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187 Cards in this Set
- Front
- Back
What are the layers of the esophagus? |
stratified squamous epithelium (mucosa), circular inner muscle layer, outer longitudinal muscle layer; no serosa
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What kind of muscle is in the upper esophagus? lower esophagus?
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striated muscle, smooth muscle |
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What is the blood supply of the cervical esophagus? and abdominal esophagus? |
Cervical esophagus – supplied by the inferior thyroid artery |
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Which direction does the lymphatics of the esophagus drain?
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upper 2/3 drains cephalad, lower 1/3 caudad |
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Right vagus nerve – travels on ____ portion of stomach as it exits chest; becomes ____ plexus; also has the criminal nerve of ___ → can cause persistently high acid levels postoperatively if left undivided
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posterior, celiac, Grassi
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Left vagus nerve – travels on what portion of stomach? and goes where? |
anterior, goes to liver and biliary tree |
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The upper esophageal sphincter is how far from the incisors? and lower? |
15 cm, 40 cm
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What is the most common site of esophageal perforation (usually occurs with EGD)? |
cricopharyngeus muscle
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What muscle comprises the upper esophageal sphincter and prevents air swallowing? |
cricopharyngeus muscle
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What are the 3 anatomic areas of narrowing of the esophagus?
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cricopharyngeus muscle,
compression by the left mainstem bronchus and aortic arch, diaphragm |
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What is the surgical approach to the cervical esophagus? upper 2/3 thoracic? Lower 1/3 thoracic?
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Cervical esophagus – left
Upper ⅔ thoracic – right (avoids the aorta) Lower ⅓ thoracic – left (left–sided course in this region) |
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What is the cause in primary esophageal dysfunction? secondary?
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unknown in primary
secondary includes systemic disease, gastroesophageal reflux disease (GERD; most common), scleroderma, polymyositis |
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What is the diagnostic procedure of choice for dysphagia and odynophagia?
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barium swallow (better at picking up masses)
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What is the usual cause of cervical esophageal dysphagia?
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plummer–vinson syndrome
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What is the 3 parts of tx for plummer–vinson syndrome?
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dilation, Fe, screen for oral CA
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What can occur between the cripharyngeus and pharyngeal constrictors?
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Zenker's diverticulum
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What is the tx for Zenker's diverticulum?
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cricopharyngeal myotomy; Zenker's itself can either be resected or suspended
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What do you get on POD #1 after a cricopharyngeal myotomy for Zenker's?
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esophagogram
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How is a traction diverticulum different from Zenker's?
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Zenker's is a false diverticulum and lies posterior; traction is a true diverticulum is usually lateral in the mid esophagus
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What is the tx for a traction diverticulum of the esophagus?
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excision and primary closure; may need palliative therapy if due to invasive CA
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What is caused by failure of peristalsis and lack of LES relaxation after food bolus, and is secondary to neuronal degeneration in muscle wall?
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Achalasia
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What is the medical tx for achalasia (2)? what is next step?
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first, LES dilation (effective in 80%) |
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What is the next step in tx of achalasia if CCB, nitrates and LES dilation fail?
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Heller myotomy
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What infection can produce similar sx to achalasia?
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T. cruzi
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sx similar to achalasia. May have psych history, normal LES tone, strong unorganized contractions.
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Diffuse esophageal spasm
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What are 4 types of tx for diffuse esophageal spasm?
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calcium channel blocker, trazodone; Heller myotomy if those fail (myotomy of upper and lower esophagus; right thoracotomy)
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Causes dysphagia, loss of LES tone; most have strictures, fibrous replacement of smooth muscle
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Scleroderma
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GERD sx with bloating suggests what?
how to dx |
aerophagia and delayed gastric emptying
may want gastric emptying study |
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What is the best test for GERD?
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pH probe
also endoscopy, histology, manometry (resting LES < 6 mm Hg) |
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What is the surgical tx for GERD?
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Nissen
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What is name of the approach through the chest in a Nissen?
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Belsey
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During a Nissen, when not enough esophagus exists to pull down into abdomen, can staple along stomach and create a “new” esophagus. What is this called?
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Collis gastroplasty
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Name the type of hiatal hernia:
Sliding hernia from dilation of hiatus (most common); often associated with GERD |
Type I
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Name the type of hiatal hernia:
Paraesophageal; hole in the diaphragm alongside esophagus, normal GE junction. |
Type II
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What is a Type III hiatal hernia? and type IV?
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Type III – combined ■ Type IV – entire stomach in the chest plus another organ (i.e., colon, spleen)
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Almost all pts with Schatzki's ring have an associated ___
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sliding hiatal hernia
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What is the tx for Schatzki's ring?
