrosispulmonary fibrosis

•Tx first line: H2 blockers, Tx first line: H2 blockers, PPIPPI, surgery if medical management fails, surgery if medical management fails

•Surgical Tx Indicated: Barrett’s metaplasia, ulcer, stricture, failure Surgical Tx Indicated: Barrett’s metaplasia, ulcer, stricture, failure of medical tx, structurally defective LESof medical tx, structurally defective LES

•Anti-reflux surgery restores gastroesophageal barrierAnti-reflux surgery restores gastroesophageal barrier

•Laparoscopic Nissen Fundoplication, Transthoracic Nissen Laparoscopic Nissen Fundoplication, Transthoracic Nissen FundoplicationFundoplication

•Type IType I sliding hernia, upward dislocation of cardia in the posterior sliding hernia, upward dislocation of cardia in the posterior mediastinummediastinum

•Type II Type II rolling/paraesophageal hernia, upward dislocation of gastric rolling/paraesophageal hernia, upward dislocation of gastric fundus alongside normally positioned cardiafundus alongside normally positioned cardia

•Type III Type III combined sliding-rolling/mixed hernia, upward dislocation of combined sliding-rolling/mixed hernia, upward dislocation of cardia and gastric funduscardia and gastric fundus

•Type IVType IV: additional organ (colon) herniates along with stomach into : additional organ (colon) herniates along with stomach into chestchest

•Sx: same as GERD, anemiaSx: same as GERD, anemia

•Dx: Barrium swallow, endoscopyDx: Barrium swallow, endoscopy

•Indications for surgery: paraesophageal hernia (prevent bleeding, Indications for surgery: paraesophageal hernia (prevent bleeding, infarction, perforation)infarction, perforation)

•Approach: transabdominal or transthoracic to repair diaphragm +/- Approach: transabdominal or transthoracic to repair diaphragm +/- fundoplicationfundoplication

•Recurrence rates 10-15%Recurrence rates 10-15%

•Thin circumferential submucosal ring in the lower esophagus at the Thin circumferential submucosal ring in the lower esophagus at the squamocolumnar junction, often associated with hiatal herniasquamocolumnar junction, often associated with hiatal hernia

•Significance and pathogenesis unclear, prevalent in 0.2-14% of Significance and pathogenesis unclear, prevalent in 0.2-14% of populationpopulation

•Symptoms: dysphagia (solid food), refluxSymptoms: dysphagia (solid food), reflux

•Tx: dilation, incision or excision of ring, antireflux procedureTx: dilation, incision or excision of ring, antireflux procedure

•Esophageal abnormalities in 80% patients with this diagnosisEsophageal abnormalities in 80% patients with this diagnosis

•Perivascular deposition of collagen leads to smooth muscle atrophy Perivascular deposition of collagen leads to smooth muscle atrophy in GI tractin GI tract

•Primary neurogenic disorder in regards to esophageal symptoms as Primary neurogenic disorder in regards to esophageal symptoms as methacholine and edrophonim relieve symptoms methacholine and edrophonim relieve symptoms

•Dx: manometry demonstrates absence of peristalsis in distal Dx: manometry demonstrates absence of peristalsis in distal smooth muscle portion, progressively weakened LESsmooth muscle portion, progressively weakened LES

•Can lead to strictures and severe esophagitisCan lead to strictures and severe esophagitis

•Tx: medical, serial dilations, partial fundoplication for severe casesTx: medical, serial dilations, partial fundoplication for severe cases

•: : Zenker’s diverticulum- Zenker’s diverticulum- most most common sign of pharyngoesophageal common sign of pharyngoesophageal dysfunctiondysfunction

•Sx: dysphagia, regurgitation of undigested bland material, chronic Sx: dysphagia, regurgitation of undigested bland material, chronic aspiration, weight lossaspiration, weight loss

•Dx: barium swallowDx: barium swallow

•Tx: open cricopharyngeal myotomy, diverticularpexy, Tx: open cricopharyngeal myotomy, diverticularpexy, diverticulectomy, endoscopicdiverticulectomy, endoscopic

•Achalasia-Achalasia- primary disorder of LES not relaxing primary disorder of LES not relaxing

