powerpoint: disorders of the esophagus ii
TRANSCRIPT
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