Esophagus review 1 Nir Hus MD., PhD.

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Esophagus review 1 Nir Hus MD., PhD.

  1. 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
  2. 2. Esophagus: Anatomy Nir Hus MD., PhD. Ryder Trauma Center Jackson Memorial Hospital
  3. 3. Esophagus: Anatomy Nir Hus MD., PhD. Ryder Trauma Center Jackson Memorial Hospital
  4. 4. Esophagus: Anatomy Nir Hus MD., PhD. Ryder Trauma Center Jackson Memorial Hospital
  5. 5. Esophageal Studies <ul><li>Anatomic </li></ul><ul><ul><li>Esophagogram </li></ul></ul><ul><ul><li>CT-Scan </li></ul></ul><ul><ul><li>Endoscopy(Biopsy/Ultrasound) </li></ul></ul><ul><li>Functional </li></ul><ul><ul><li>Esophageal manometry </li></ul></ul><ul><ul><li>24 hour pH probe </li></ul></ul>Nir Hus MD., PhD. Ryder Trauma Center Jackson Memorial Hospital
  6. 6. Esophagus: Physiology Nir Hus MD., PhD. Ryder Trauma Center Jackson Memorial Hospital
  7. 7. Esophageal Manometry Nir Hus MD., PhD. Ryder Trauma Center Jackson Memorial Hospital
  8. 8. Esophageal Manometry: Swallowing Nir Hus MD., PhD. Ryder Trauma Center Jackson Memorial Hospital
  9. 9. <ul><li>Intramural pressure </li></ul><ul><li>Length of LES </li></ul><ul><li>Abdominal length LES </li></ul>Characteristics of Lower Esophageal Sphincter Nir Hus MD., PhD. Ryder Trauma Center Jackson Memorial Hospital
  10. 10. Manometry LES: Pressure/Length Relationship Nir Hus MD., PhD. Ryder Trauma Center Jackson Memorial Hospital
  11. 11. 24-Hour pH Monitoring Nir Hus MD., PhD. Ryder Trauma Center Jackson Memorial Hospital
  12. 12. Esophageal Motility Disorders <ul><li>Esophageal Diverticula </li></ul><ul><ul><li>Zenker ’ s (pulsion) </li></ul></ul><ul><ul><li>Epiphrenic </li></ul></ul><ul><ul><li>Traction (pulsion) </li></ul></ul><ul><li>Functional Disorders </li></ul><ul><ul><li>Achalasia </li></ul></ul><ul><ul><li>Diffuse esophageal spasm </li></ul></ul><ul><ul><li>Nutcracker esophagus </li></ul></ul>Nir Hus MD., PhD. Ryder Trauma Center Jackson Memorial Hospital
  13. 13. Zenker ’ s Diverticulum <ul><li>Dysphagia </li></ul><ul><li>Regurgitation undigested food </li></ul><ul><li>Aspiration </li></ul><ul><li>Unyielding cricopharingeous </li></ul><ul><li>Dx: barium swallow </li></ul><ul><li>No endoscopy </li></ul><ul><li>Tx: diverticulectomy/myotomy </li></ul><ul><li>Left cervical incision </li></ul>Nir Hus MD., PhD. Ryder Trauma Center Jackson Memorial Hospital
  14. 14. Achalasia <ul><li>Dysphagia and regurgitation undigested food </li></ul><ul><li>Substernal/epigastric pain </li></ul><ul><li>Diagnosis and work-up: CXR, UGIS </li></ul><ul><li>endoscopy/bx: esophagitis, r/o Ca </li></ul><ul><li>Manometry: </li></ul><ul><ul><li>aperistalsis </li></ul></ul><ul><ul><li>incomplete relaxation of LES </li></ul></ul><ul><ul><li>High resting pressure LES (>30 mmHg) </li></ul></ul>Nir Hus MD., PhD. Ryder Trauma Center Jackson Memorial Hospital
  15. 15. Achalasia Nir Hus MD., PhD. Ryder Trauma Center Jackson Memorial Hospital
  16. 16. Achalasia: Treatment <ul><li>Esophageal dilations, success rate: 70% </li></ul><ul><li>Botulinum toxin injections: short lived </li></ul><ul><li>Surgery: Heller myotomy, success rate: 95% </li></ul><ul><li>Indications: </li></ul><ul><ul><li>children </li></ul></ul><ul><ul><li>vigorous achalasia </li></ul></ul><ul><ul><li>medical failures </li></ul></ul>Nir Hus MD., PhD. Ryder Trauma Center Jackson Memorial Hospital
  17. 17. Achalasia: Heller Operation Nir Hus MD., PhD. Ryder Trauma Center Jackson Memorial Hospital
  18. 18. Diffuse Esophageal Spasm and Nutcracker Esophagus <ul><li>Intermittent chest pain and dysphagia </li></ul><ul><li>Negative cardiac work-up </li></ul><ul><li>Manometry: normal LES, tertiary peristalsis </li></ul><ul><li>Treatment: </li></ul><ul><ul><li>Medical: reduce stress and precipitating factors </li></ul></ul><ul><ul><li>NTG, Isosorbide, Nifedipine </li></ul></ul><ul><ul><li>Surgery: Full length myotomy, success rate 65% </li></ul></ul>Nir Hus MD., PhD. Ryder Trauma Center Jackson Memorial Hospital
  19. 19. Nutcracker Esophagus Nir Hus MD., PhD. Ryder Trauma Center Jackson Memorial Hospital
