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Esophagus - Coggle Diagram

- - - - Treatment
        
        CAB
        
        Investigate agent
        
        Composition
        Concentration
        Ingestion
        
        ENDOSCOPY
        
        24 - 48 hrs
        
        Do not pass burn c endoscope?? controversial
        
        3 more items...
        
        NO ENDOSCOPY d7 - 21
        Risk of perforation
        
        No endoscopy > 5 d.
        
        1 more item...
        
        Examine oral cavity
        CXR
        
        TECHNETIUM 99m- labeled sucralfate isotope scan
        
        Abnormal adhesion of sucralfate to entire esophagus
        
        Residual buccal activity
        
        No oral lesions
        pH>3 and < 11 forego endoscopy
        
        No endoscopy
        
        PO liquids
        d/c home
        
        NO VOMITING-- Caustic agent neutralized by gastric acid
        Inhaled or aspirated vomitus-- Introduce corrosive material to airway
        Acute inflammation and edema
    - - pH > 12
        pH > 1.5
  - - - Coagulation necrosis
        Hard eschar formation
        MUCOSAL ONLY
    - - Liquefactive necrosis (Alk combines c tissue prot causing liq nec and saponification)
        Destruction of epithelium and submucosa
        which may extend through muscle layer
        ISCHEMIA AND THROMBOSIS
        
        Transmural injury
        
        Necrosis may extend to mediastinum
        
        Anterior direction:
        T-E Fistulas or Ao - E fistula
        
        Phases
        
        Liquefactive necrosis
        
        Reparative phase
        
        Scar retraction
    - - House hold cleaning items 11%
        
        NaOCl Hypochlorite
  - - - Hemorrage
        Thrombosis
        Inflammation & edema
      - 48 hrs
        
        7 days
        
        14 days
        
        21 days
        3 wks
        
        Scar formation
        FIBROBLAST proliferation replaces submucosa and muscularis
        STRICTURE FORMATION BEGINS
        
        6 wks
        
        Mucosal re-epithelization
        
        MAX risk for perforation
        
        REPARATIVE SUBACUTE PHASE
        
        Necrotic tissue sloughed
        Edema decreases
        Neovascularization
        
        ULCERATION GRANULATION
        
        Thrombosis submucosal vessels
        Necrosis
        Gangrene
      - ACUTE PHASE
  - - - Viscosity + specific gravity < Alkali
        Faster transit through esophagus
        6-20% ingestions = burns
        
        DAMAGE: ANTRUM
        Pooling of swallowed acid
        Pylorus spasms in contact with acid
    - - pH < 1
        Adhere to moist surfaces
        Immediate pain
        
        Stricture areas MAJOR DAMAGE
- - - - Inferior thyroid artery o. thyrocervical trunk
        Less consistent:
        Pharyngeal
        Subclavian
        Common carotid
        Superior thyroid
        Vertebral arteries
        Costocervical trunk
      - Upper esophageal veins
        Inferior thyroid vein
        Brachicephalic vein
        IJV
      - Subepithelial venous plexi in lamina propia run longitudinally along whole length.
        Drain into the submucous plexus
        (Intrinsic esophageal venous plexus)
        (Extrinsic esophageal venous plexus)
    - - Upper Thoracic
        
        Inferior thyroid A.
        Less consistently
        Anterior esophagotracheal branch o. Ao.
        
        Upper thoracic esophageal veins
        Bronchial
        Posterior intercostal
        Azygos
        Hemiazygos
        Accesory azygos vein
      - Midesophagus
        
        Bronchial Arteries o. Ao
        or Ao.
      - Lower
        
        L. gastric artery
        L. inferior phrenic artery
    - - L. gastric artery
        L. inferior phrenic artery
      - Continuing c cardia and has many interconnecting pathways to porta venous system
- - - - Thick layer of non-keratinizing, stratified squamous epithelium with lining of oropharynx
    - - Loose connective tissue externa to mucosa
        Strongest part of esophageal wall
        
        THIS LAYER + LAMINA PROPIA FOR STRONG ANASTOMOSIS
    - - Chief mx of esophagus:
        Internal circular layer
        External longitudinal layer
        
        Pharynx
        External circular
        Internal longitudinal
    - - Connective tissue of mediastium around the esophagus
        Not a true layer
        Not a good anchor for sutures
        LACK OF SEROSA
    - - Killian
        
        Above crychopharygeal
      - Lairmer
        
        Below crychopharyngeal
- - - - Involuntary retrograde passage of gastric contents into esophagus c o s regurgitation or vomiting
        
        Transient relaxation of LES
        
        Allows contents to reflux into esophagus
        
        Delayed gastric emptying:
        Increase postprandial reflux--> by increasing transient relaxtions and likelihood of reflux
        
        GERD
        
        Reflux afects QOL and complications:
        +Failure to grow
        
        Respiratory complications
        
        Esophagitis
        
        Feeding or sleeping problems
        
        Chronic respiratory disorders
        
        Apnea
        
        ALTEs
        
        Pathophysiology
        
        Transient LES relaxations
        
        40% no acidic
        non acid 4 < pH > 7 45-90%
        
        Barriers against GERD
        
        LES
        
        Inner mx circular layer
        Thickened mx layer created a high pressure zone.
        
