Esophageal emergencies

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Esophageal emergencies
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esophagus

• 20-25 cm muscular tube posterior and lateral to
  trachea
• Upper third is striated, then smooth muscle
• Three constrictions in adults
• C6 (cricopharyngeous muscle) resting pressure
  here at UES is 100 mm Hg
• T4 (aortic arch)
• T11 (GE junction) resting pressure at LES is 25
  mmHG

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Transfer Dysphagia (Oropharyngeal) Transport Dysphagia (Esophageal)
Discoordination in transferring bolus from pharynx to esophagus Improper transfer of the bolus from the upper esophagus into the stomach
Swallowing symptomsgagging, coughing, nasal regurgitation, inability to initiate swallow, need for repeated swallows Swallowing symptomsfood "sticking," retrosternal fullness with solids (and eventually liquids), possibly odynophagia
Risk of aspiration present Risk of aspiration present, generally less pronounced than in transfer dysphagia
Long termweight loss, malnutrition, chronic bronchitis, asthma, multiple episodes of pneumonia Long termmalnutrition, dehydration, weight loss, systemic effects of cancer
Neuromuscular disease (80)cerebrovascular accident, polymyositis and dermatomyositis, scleroderma, myasthenia gravis, tetanus, Parkinson's disease, botulism, lead poisoning, thyroid disease Obstructive disease (85)foreign body, carcinoma, webs, strictures, thyroid enlargement, diverticulum, congenital or acquired large-vessel abnormalities
Localized diseasepharyngitis aphthous ulcers candidal infection peritonsillar and retropharyngeal abscesses carcinoma of tongue, pharynx, larynx Zenker diverticulum cricopharyngeal bar cervical osteophytes Motor disorderachalasia, peristaltic dysfunction (nutcracker esophagus), diffuse esophageal spasm, scleroderma
Inadequate lubricationscleroderma Inflammatory disease
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dysphagia

• Is there odynophagia?
• Is it just solids (mechanical or obstructive) or
  liquids and solids (motility disorders)
• Is there a foreign body sensation?

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Structural and obstructive causes

• Neoplasms
• Esophageal stricutre
• Schatzkis ring
• intermittent dysphagia with solids
• Esophageal webs
• Zenkers diverticulum

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Motor lesions

• Neuromuscular disorders
• CVA
• Polymyositis and dermatomyositis
• Achalasia
• Impaired relaxation of the lower sphincter
• Impaired esophageal peristalsis
• Diffuse esophageal spasm

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Causes of GERD
Decreased Pressure of Lower Esophageal Sphincter Decreased Esophageal Motility Prolonged Gastric Emptying
High-fat food Achalasia Medicines (anticholinergics)
Nicotine Scleroderma Outlet obstruction
Ethanol Presbyesophagus Diabetic gastroparesis
Caffeine Diabetes mellitus High-fat food
Medicines (nitrates, calcium channel blockers, anticholinergics, progesterone, estrogen)
Pregnancy
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treatment

• H2 blockers
• PPIs
• Avoiding caffeine, alcohol, smoking, fatty foods
  and eating within 3 hours of bed.

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Cause of Perforation Description
Iatrogenic Intraluminal procedures
Iatrogenic Endoscopy
Iatrogenic Dilatation
Iatrogenic Variceal therapy
Iatrogenic Gastric intubation
Iatrogenic Intraoperative injury
Boerhaave syndrome "Spontaneous," usually associated with transient increase in intraesophageal pressure
Trauma Penetrating
Trauma Blunt (rare)
Trauma Caustic ingestion
Foreign body Includes pill-related injury
Infection Rare
Tumor May be intrinsic or extrinsic cancer
Aortic pathology Aneurysm
Aortic pathology Aberrant right subclavian artery
Miscellaneous Barrett esophagus
Miscellaneous Zollinger-Ellison syndrome
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Esophageal perforations

• Most spontaneous perforations occur through the
  left posterolateral wall of the distal esophagus
• Pain is acute, severe, unrelenting, and diffuse
• CXR and chest CT
• Hammans crunch mediastinal air moved by the
  beating heart.

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Esophageal perforation

• Boerhaave syndrome
• full-thickness perforation after a sudden rise in
  intraesophageal pressure
• Sudden, forceful emesis, commonly seen after
  alcohol
• Trauma
• Penetrating gt blunt
• Foreign body ingestion

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Esophageal foreign body

• Children usually proximal locations
• Adults usually distal impactions
• If FB makes it past pylorus, most will pass
• Endoscopy for diagnosis/treatment
• Can try glucagon (smooth muscle relaxer)

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Special situations

• Food impaction
• Coin ingestion
• Can try foley catheter removal technique
• Button battery
• Sharp objects
• Need removed is still in stomach or duodenum
• Narcotics
• Packers cannot undergo endoscopy due to risk of
  perforation, which could be fatal

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references

• Tintinalli, Ch. 80