powerpoint: disorders of the esophagus ii

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HIATAL HERNIA

HIATAL HERNIADistal esophagus- held in position by the

phrenoesophageal ligamentOccurs most commonly in womenMost hiatal hernias are asymptomatic5-10% of pts.will develop GERDThere is strong association with obesitySaint’s triad= gall stones+colonic

diverticular disease+hiatal hernia

HIATAL HERNIAType I or sliding HH: ph.-esoph.lig.intact but

lax- distal esoph. and cardia herniate through the hiatus.

Type II or paraesophageal HH- focal defect of the ph.-esoph. lig.,greater curvature herniates upward alongside the esoph.

Type III- a combination of type I and II

HIATAL HERNIASYMPTOMSType I- sy.of associated GERDType II, III- postprandial pain,

- bloating,- breathlessness with meals,- mild dysphagia

The herniated gastric pouch is susceptible to volvulus, obstruction, infarction, ischemic ulcers, occult bleeding, perforation, gangrene.

HIATAL HERNIADIAGNOSIS AND EVALUATION

CXR- air/fluid level in post.M.on lat.view

Barium swallow- the dg.study of choice

Esophagoscopy- for GERD and esophagitis

Manometry and pH testing for refux sy.

Hiatus hernia seen from below with the endoscope in an inverted position inside the stomach

HIATAL HERNIAMANAGEMENTAsymptomatic HH- no treatmentHH+GERD- medical treatmentIndications for surgery:

Symptomatic HH (chest pain, dysphagia)HH+ severe esophagitisHH type II, IIIOprative objectives: - reduction of hernia

- closure of the hiatal defect

- antireflux procedure

ESOPHAGEAL STRICTURES

Caustic stricture

Strictures secondary to reflux esophagitis

CAUSTIC STRICTURESCaused by ingestion of caustic agents: lye,

soda, acidsCommonly taken: caustic soda, sulphuric acid

from car batteries in attempted suicideDiagnosis:- history of caustic ingestion- sy: retrosternal pain, dysphagia, shock- endoscopy- the severity and extent of lesions

CAUSTIC LESIONSPharynx is relatively spared- short contact timeEdema of the laryngopharynx- respiratory sy.Esoph. takes the brunt of the injury-

inflammation, ulceration, necrosis, perforationStomach is protected- its contents dilute

whatever and neutralizes alkali.Perforation can occur between 3h.-3 weeksEarly endoscopy within a few hours of injury is

the keyComplete endoscopy should not be attempted if

there is a severe necrotizing lesion and air insuflation is kept to a minimum

CAUSTIC STRICTURESTreatment:- fluid ressuscitation,- total parenteral nutrition,- antibiotics,- steroidsBarium swollow after 10-14 daysStrictures- dilatation treatment 3/4w.after

injestion or esophageal replacement

SECONDARY STRICTURESCaused by acid GERD with mucosal

destruction and subsequent healingCommon site- GE junctionDiagnosis- history of reflux sy.+ dysphagiaBarium swollow confirms the dg.Endoscopy- extent of lesion, rule out a ca.Treatment- dilatation+ antireflux op

- reconstructive procedure

TUMORS OF THE ESOPHAGUSBenign lesions- < 1% of all neoplasmsThe commonest is leiomyomaOccurs in the lower esoph.as uniform, oval

swelling, protruding into the lumen, covered by intact mucosa

Main symptom- dysphagiaWell incapsulated- removal by enucleation

ESOPHAGEAL CANCERMostly are carcinomas- bad prognosisThe predominant histo.type is squamousPremalignant conditions: acalasia,

esophagitis and Barret’s esophagusMacroscopically- 3 forms: polypoid, stenosing

and ulcerativeSurgical treatment for early ca.-5-years

survival of 80-85%

SQUAMOUS-CELL CARCINOMAInfiltrates the submucosal plane,

longitudinally and circumferentiallyInvades the muscle walls and adjacent

mediastinal structuresCommon in the middle and lower thirdLymph node spread: cervical, mediastinal,

subdiaphragmaticMetastatic spread to the liver and bonesSensitive to radiotherapy