        2 more items...
        
        Length of intrabdominal esophagus
        
        4 more items...
        
        Creates pressure gradient in distal esophagus
        
        1 more item...
        
        Malpositioning
        LES
        
        1 more item...
        
        Tone
        
        1 more item...
        
        Length
        
        1 more item...
        
        Esophageal contractions
        
        Secondary
        
        1 more item...
        
        Terciary
        
        1 more item...
        
        Primary
        
        1 more item...
        
        Neurologic chidren
        
        Increased spasticity c retching
        
        Increased abdominal pressure
        
        Poor swallowing mechanisms
        
        Gagging and choking
        
        Congential abnormalites
        
        Esophageal atresia (EA) c (TEF)
        
        Duodenal and proximal small bowel atresia
        
        Congenital Diaphragmatic hernia
        
        Gastroschisis/omphalocele
        
        Complications
        
        Erosive esophagitis
        
        Stricture and Barret Esophagitis
        
        Reactive airway disease
        
        Pneumonia
        
        Malnutrition
        
        Clinical manifestations
        
        Dysphagia b/c of narrowed esophageal lumen
        Dysmotility secondary to mucosal inflammation
        
        Obstructive symptoms and pain
        Esophageal strictures
        
        Infants: Regurgitation/Vomiting
        Irritability
        Children: Dolor
        Adults: Heartburn
        
        Barret esophagitis
        Metaplasia
        Squamous replaced and columnar
      - Treatment
        
        Operative management
        
        Funduplication surgical technique
        
        Divide left triangular ligament (avascular plane)
        
        Retract L liver lobe to the right
        
        Movilize fundus of stomach (Divide and ligate short gastric vessels.)
        +Exposure of esophageal hiatus
        (Phrenoesophageal membrane strech downward.)
        +Incise white line of avascular membrane
        +Preserve anterior vagus nerve.
        +Mobilize of distal esophagus
        (Dissect lower end of esophagus avoid injury to posterior vagus nerve)
        +Narrow Hiatus sutures in crura
        
        Partial funduplications Indications:
        
        Heller Myotomy
        
        Motility problems
        
        Esophageal atresia (Stomach lengthening problems)
        
        Boix-Ochoa pretende restaurar las relaciones anatómicas y las características fisiológicas normales:
        
        Descenso 5 cm de esófago intratorácico al abdomen.
        
        Cierre de pilares y sutura de la membrana frenoesofágica al extremo proximal del esófago descendido.
        
        Agudización del ángulo de Hiss mediante dos hileras de puntos entre el fundus y el esófago creando de esta forma, además, una funduplicatura anterior.
        
        Sutura del margen superior del fondo al diafragma izquierdo y finalmente para mantener esófago y estómago en esta posición anclaje de la curvatura menor al recto derecho con dos puntos de seda
        
        Initial operative management:
        
        Infant cannot swallow and requires tube feelings
        
        Respiratory disease
        
        ATLT and GRE
        
        Barret Esophagitis
        
        Esophageal strictures
        
        Hiatal hernia
        
        Indications
        
        Rossetti. 360 anterior funduplications s cutting short gastric vessels.
        
        Stretta procedure
        
        Esophagus reconstruction with the Stretta® device uses low-frequency heat to reshape the ring of muscles in your lower esophagus (lower esophageal sphincter)
        
        Restores natural antireflux barrier
        
        Failed medical management
        Failure to thrive
        Respiratory symptoms
        Pain and esophagitis
        
        Medical management
      - Diagnosis
        
        Upper GI series
        
        Morphology
        Exclude HPS and malrotation
        Visualize GE junction
        Demonstration of hiatal hernia
        Assess angle of His
        Course of esophageal peristalsis
        
        24 pH monitoring
        
        pH drops < 4 or at least 15seg duration
        
        Time required to increase pH to 4 (reflux clearance)
        
        Number of reflux episodes c clearance more than 5 min
        
        Longest reflux
        
        REFLUX INDEX
        
        % of time pH < 4 in 24 hrs.
        Children threshold 4%
        Infants 3%
        
        Boyle's Criteria
        
        Multichannel probes measure pH in esophagus and stomach
        
        24 pH + multiple intraluminal impedance
        
        Acid and alkaline reflux
        Movement of
        
        Manometry
        
        Endoscopy
        
        Los Angeles Classification
    - - Treatment
        
        Medical
        
        Ca channel blockers
        Forceful dilatations
        Botox
        
        Surgical
        
        Heller myotomy
        
        Esophagomyotomy
        Muscularis propia
        4-6 cm dissection proximal
        2-3 cm distal
        Anti reflux procedure
        Partial funduplication (Thal 270, Dor 180) Toupet 270)
        
        POEM
        Peroral endoscopic myotomy
        Submucosal plane
      - IRP Integrated relaxation pressure
      - Definition:
        
        Chronic esophageal motility
      - Etiology
        
        Asociated with varios syndroms
        Down
        Allgrove
        Adrenal insufficieny
      - Pathophysiology
        
        Selective loss of neurons
      - Symptoms
        
        Infants:
        Regurgitation
        Asphyxia
        Pneumonia
        Failure to thrive
      - Diagnosis
        
        HRM
        Achalasia I
        Achalasia II
        Achalasia III
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