•Sx: pain, regurgitation, weight lossSx: pain, regurgitation, weight loss

•Dx: 24-Hr motility monitoring, radiographic “bird’s beak” narrowing Dx: 24-Hr motility monitoring, radiographic “bird’s beak” narrowing distal esophagusdistal esophagus

•Tx: dilation, medication, Botox injection, surgeryTx: dilation, medication, Botox injection, surgery

•Diffuse esophageal spasm (DES), nutcracker esophagus, Diffuse esophageal spasm (DES), nutcracker esophagus, hypertensive LEShypertensive LES

•Long Myotomy- thoracic approach, myotomy extends from 1-2cm Long Myotomy- thoracic approach, myotomy extends from 1-2cm below GEJ proximally to level of dysmotilitybelow GEJ proximally to level of dysmotility

•Heller Myotomy- myotomy of LES via thoracic or abdominal Heller Myotomy- myotomy of LES via thoracic or abdominal approachapproach

•Open Esophageal Myotomy- used for reoperationOpen Esophageal Myotomy- used for reoperation

•Laparoscopic Heller Myotomy and partial fundoplicationLaparoscopic Heller Myotomy and partial fundoplication- beat - beat pneumatic dilation and Botox injections in several RCT for pneumatic dilation and Botox injections in several RCT for esophageal motility disordersesophageal motility disorders

•Most common worldwide: squamous carcinoma, associated Most common worldwide: squamous carcinoma, associated with etoh and tobacco, lye ingestion, long standing achalasia, with etoh and tobacco, lye ingestion, long standing achalasia, HPVHPV

•Increasing incidence of adenocarcinoma: associated with Increasing incidence of adenocarcinoma: associated with GERD and Barrett’s esophagusGERD and Barrett’s esophagus

•Sx: Dysphagia, asymptomatic found in EGD, stridor, cough, Sx: Dysphagia, asymptomatic found in EGD, stridor, cough, choking, recurrent aspiration or pneumonia, pain swallowing choking, recurrent aspiration or pneumonia, pain swallowing rough or dry food , vocal cord paralysis, TEFrough or dry food , vocal cord paralysis, TEF

•Staging by CXR, CT, PET, EUSStaging by CXR, CT, PET, EUS

•Tx: chemoradiation and surgeryTx: chemoradiation and surgery

•Rare 0.5-1.5% of all esophageal tumorsRare 0.5-1.5% of all esophageal tumors

•Sx: Dysphagia, same as carcinomaSx: Dysphagia, same as carcinoma

•Dx: barium swallow shows large polypoid intraluminal mass Dx: barium swallow shows large polypoid intraluminal mass causing dilation and obstruction of proximal esophagus causing dilation and obstruction of proximal esophagus (carcinomas tend to ulcerate and stenos) and EGD with (carcinomas tend to ulcerate and stenos) and EGD with biopsy (must get to bleeding tissue or bx only demonstrate biopsy (must get to bleeding tissue or bx only demonstrate necrosis)necrosis)

•Tx: resection, little role for radiation as tumors remain Tx: resection, little role for radiation as tumors remain superficial with rare metastasis or spread to LNsuperficial with rare metastasis or spread to LN

•Uncommon, divided into within lumen or within muscular wallUncommon, divided into within lumen or within muscular wall

•Leiomyoma: constitute more than 50% benign esophageal tumors, Leiomyoma: constitute more than 50% benign esophageal tumors, average age at presentation is 38, more common in males, smooth average age at presentation is 38, more common in males, smooth muscle origin so >90% are found in lower 2/3 of esophagusmuscle origin so >90% are found in lower 2/3 of esophagus

•Dysphagia and pain most common complaints, followed by bleedingDysphagia and pain most common complaints, followed by bleeding

•Dx: barium swallow classical smooth, contoured, punched-out lesionDx: barium swallow classical smooth, contoured, punched-out lesion

•Tx: enucleation with closure and reconstruction of muscular layerTx: enucleation with closure and reconstruction of muscular layer

•Congenital or acquired cystsCongenital or acquired cysts

•Tx: excisionTx: excision

•True Emergency, cause is most commonly True Emergency, cause is most commonly iatrogeniciatrogenic

