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Structure:

  • Epithelium: Squamous
  • Muscle:
    • Inner layer: Circular
    • Outer layer: Longitudinal
  • No serosa
  • Mucosa is strongest layer (in small bowel, submucosa is strongest)

Swallow:

  • Central input initiates swallow which elicits primary peristalsis
  • Distention then elicits secondary peristalsis.

Swallowing order of events:

  • Soft palate closes nasopharynx,
  • Larynx up,
  • Larynx closes,
  • UES relaxes,
  • Pharyngeal contraction

Sphincters: are contracted at rest.

  • UES (cricopharyngeous muscle): tone 50-70 mmHg
  • LES tone: 10-25 mmHg (length 4cm)

Anatomical narrowing:

  • Cripharyngeus muscle
  • Mainstem broncus, aortic arch
  • Diafragm

Zencker's diverticulum: (false diverticulum)

  • Occurs in Killian's triangle (region b/t oblique pharyngeal constrictors and transverse cricopharyngeous fibers)
  • Due to increase pressure (pulsion tic)
  • Dx: Barium swallow studies
  • Tx: myotomy, diverticulectomy/pexy to spinous process.
  • Approach via left cervical incision


Achalasia:

  • Decrease ganglion cells (neuronal degeneration) in Auerbach's plexus
  • Absence of peristalsis and esophageal relaxation
  • Bird's beak on Ba swallow
  • Manometry:
  • No peristalsis
  • é LES pressure
  • Incomplete LES relaxation
  • Tx:
    • Ca channel blockers, Dilation (effective 60%)
    • Laparoscopic or thoracoscopic Heller myotomy

Diffuse esophageal spasm:

  • Manometry:
    • Normal LES tone
    • Strong unorganized contractions
  • Medical treatment (Ca++ channel blockers)

Hiatal Hernias:

  • Type I: (most common) Sliding hernia GE junction sliding above diaphragm.
  • Type II:(Paraesophageal hole in diafragm) GE junction in abdomen, fundus of stomach above the diaphragm; Associated with Gastric Volvulus
  • Type III: Combined
  • Type IV: Entire stomach in chest + another organ

  • Paraesophageal hernia: always operate since risk of incarceration, strangulation

Barrett's esophagus:

  • Metaplasia from squamous to columnar cells.
  • 1-2% get adenocarcinoma (30-100 x risk)
  • P53 associated (tumor suppressor gene)
  • Severe Barrett’s dysplasia = esophagectomy
  • Uncomplicated Barrett’s needs careful follow up despite medical or surgical therapy.

Assessing T staging:

  • EUS is more accurate than CT

AdenoCA #1 esophageal cancer over squamous (also true for lung CA)

Rigth gastroepiploic artery: primary blood supply to stomach after replacing esophagus

Achalasia and chemical ingestion also increase risk of esophageal CA

Leiomyoma:

  • Most common benign tumor of the esophagus
  • Do not biopsy on EGD.
  • If symptomatic or > 5cm excise by enucleation via thoracotomy (R if middle, L if lower esophagus).

Caustic esophageal injury:

  • No NGT
  • No not induce vomiting
  • Nothing to drink

Esophageal rupture (Boerhaave's):

  • Key to survival is early Dx (85% mortality if > 36 hours)

Pages in category "Esophagus"

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