Transcript Nir_Hus_s_ABSITE_REVIEW_files/Esophageal review 1

Esophagus
Nir Hus MD, PhD.
ABSITE Review
Department of Surgery
Mount Sinai Medical Center
Nir Hus MD., PhD. Ryder Trauma
Center Jackson Memorial Hospital
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Esophagus: Anatomy
Nir Hus MD., PhD. Ryder Trauma
Center Jackson Memorial Hospital
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Esophagus: Anatomy
Nir Hus MD., PhD. Ryder Trauma
Center Jackson Memorial Hospital
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Esophagus: Anatomy
Nir Hus MD., PhD. Ryder Trauma
Center Jackson Memorial Hospital
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Esophageal Studies
• Anatomic
– Esophagogram
– CT-Scan
– Endoscopy(Biopsy/Ultrasound)
• Functional
– Esophageal manometry
– 24 hour pH probe
Nir Hus MD., PhD. Ryder Trauma
Center Jackson Memorial Hospital
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Esophagus: Physiology
Nir Hus MD., PhD. Ryder Trauma
Center Jackson Memorial Hospital
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Esophageal Manometry
Nir Hus MD., PhD. Ryder Trauma
Center Jackson Memorial Hospital
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Esophageal Manometry: Swallowing
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Characteristics of Lower Esophageal
Sphincter
• Intramural pressure
• Length of LES
• Abdominal length LES
Nir Hus MD., PhD. Ryder Trauma
Center Jackson Memorial Hospital
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Manometry LES: Pressure/Length
Relationship
Nir Hus MD., PhD. Ryder Trauma
Center Jackson Memorial Hospital
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24-Hour pH Monitoring
Nir Hus MD., PhD. Ryder Trauma
Center Jackson Memorial Hospital
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Esophageal Motility Disorders
• Esophageal Diverticula
– Zenker’s (pulsion)
– Epiphrenic
– Traction (pulsion)
• Functional Disorders
– Achalasia
– Diffuse esophageal spasm
– Nutcracker esophagus
Nir Hus MD., PhD. Ryder Trauma
Center Jackson Memorial Hospital
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Zenker’s Diverticulum
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Dysphagia
Regurgitation undigested food
Aspiration
Unyielding cricopharingeous
Dx: barium swallow
No endoscopy
Tx: diverticulectomy/myotomy
Left cervical incision
Nir Hus MD., PhD. Ryder Trauma
Center Jackson Memorial Hospital
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Achalasia
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Dysphagia and regurgitation undigested food
Substernal/epigastric pain
Diagnosis and work-up: CXR, UGIS
endoscopy/bx: esophagitis, r/o Ca
Manometry:
– aperistalsis
– incomplete relaxation of LES
– High resting pressure LES (>30 mmHg)
Nir Hus MD., PhD. Ryder Trauma
Center Jackson Memorial Hospital
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Achalasia
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Center Jackson Memorial Hospital
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Achalasia: Treatment
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Esophageal dilations, success rate: 70%
Botulinum toxin injections: short lived
Surgery: Heller myotomy, success rate: 95%
Indications:
– children
– vigorous achalasia
– medical failures
Nir Hus MD., PhD. Ryder Trauma
Center Jackson Memorial Hospital
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Achalasia: Heller Operation
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Center Jackson Memorial Hospital
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Diffuse Esophageal Spasm and
Nutcracker Esophagus
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Intermittent chest pain and dysphagia
Negative cardiac work-up
Manometry: normal LES, tertiary peristalsis
Treatment:
– Medical: reduce stress and precipitating factors
– NTG, Isosorbide, Nifedipine
– Surgery: Full length myotomy, success rate 65%
Nir Hus MD., PhD. Ryder Trauma
Center Jackson Memorial Hospital
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Nutcracker Esophagus
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Center Jackson Memorial Hospital
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GERD
• Abnormal exposure of distal esophagus to
refluxed gastric juice
• Etiology
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Mechanically defective LES (60%)
Poor esophageal clearance
Gastric outlet obstruction
Functional delayed gastric emptying
Increased gastric acid secretion
inappropriate relaxation of LES
Nir Hus MD., PhD. Ryder Trauma
Center Jackson Memorial Hospital
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GERD
• Symptoms
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Substernal/epigastric burning pain
Regurgitation
Effortless emesis
Dysphagia
Flatulence
Atypical symptoms
Nir Hus MD., PhD. Ryder Trauma
Center Jackson Memorial Hospital
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GERD
• Complications (20%)
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Esophagitis
Stricture
Barrett’s esophagus
Ulceration
Esophageal shortening
Nir Hus MD., PhD. Ryder Trauma
Center Jackson Memorial Hospital
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GERD: Work-up
• UGIS and EGD
• Manometry: characterizes LES and motility
– LES pressure < 6 mm Hg
– Overall length < 2 cm
– Abdominal length < 1 cm
• Esophageal pH testing (sens/specif - 90%)
– pH < 4 more than 1 hour and a half/24 hours (6%)
– Composite score derived from: total time pH <4,
upright time pH <4, supine time pH <4, # episodes,
episodes >5 min, longest episode.
Nir Hus MD., PhD. Ryder Trauma
Center Jackson Memorial Hospital
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GERD: Treatment
• Medical
– Postural alterations
– Dietary alterations
– Pharmacologic
• Surgery
– Symptomatic reflux, manometric evidence of
incompetent LES, and failure of medical therapy
– Development of complications
Nir Hus MD., PhD. Ryder Trauma
Center Jackson Memorial Hospital
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Nir Hus MD., PhD. Ryder Trauma
Center Jackson Memorial Hospital
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Center Jackson Memorial Hospital
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Center Jackson Memorial Hospital
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Nissen Fundoplication
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Belsey-Mark IV
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Collis Gastroplasty
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Barrett’s Esophagus
• Columnar metaplasia of the distal esophagus
at least 3-cm above GE junction or any
length with intestinal metaplasia
• Incidence
– 2% of all endoscopies
– 15% of all esophagitis
• Types
– Fundic
– Junctional
– Intestinal
Nir Hus MD., PhD. Ryder Trauma
Center Jackson Memorial Hospital
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Barrett’s Esophagus
• Dx; endoscopy/bx
• Complications
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Ulceration (50%)
Stricture (30%)
Low grade dysplasia (5-10%)
High grade dysplasia/ Ca in situ
Adenocarcinoma (2%)
Nir Hus MD., PhD. Ryder Trauma
Center Jackson Memorial Hospital
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Barrett’s Esophagus
• Asymptomatic uncomplicated Barret’s
– Surveillance and yearly biopsies
• Symptomatic uncomplicated Barret’s
– treat as GERD
• Barret’s Ulcers
– aggressive medical therapy, recurrence or
failure to heal - surgery
• Barret’s Strictures
– medical management and esophageal dilation
– recurrence or persistence - surgery
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Center Jackson Memorial Hospital
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