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dilatation of the ring usually sufficient
PPI dont resect |
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What is the transformation in pts with Barrett's esophagus?
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squamous metaplasia to columnar epithilium
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Pts with Barrett's esophagus are at 50x increased risk for what?
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adenocarcinoma
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Severe Barrett's dysplasia is an indication for what?
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Esophagectomy
or Endoscopic surveillance (3-month intervals; 4 quadrant Bx’s at 1-cm intervals for entire length of HGD and Bx of any suspicious areas) |
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Uncomplicated Barrett's can be treated like GERD with PPI or Nissen and surgery will decrease esphagitis and further metaplasia but it will not prevent what?
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malignancy or cause regression of the columnar lining
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Pts with Barrett's esophagus who get a Nissen still need careful lifetime follow up with what?
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annual follow-up EGD
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Esophageal tumors are almost always malignant. How does it spread?
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submucosal lymphatic channels
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What is the best test for unresctablity in esophageal CA?
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Chest/abdominal CT
hoarseness (RLN invasion), Horner’s syndrome (brachial plexus invasion), phrenic nerve invasion, malignant pleural effusion, malignant fistula, invasion of another structure (eg airway invasion, vertebra, lung) |
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What is the #1 esophageal CA?
What type occurs most often in the upper 2/3? |
Adenocarcinoma lower 1/3
Squamous cell carcinoma |
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mets to what nodes indicate unresectability |
celiac nodes – M1 disease and Supraclavicular nodes in esophageal CA |
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Distant metastases with esophageal CA is a contraindication to what? what is the survival?
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esophagectomy, < 12 mos
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What is the mortality from surgery in esophagectomy for CA? and what percentage is it curative?
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5%, 20%
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What is the primary blood supply to stomach after replacing esophagus in esphagectomy?
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right gastroepiploic artery (have to divide left gastric and short gastrics)
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What is the name of the type of esophagectomy with an abdominal incision and right thoracotomy –> exposes all of the esophagus; intrathoracic anasomsis
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Ivor Lewis
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What type of esophagectomy may be choice in young pts with benign disease when you want to preserve gastric function.
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Colonic interposition
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What do you need after esophagectomy on post op day 7?
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contrast study to rule out leak
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Name two chemo agents that can be used with esophageal CA for node positive disease or use preop to shrink tumors?
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5FU and cisplatin
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In esophageal CA with malignant fistulas, most die within 3 months due to what?
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aspiration
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What is the most common benign tumor of the esophagus?
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Leiomyoma
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Diagnosis of Leiomyoma is __, ___, and ___ to rule out CA.
Why don't you bx? |
esophogram, endoscopic u/s, CT |
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Tx for Leiomyoma of the esophagus is excision via thoractomy.
What are the 2 indications? |
>5 cm or sx
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Caustic esophageal injury:
NG tube? Induce vomiting? drink? |
no, no, no
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What is first step in dx in caustic esophageal injury? then what?
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best test- endoscopy to assess lesion (but not with suspected perforation) Chest and Abd CT to look for free air, |
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What is the most common cause of esophageal perforation?
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EGD
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What is the most common site of esophageal perforation?
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cricopharyngeus muscle
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How to dx esophageal perforation?
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cxr initially
gastrograffin swallow followed by barium swallow no egd |
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What is the tx for esophageal perforation that is contained, self–draining and no systemic effects?
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Conservative: IVF, NPO, spit
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What type of flap can be used with repair of esophageal perforation to help the area heal?
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intercostal muscle pedicle flap
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What is Hartmann's sign?
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mediastinal crunching on ascultation
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How to dx Boerhaave's syndrome?
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gastrofrafin swallow
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What is the stomach transit time?
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3–4 hours
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Where does peristalsis occur in the stomach?
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only in the distal stomach
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What are the branches of the Celiac trunk?
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left gastric, common hepatic, splenic
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Left gastroepiploic and short gastrics are branches of what artery?
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splenic
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What is the blood supply of the greater curvature of the stomach?
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right and left gastroepiploics, short gastrics
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What is the blood supply of the lesser curvature of the stomach?
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right and left gastrics
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The right gastric is a branch of what artery?
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common hepatic
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What is the blood supply of the pylorus?
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gastroduodenal artery
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What is the mucosa of the stomach lined with?
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simple columnar epithelium
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What is the first enzyme in proteolysis and what cell secretes it?
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Pepsinogen, secreted by chief cells
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What do the parietal cells secrete?
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H+ and intrinsic factor
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What 2 things do Brunner's glands in the duodenum secrete?
