GI- Surgical Aspects of Esophageal Disease
Type/Location Cause Symptoms Diagnosis
HIATAL HERNIA
Type I- Sliding -Type I are more common -LES becomes incompetent and -many pts have no symptoms
than type to by 100:1 gastric juice reflux produces a -can cause a burning epigastric or -weight loss is a feature die to
-predominantly in women chemical burn in the esophagus substernal pain/tightness
who have been pregnant -degree of mucosal injury is due to -can be confused with MI, but
-men and women due to ↑ duration of acid contact and NOT usually pain does not radiate
intra-abdominal P a disease of hyperacidity -continued inflammation of the
-Type I hiatal hernias are distal esophagus may lead to:
often in overweight pts 1. mucosal erosion
2. unlceration
3. scarring
4. stricutre
-other presentations:
3. lump or feeling that food is
stuck beneath the xiphoid
2. worse when the patient is
supine or leaning over
3. antacid therapy frequently
improves the symptoms
4. alcohol, aspirin, tobacco,
and caffeine exacerbate sxs
5. late dysphagia & vomiting
usually suggest strictures
Type II- -generally show no symptoms until
Para-Esophageal they incarcerate and become
ischemic
-symptoms present include:
1. dysphagia
2. bleeding
3. occasional resp. distress
MOTILITY
DISORDER
Achalasia -failure of high-P zone -painless dysphagia
(LES) sphincter to relax -progressive dilation of the
-not due to spasm proximal esophagus
-regurg. of undigested food and
spitting up foul smelling
secretions on leaning forward
-weight loss
-aspiration pneumonia
Treatment & Recurrence
-suspected based on pt hx
distal esophageal stricture)
-hh’s and reflux esophagitis can be -do not eat/drink within
confirmed by fluoroscopy during a several hrs of sleeping
barium swallow
-esophagogastric endoscopy and
biopsy of inflamed esophagus
-manometry may show a loss of the -regular use of antacids to
lower esophageal high pressure
area
-1st confirmed
roentgeno-graphically by contrast
studies (“bird beak” appearance)
-dilation of proximal esophagus &
poss. diverticula at any level
-endoscopy (must be careful to
avoid diverticular perforations)
-esophageal manometry
-avoid gastric stimulants
-eliminate tight garments that
↑ intra-abdominal P
-sleep with the head of the bed
elevated at least 6in
-weight loss in obese pts
provide steady protection
-H blockers (increase the pH
of the gastric juice reflux)
-metoclopramide (may be
helpful when poor gastric
emptying is a symptom)
*1/3 of pts don’t respond to
medical tx and ½ of those
who respond will relapse and
require surgery
-surgery: correct anatomic
defect and prevent reflux
(reconstruction of a valve)
*complications of surgery:
1. dysphagia
2. gas-bloat syndrome:
inability to belch/vomit
3. disruption of the repair
(recurrent symptoms)
4. intra-abd infection
5. esophageal perforation
6. splenic injury
-medical tx has generally not
been helpful
-invasive endoscopy (forceful
dilation)
-esophageal myotomy
(surgical transection of m)
GI- Surgical Aspects of Esophageal Disease
Diverticulum -2nd most common of the -distal 1/3 of esophagus: -pulsion diverticula complain of: -pulsion: excision of the
-Pulsion esoph. motility disorders esophagogastric jxn problem due 1. regurgitation of recently diverticula and myotomy of
(Cervical/Zenker’s) -either pulsion or traction to chronic stricture from: swallowed food or pills the cricopharyngeal m.
-Traction depending on the mech that 1. acid reflux 2. choking *excision should always be
causes development 2. anti-reflux surgery 3. putrid breath odor accompanied by correction of
-pulsion diverticula are 3. achalasia underlying path process
related to dysfunction of
the cricopharyngeal m. -middle 1/3: almost always traction -traction: asymptomatic -traction: don’t need tx
(not related to an intrinsic
abnormality in esoph. motility),
caused by:
1. mediastinal inflammation
(inflam. nodal dis. from TB)
2. histoplasmosis (results in
scar formationcontracture
 traction on esophagus)
NEOPLASMS
Benign -exceedingly rare -leiomyoma: grow progressively -leiomyoma: indent the lumen of
-Leiomyoma -leiomyomas are the most and cause dysphagia the esoph. on contrast study
common intramural tumors
(potential for malignant
degeneration is low)
Malignant -usually arises from -commonly occurs in black men in -symptoms have insidious onset, -barium contrast of the esoph. -very poor prognosis (both)
-Squamous cell c squamous epithelium association with alcohol and/or precluding early diagnosis and the *apple core lesion is -upper esophageal cancer:
-Adenocarcinoma tobacco abuse opportunity for effective tx patho-gnomonic of esoph radiotherapy is the 1˚ tx
-in other parts of the world the -as the tumor enlarges progressive carcinoma (usually requires extirpation
etiology has been related to: dysphagia becomes the -endoscopy and biopsy of lesion of esoph. en bloc w/the
1. diet predominant symptom -CT of chest and upper abdomen is larynx, permanent
2. vitamin deficiency -other symptoms: used to assess the extent of tumor tracheostomy, and restoration
3. poor oral hygiene 1. pain involvement (important to stage of swallowing- palliation)
4. surgical procedures 2. weight loss the disease) -middle 1/3: tx by a staged
5. # of premalignancies 3. difficulty swallowing procedure w/total thoracic
(burns, barrett esophagitis, 4. acquired tracheaesophageal esophagectomy & bypass
radiation, P-V syndrome, fistula (due to erosion of the -lower 1/3: esophagogastric
and esophageal diverticula) tumor in trachea/bronchus) resection & end-to-end
~10% of pts with Barrett’s develop 5. frequent pneumonia (due to anastomosis in mid chest
adenocarcinoma recurrent aspiration)
DIAPHRAGMATIC
HERNIA
Bochdalek
Larrey
TRAUMATIC
DISORDERS
Traumatic Rupture of
GI- Surgical Aspects of Esophageal Disease
the Diaphragm
Esophageal -instrumentation by endoscopic
Perforation and/or biopsy
-blind nasogastric tubes
-instuments designed for dilation of 3. mediastinal sepsis
strictures
-Sengstaken-Blakemore tubes
(balloon dilation for achalasia)
-Boerhaave’s syndrome
(spontaneous perforation
secondary to forceful vomiting)
Ingestion of Casutic *medical emergency -alkaline containing products
Materials (drano, liquid plummer, etc.)
-corrosive gastritis: due acetic acid
or hydrochloric acid
-sxs of Boerhaave’s syndrome: -tx requires aggressive surgical
1. draumatic or occult intervention
2. profound shock
4. severe chest or abd pain
5. hypotension
6. diaphoresis
7. nausea/vomiting
-inspect mouth to assess injury -neutralization and induced
emesis not recommended
-perform endoscopy, airway
maintenance, and patency of
the esophagus
-NO steroids