  20. 20. GERD <ul><li>Abnormal exposure of distal esophagus to refluxed gastric juice </li></ul><ul><li>Etiology </li></ul><ul><ul><li>Mechanically defective LES (60%) </li></ul></ul><ul><ul><li>Poor esophageal clearance </li></ul></ul><ul><ul><li>Gastric outlet obstruction </li></ul></ul><ul><ul><li>Functional delayed gastric emptying </li></ul></ul><ul><ul><li>Increased gastric acid secretion </li></ul></ul><ul><ul><li>inappropriate relaxation of LES </li></ul></ul>Nir Hus MD., PhD. Ryder Trauma Center Jackson Memorial Hospital
  21. 21. GERD <ul><li>Symptoms </li></ul><ul><ul><li>Substernal/epigastric burning pain </li></ul></ul><ul><ul><li>Regurgitation </li></ul></ul><ul><ul><li>Effortless emesis </li></ul></ul><ul><ul><li>Dysphagia </li></ul></ul><ul><ul><li>Flatulence </li></ul></ul><ul><ul><li>Atypical symptoms </li></ul></ul>Nir Hus MD., PhD. Ryder Trauma Center Jackson Memorial Hospital
  22. 22. GERD <ul><li>Complications (20%) </li></ul><ul><ul><li>Esophagitis </li></ul></ul><ul><ul><li>Stricture </li></ul></ul><ul><ul><li>Barrett ’ s esophagus </li></ul></ul><ul><ul><li>Ulceration </li></ul></ul><ul><ul><li>Esophageal shortening </li></ul></ul>Nir Hus MD., PhD. Ryder Trauma Center Jackson Memorial Hospital
  23. 23. GERD: Work-up <ul><li>UGIS and EGD </li></ul><ul><li>Manometry: characterizes LES and motility </li></ul><ul><ul><li>LES pressure < 6 mm Hg </li></ul></ul><ul><ul><li>Overall length < 2 cm </li></ul></ul><ul><ul><li>Abdominal length < 1 cm </li></ul></ul><ul><li>Esophageal pH testing (sens/specif - 90%) </li></ul><ul><ul><li>pH < 4 more than 1 hour and a half/24 hours (6%) </li></ul></ul><ul><ul><li>Composite score derived from: total time pH <4, upright time pH <4, supine time pH <4, # episodes, episodes >5 min, longest episode. </li></ul></ul>Nir Hus MD., PhD. Ryder Trauma Center Jackson Memorial Hospital
  24. 24. GERD: Treatment <ul><li>Medical </li></ul><ul><ul><li>Postural alterations </li></ul></ul><ul><ul><li>Dietary alterations </li></ul></ul><ul><ul><li>Pharmacologic </li></ul></ul><ul><li>Surgery </li></ul><ul><ul><li>Symptomatic reflux, manometric evidence of incompetent LES, and failure of medical therapy </li></ul></ul><ul><ul><li>Development of complications </li></ul></ul>Nir Hus MD., PhD. Ryder Trauma Center Jackson Memorial Hospital
  25. 25. Nir Hus MD., PhD. Ryder Trauma Center Jackson Memorial Hospital
  26. 26. Nir Hus MD., PhD. Ryder Trauma Center Jackson Memorial Hospital
  27. 27. Nir Hus MD., PhD. Ryder Trauma Center Jackson Memorial Hospital
  28. 28. Nissen Fundoplication Nir Hus MD., PhD. Ryder Trauma Center Jackson Memorial Hospital
  29. 29. Belsey-Mark IV Nir Hus MD., PhD. Ryder Trauma Center Jackson Memorial Hospital
  30. 30. Collis Gastroplasty Nir Hus MD., PhD. Ryder Trauma Center Jackson Memorial Hospital
  31. 31. Barrett ’ s Esophagus <ul><li>Columnar metaplasia of the distal esophagus at least 3-cm above GE junction or any length with intestinal metaplasia </li></ul><ul><li>Incidence </li></ul><ul><ul><li>2% of all endoscopies </li></ul></ul><ul><ul><li>15% of all esophagitis </li></ul></ul><ul><li>Types </li></ul><ul><ul><li>Fundic </li></ul></ul><ul><ul><li>Junctional </li></ul></ul><ul><ul><li>Intestinal </li></ul></ul>Nir Hus MD., PhD. Ryder Trauma Center Jackson Memorial Hospital
  32. 32. Barrett ’ s Esophagus <ul><li>Dx; endoscopy/bx </li></ul><ul><li>Complications </li></ul><ul><ul><li>Ulceration (50%) </li></ul></ul><ul><ul><li>Stricture (30%) </li></ul></ul><ul><ul><li>Low grade dysplasia (5-10%) </li></ul></ul><ul><ul><li>High grade dysplasia/ Ca in situ </li></ul></ul><ul><ul><li>Adenocarcinoma (2%) </li></ul></ul>Nir Hus MD., PhD. Ryder Trauma Center Jackson Memorial Hospital
  33. 33. Barrett ’ s Esophagus <ul><li>Asymptomatic uncomplicated Barret ’ s </li></ul><ul><ul><li>Surveillance and yearly biopsies </li></ul></ul><ul><li>Symptomatic uncomplicated Barret ’ s </li></ul><ul><ul><li>treat as GERD </li></ul></ul><ul><li>Barret ’ s Ulcers </li></ul><ul><ul><li>aggressive medical therapy, recurrence or failure to heal - surgery </li></ul></ul><ul><li>Barret ’ s Strictures </li></ul><ul><ul><li>medical management and esophageal dilation </li></ul></ul><ul><ul><li>recurrence or persistence - surgery </li></ul></ul>Nir Hus MD., PhD. Ryder Trauma Center Jackson Memorial Hospital

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