•Spontaneous: Boerhaave’s Syndrome (15%), Foreign body (14%), Spontaneous: Boerhaave’s Syndrome (15%), Foreign body (14%), trauma (10%)trauma (10%)

•Sx: PainSx: Pain

•Dx: CXR- mediastinal emphysema and widening, pneumothorax Dx: CXR- mediastinal emphysema and widening, pneumothorax (pleural rupture)(pleural rupture)

•Contrast esophogram with gastrograffin confirms in 90% patients Contrast esophogram with gastrograffin confirms in 90% patients (position in right lateral decubitus position for best result)(position in right lateral decubitus position for best result)

•Tx: Tx: Key is early dx! Radiographic signs could take hours to show upKey is early dx! Radiographic signs could take hours to show up

•Primary closure within 24 hoursPrimary closure within 24 hours 80-90% survival rate 80-90% survival rate

•Repair after 24hrs < 50% survival rate Repair after 24hrs < 50% survival rate

•Syndrome characterized by acute upper GI bleeding following Syndrome characterized by acute upper GI bleeding following repeated vomiting is considered to be cause to up to 15% of all repeated vomiting is considered to be cause to up to 15% of all severe upper GI bleedingsevere upper GI bleeding

•Caused by arterial bleeding, which may be massiveCaused by arterial bleeding, which may be massive

•Can also be caused by paroxysmal coughing, seizures, or retchingCan also be caused by paroxysmal coughing, seizures, or retching

•Dx: Upper endoscopyDx: Upper endoscopy

•Tx: nonoperative management in majority of patients (bleeding Tx: nonoperative management in majority of patients (bleeding stops spontaneously)stops spontaneously)

•Resuscitate, stomach decompression, antiemetics, endoscopic Resuscitate, stomach decompression, antiemetics, endoscopic injection of epinephrineinjection of epinephrine

•Surgery as last resortSurgery as last resort

•Mortality uncommon and rare recurrenceMortality uncommon and rare recurrence

•Occurs mainly in children, in adults/teenagers associated with Occurs mainly in children, in adults/teenagers associated with suicide attemptssuicide attempts

•Alkalies more frequently accidentally swallowed because strong Alkalies more frequently accidentally swallowed because strong acids cause immediate burning pain in mouth that prevents acids cause immediate burning pain in mouth that prevents swallowingswallowing

•Alkalies cause liquefaction necrosis and acids cause coagulation Alkalies cause liquefaction necrosis and acids cause coagulation necrosisnecrosis

•Lye injury: acute necrotic phase (1-4 days), ulceration and Lye injury: acute necrotic phase (1-4 days), ulceration and granulation phase (3-12 days), and cicatrization and scarring phase granulation phase (3-12 days), and cicatrization and scarring phase (three weeks +)(three weeks +)

•Sx: depend on extend of lesionSx: depend on extend of lesion

•Tx: immediate neutralizing agents (within 1 hour), then depends on Tx: immediate neutralizing agents (within 1 hour), then depends on extent of lesionextent of lesion

•NO sodium bicarb (produces carbon dioxide in increases risk NO sodium bicarb (produces carbon dioxide in increases risk perforation)perforation)

•Result of esophageal or pulmonary malignancy, less common Result of esophageal or pulmonary malignancy, less common trauma or related to diverticulatrauma or related to diverticula

•Sx: Paroxysmal coughing after ingestion of liquids, recurrent or Sx: Paroxysmal coughing after ingestion of liquids, recurrent or chronic pulmonary infectionschronic pulmonary infections

•Tx: Benign fistula: Division of fistula tract, resection of abnormal Tx: Benign fistula: Division of fistula tract, resection of abnormal pulmonary tissue involved, repair of esophageal defect, interposition pulmonary tissue involved, repair of esophageal defect, interposition of pleural flapof pleural flap

•Malignant fistula: difficult usually due to radiation tx, palliative Malignant fistula: difficult usually due to radiation tx, palliative stent or surgery (esophageal diversion and feeding jejunostomy)stent or surgery (esophageal diversion and feeding jejunostomy)