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pepsinogen and alkaline mucus
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Antrectomy with gastroduodenal anastomosis?
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Billroth I
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Antrectomy with gastrojejunal anastomosis?
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Billroth II
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____ ulcer is a vascular malformation in the stomach
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Dieulafoy's
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____ disease is mucous cell hyperplasia, increased rugal folds of the stomach.
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Menetrier's
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What is the tx for gastric volvulus?
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reductiona and Nissen
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Associated with type II (paraesophageal) hernia ■ Nausea without vomiting; severe pain.
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Gastric volvulus
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Where is the tear usually located in a Mallory–Weiss tear?
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near lesser curvature of the stomach near GE junction
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What is the result of a vagotomy
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vagal denervation all forms increase liquid emptying –> vagally mediated receptive relaxation is removed, results in increased gastric pressure that accelerates liquid emptying
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In complete vagotomy (truncal or selective) there is decreased emptying of solids. In highly selective vagotomy there is normal emptying of solids. Addition of what procedure to either results in increased solid emptying?
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Pyloroplasty
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What is the most common problem following vagotomy (30–50%)?
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diarrhea
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Upper GI bleed and having trouble localizing source with EGD. What can be done next?
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tagged RBC scan
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What is the biggest risk factor for rebleeding of an upper GI bleed at the time of EGD?
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spurting blood vessel
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In a pt with liver failure, what is the most likely source of an upper GI bleed?
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esophageal varices
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What is the tx for a bleeding esophageal varices?
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EGD with sclerotherapy or TIPS, not OR
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What location of duodenal ulcers usually perforate? what location bleed from GDA?
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anterior ulcers perforate, posterior ulcers bleed from GDA
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Describe the incision and closure of a Heineke–Mikulicz pyloroplasty.
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longitudunal incision of the plyloric sphincter followed by a transverse closure
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What is the most frequent complication of duodenal ulcers?
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bleeding
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The 1st surgical option for bleeding duodenal ulcer is duodenstomy and what? what if the pt has been on PPI therapy?
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GDA ligation,
truncal vagotomy and pyloroplasty |
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With GDA ligation for bleeding duodenal ulcer, it is important to avoid hitting what structure?
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common bile duct
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What is the initial treatment of choice for obstruction due to duodenal ulcer?
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serial dilation
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Pt on H–pump inhibitor develops a perforated duodenal ulcer. What is the best surgical option? what if they were not on H–pump inhibitor?
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Graham patch and highly selective vagotomy; just do Graham patch and place on omeprazole
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What is the test for Zollinger–Ellison Syndrome?
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Secretin test results in high gastrin level
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In Zollinger–Ellison syndrome, what size tumors can be enucleated?
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<2 cm
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What is the most common location for gastric ulcers? and the most common cause?
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lesser curvature; decreased mucosal defense (normal acid secretion)
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Hemorrhage is associated with higher mortality in duodenal or gastric ulcers?
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gastric
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What location in the stomach is the bx for H. pylori taken?
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antrum
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List the locations of gastric ulcers types I–V
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Type I – lesser curve along body of stomach
Type II – 2 ulcers, lesser curve and duodenal Type III – prepyloric Type IV – lesser curve high along cardia of stomach Type V – associated with NSAIDs |
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What is the timing after event for stress gastritis?
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3–10 days after event
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Chronic gastritis has types A and B what is their location and what are they associated with?
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Type A (fundus) – associated with pernicious anemia, autoimmune disease
Type B (antral) – associated with H. pylori |
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Where are 40% of gastric cancers located?
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antrum
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What is the difference in the pain with gastric cancer vs gastric ulcer?
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gastric ulcer pain is relived by eating but recurs 30 min later.
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What blood type is a risk factor for gastric cancer?
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type A
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What is Krukenberg tumor?
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gastric cancer with mets to ovaries
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What is Virchow's nodes?
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gastric cancer with metastases to supraclavicular nodes
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What size margins in subtotal gastrectomy for gastric cancer?
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5 cm
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What is diffuse gastric cancer called?
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linitis plastica
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What is the surgical tx for linitis plastica?
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total gastrectomy
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In palliation for gastric cancer, proximal obstruction can be treated with what? and distal?
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proximal can be stented, distal lesions can be bypassed with gastrojejunostomy
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What is the most common benign gastric neoplasm? aka?
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gastric leiomyomas, also called gist tumors
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What is the chemotherapy agent and MOA for gastric leiomyomas?
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Gleevec (tyrosine kinase inhibitor)
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What is the proto–oncogene are most gastric leiomyomas positive for?
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c–kit (CD117)
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What route does gastric leiomyosarcoma spread?