Endoscopic view of the esophageal squamous cell carcinoma

ADENOCARCINOMA OF THE ESOPHAGUSOriginates from Barret’s epithelium,

following longstanding GERDCommon in the lower thirdPrognosis is poorInsensitive to radiotherapyMode of spread similar to that of squamous

tumors

Protruding esophageal carcinoma

ESOPHAGEAL CANCERDIAGNOSISSymptoms: dysphagia, weight loss, painInvestigations: barium swollow and

endoscopy with biopsyLesions longer than 5 cm.usually

unresectableInvestigations for staging: laryngoscopy,

diaphragmatic USS, bronchoscopy, CT/MRI, laparoscopy

Adenocarcinoma of the esophagus at 35 cm. distance from the incisors, invasion of the aorta

Eso-tracheal fistula typical for squamous cell carcinoma

ESOPHAGEAL CANCERTREATMENTSurgical excisionBy-pass operationRadiotherapyChemotherapyLaser coagulationTranstumoral intubationFeeding gastrostomy/jejunostomy

PERFORATION OF THE ESOPHAGUSIntraluminal causes:- instrumental injuries during endoscopy,

dilatations, tube passage,

- foreign bodies,

- caustic substance injestion,- cancer of the esophagus,- barotrauma - (Boerhaave’s syndrome)

PERFORATIONS OF THE ESOPHAGUSExtraluminal causes: - penetrating injuries: stab wounds, gunshot

wounds- blunt trauma due to rapid increase in

intraluminal pressure- operative injuries: thyroid resection, anterior

cervical spine operations, vagotomy, laparoscopic fundoplication

PERFORATION OF THE ESOPHAGUS

Symptoms and signs:- dysphagia,- chest pain,- fever, chills- leukocytosis,- tachycardia,- respiratory distress and septic shock

PERFORATION OF THE ESOPHAGUSCervical perforation:- neck stiffness,- subcutaneous emphysemaIntrathoracic perforation:- chest pain,- subcutaneous emphysema,- dyspnea,- pleural effusion

ESOPHAGEAL PERFORATIONDIAGNOSISHistoryPhysical examination:- crepitation in the neck,- crunching sound over the heart (Hamman’s

sign),- breath sounds diminished (pleural effusion)Investigations:- CXR: air in the M.,pneumothorax,pleural

effusion- esophagography

Esophageal perforation

ESOPHAGEAL PERFORATIONTREATMENTControversy- non-op.and op.managementNil by mouth, 5 daysBroad spectrum antibioticsAntiacid drugsPleural drainageMediastinal collection- surgery for drainage

and esophageal divertion

MALLORY-WEISS SYNDROMEPresents as acute upper GI bleedingPartial thickness tear near the GE junctionFollows a prolonged period of severe

vomiting and retchingDiagnosis is made by endoscopyTreatment: conservative as in most cases

bleeding subsides spontaneously

ESOPHAGEAL VARICESResult from portal venous hypertensionThe most common cause is cirrhosis usually

associated with alcohol abuseAbnormal venous communications develop

between the peripheral part of the portal system and the systematic circulation- portal-systemic shunting

ESOPHAGEAL VARICESLarge veins appear at the lower end of the

esophagus and gastric fundusThese varices are easily traumatised by food

and produce massive GI bleedingUp to 40% of cirrhotic patients suffer variceal

hemorrhage at some stageA further result is splenic enlargement-

hypersplenismPortal-systemic encephalopathy- ammonia

ESOPHAGEAL VARICESMANAGEMENTElective injection sclerotherapyAcute bleeding- resuscitation

- balloon tamponadeSurgery-less commonly performed- transgastric esophageal staplingThe best treatment- repeated injection

sclerotherapy

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