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hematogenous
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What is the tx for mucosa associated lymphoid tissue lymphoma (MALT lymphoma)? and if it does not regress?
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Triple therapy abx for H. pylori; CHOP
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What are the surgical eligibility criteria for bariatric surgery?
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BMI >40 kg or BMI >35 kg with coexisting comorbiditiies
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What is the medical and surgical tx for dumping syndrome?
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octreotide may be effective. Surgery is rarely needed but includes converting a billroth I or II to a roux–en–Y gastrojejunostomy. Or increasing the gastric reserve with a jejunal pouch or increasing emptying type with a reversed jejunal loop
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What is the dietary tx for dumping syndrome?
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small, low–fat, low–carb, increased–protein meals; no liquids with meals; no lying down after meals
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What are two surgical options for treating dumping syndrome after gastrectomy?
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conversion of billroth I or billroth II to Roux–en–Y gastrojejunostomy
Operations to increase gastric reservoir (jejunal pouch) or increase emptying time (reversed jejunal loop) |
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After a gastrectomy there is postprandial epigastric pain associated with N/V; pain not relived with vomiting. Evidence of bile reflux into stomach and histologic evidence of gastritis. Dx?
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Alkaline reflux gastritis
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What are 3 medical options for the tx of alkaline reflux gastritis after gastrectomy?
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H2 blockers, cholestyramine, metoclopramide
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What is the surgical option for treating alkaline reflux gastritis after gastrectomy?
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Conversion of Billroth I or Billroth II to Roux–en–Y gastrojejunostomy with afferent limb 60 cm distal to original gastrojejunostomy
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In roux–en–y which limb is the roux limb? Which is the afferent limb?
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The roux limb goes from the gastrojejunostomy to the jejunojenuostomy. The afferent limb is the portion of duodenum and jejunum feeding the jejunojenunostomy.
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What is the cause of roux stasis?
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stasis of chyme in Roux limb due to loss of jejunal motility.
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How do you dx Roux stasis?
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EGD, emptying studies
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What are 2 treatment options for Roux stasis?
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metoclopramide/prokinetics
shorten Roux limb to 40 cm |
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What is caused by delayed gastric emptying after vagotomy?
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chronic gastric atony
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What is the surgical treatment for chronic gastric atony after gastrecomy?
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near total gastrectomy with Roux–en–Y
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What is the surgical option for small gastric remnant and early satiety after gastrectomy?
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jejunal pouch reconstruction
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After Billroth II or Roux–en–Y, symptoms include pain, diarrhea, malabsorption, B12 deficiency, steatorrhea. Caused by bacterial overgrowth and stasis in affarent limb.
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Blind–loop syndrome
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What is the medical and surgical treatment options for blind–loop syndrome?
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tetracycline, Flagyl, metoclopramide
reanastomosis with shorter (40 cm) afferent limb |
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zenker's diverticulus true diverticulum? |
no, false diverticulum |
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traction diverticulum true diverticulum? |
yes, true diverticulum |
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pharyngoesophageal disorders, solids or liquids worse? |
liquids |
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tx for zenkers |
Tx: cricopharyngeal myotomy (key point); Zenker’s itself can either be resected or suspended (removal of diverticula is not necessary) Left cervical incision; leave drains in; esophagogram POD #1 |
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posterior or lateral? zenkers and traction divertiuclum |
zenkers posterior traction lateral |
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tx of traction diverticulum |
sx? excision and close asx? nothing. |
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Epiphrenic diverticulum Rare; associated with |
esophageal motility disorders(eg achalasia) |
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Tx: Epiphrenic diverticulum |
Tx: diverticulectomy and esophageal myotomy on the side opposite the diverticulectomy if symptomatic |
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ACHALASIA cause |
Caused by lack of peristalsis and failure of LES to relaxafter food bolus |
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ACHALASIA pathophys |
Secondary to autoimmune destruction of neuronal ganglion cells in muscle wall |
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imaging of ACHALASIA |
Can get tortuous dilated esophagus and epiphrenic diverticula; bird’s beak appearance |
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if dilation and medication fail in ACHALASIA |
Heller myotomy (left thoracotomy, myotomy of lower esophagus only; also need partial Nissen fundoplication) |
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can get what cancer in achalasia |
Can get esophageal CA late (squamous cell most common) |
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infection that can cause achalasia |
T. cruzi can produce similar symptoms |
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medical tx for DIFFUSE ESOPHAGEAL SPASM |
: calcium channel blocker, trazodone; |
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if meds fail for DIFFUSE ESOPHAGEAL SPASM |
Heller myotomy if those fail (myotomy of upper and lower esophagus; right thoracotomy) |
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what is dx of CHEST pain +/- dysphagia |
NUTCRACKER ESOPHAGUS |
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manometry of NUTCRACKER ESOPHAGUS |
high-amplitude peristaltic contractions (> 180 mm Hg); LES ok |
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tx of NUTCRACKER ESOPHAGUS |
same as diffuse esophageal spasm calcium channel blocker, trazodone; Heller myotomy if those fail (myotomy of upper and lower esophagus; right thoracotomy) |
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sx of scleroderma esophagus |
Heartburn, massive reflux, dysphagia |
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how is LES tone? reflux? |
loss of LES tone massive refluxand strictures |
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tx SCLERODERMA |
Tx: PPI and Reglan; esophagectomy usual if severe |
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dx GERD? |
Dx: pH probe (best test), endoscopy, histology, manometry |
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(resting LES in GERD? |
(resting LES < 6 mm Hg) |
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GERD Key maneuver for dissection is __ Key maneuver for wrap is__ |
Key maneuver for dissection is finding the right crura Key maneuver for wrap is identification of the left crura |
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sx of Type II –HIATAL HERNIA |
Symptoms: chest pain, dysphagia, early satiety |
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best way to dx schatzki's ring |
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what to do if have dysphagia after nissen |
wrap too tight (generally resolves on its own; give clears for 1st week; can dilate after 1 week) |
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pt with chest pain, retching without vomiting, can’t pass NG tube; what is it? what to do |
paraesophageal hernia II-IV.. risk for incarceration usually need repair may want to avoid repair in the elderly and frail if minimal symptoms |
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adenoca of esophagus met to where? |
liver mc |
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SCC of esophagus met to where?
|
lung mc |
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Most important prognostic factor in patient devoid of systemic metastases |
nodal spread |
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primary blood supply to stomach after replacing esophagus in ca resection |
Right gastroepiploic artery (have to divide left gastric and short gastrics) |
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to resect esophageal ca- can use what approaches |
Transhiatal approach-cervical anastomosis (mortality from esophageal leaks) Ivor Lewis – intrathoracic anastomosis 3-Hole esophagectomy - abdominal, thoracic, and cervical incisions |
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need to als perform __ in these 3 procedures |
pyloromyotomy |
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when to Thoracic duct ligation where at? |
> 2 L/day or is refractory to medical Tx right side, low in the mediastinum) |
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Post-op chemo? (indicated for node-positive disease) |
cisplatin and 5FU |
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complication of esophageal ca resection-- die w/i 3 mo |
Malignant fistulas Tx – esophageal stent for palliation |
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After esophagectomy how to r/o leak |
→ need contrast study on postop day 7 to rule out leak |
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Esophagectomy margins |
Need 6–8 cm margins |
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ESOPHAGEAL POLYPS Symptoms |
dysphagia, hematemesis |
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2nd most common benign tumor of the esophagus where aT? |
ESOPHAGEAL POLYPS cervical esophagus |
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alkali ingestion- ____necrosis acid ingestion- ___ necrosis |
deep liquefaction necrosis coagulation necrosis; |
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Degree of injury:Primary burn looks like tx? |
hyperemia Conservative Tx: IVFs, spitting, antibiotics, oral intake after 3–4 days; may need future serial dilation for strictures (usually cervical) |
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Degree of injury: secondary burn looks like tx? |
ulcerations, exudates, and sloughing Tx: prolonged observation and conservative therapy as above; TPN Indications for esophagectomy – sepsis, peritonitis, mediastinitis, free air, mediastinal or stomach wall air, crepitance, contrast extravasation, pneumothorax, large effusion |
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Degree of injury: Tertiary burn looks like tx? |
deep ulcers, charring, and lumen narrowing Tx: as above; esophagectomy usually necessary |
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Degree of injury:Primary burn complication... |
Can also get shortening of esophagus with GERD (Tx: PPI) |
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Caustic esophageal perforations are repaired? |
NO- esophageal perforations require esophagectomy (are not repaired due to extensive damage) |
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tx for if esophageal perf not contained < 24 hours or minimal contamination : |
primary repair with drains Need longitudinal myotomy to see the full extent of injury |
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tx for if esophageal perf not contained >48 or extensive contamination : |
Neck – just place drains (no esophagectomy) → will eventually heal Chest – 1) resection (esophagectomy, cervical esophagostomy) or 2) exclusion and diversion (cervical esophagostomy, staple across distal esophagus, washout mediastinum, place chest tubes – late esophagectomy at time of gastric replacement) Gastric replacement of esophagus late when patient fully recovers |