LMCC Review in Thoracic Surgery April 2010 Dysphagia GERD and Hiatus hernia Chest trauma Massive hemoptysis Pneumothorax Empyema

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  • LMCC Review in Thoracic Surgery April 2010DysphagiaGERD and Hiatus herniaChest traumaMassive hemoptysisPneumothoraxEmpyema

  • A barium swallow was performed on an ELDERLY patient who had difficulty in swallowingWhat is the diagnosis?What are the complications of this condition?Is treatment necessary?What treatment is possible ?

  • Dysphagia Zenkers Diverticulum WHAT IS IT?Pharyngo-esophageal diverticulumFalse pulsion diverticulum containing mucosa and submucosaOccurs in the neck just above the UES at the pharyngoesophageal junction through Killians triangle

  • Develops on posterior wall of pharynx between upper and lower divisions of inferior constrictor muscleUES

  • Zenkers DiverticulumIn most cases the initiating cause is unknownIn some cases the cause is GERD related UES spasmACQUIRED 80% occur in age >50 yrsMost common esophageal diverticulum

    WHAT ARE THE SYMPTOMS AND SIGNS?Intermittent cervical dysphagiaGurgling noises in the neck on drinking liquidsFood regurgitationFoul breathLeft neck swellingSpells of choking

  • Zenkers DiverticulumHOW IS THE DIAGNOSIS MADE?

    Barium Swallow

    IS IT SERIOUS?Life-threatening due to acute aspiration pneumonia, lung abscess and empyemaDisability due to recurrent aspiration pneumonia, fibrosis, bronchiectasisTotal dysphagia can occur with large diverticulum distending with retained food causing extrinsic compression

  • What is the treatment? NEED AN OPERATION1. Cricopharyngeal myotomy in all the cases2. Management of diverticulum depends on sizeSmall < 3 cm: no need for excisionLarge > 3 cm: add diverticulectomy

    Concomitant Symptomatic GERDShould be managed first - otherwise risk free aspiration after operation for diverticulumReason: Reflux is due to incompetent LES. Operation for Zenkers diverticulum will make UES hypotensive

  • A 35-year-old man with slowly worsening difficulty swallowing had barium study performed1. What is demonstrated in this barium swallow?2. What are the essential clinical features?3. What is necessary to confirm diagnosis?4. What treatment would you suggest?

  • Dysphagia - Achalasia WHAT IS IT?Esophageal motility disorder characterized by 1.Absence of peristalsis in the body of the esophagus 2.Failure of or incomplete relaxation of LES is response to swallowing, 3. Higher than normal resting LES pressure

  • Achalasia WHAT IS THE CAUSE?

    NA cause is unknown, viral infection, autoimmuneSA Chagas disease due to parasite Trypanosoma CruziFinding: degeneration of ganglion cells in Auerbachs plexus

    WHAT ARE THE SYMPTOMS?Dysphagia for both solids and liquids; worse with liquidsRetrosternal burning discomfort due to food stasis and retention esophagitisNocturnal regurgitation of food and choking episodes aspiration

  • Esophageal Manometry confirms the diagnosisLES does not relax during swallowAbsence of peristalsis

  • Achalasia: Investigations and Results

  • Diagnosis of AchalasiaSuspect diagnosis: from symptoms Support diagnosis: from esophagogram see Birds Beak deformityConfirm diagnosis: from UGI Endoscopy and Manometry

  • Achalasia and Epiphrenic DiverticulumAlways suspect underlying cause for epiphrenic diverticulumThe cause must be treated as well

  • Complications of AchalasiaESOPHAGUSMalnutritionProgressive dilatation Retention esophagitisEpiphrenic diverticulumEsophageal cancer: squamous (due to retention esophagitis) adenocarcinoma ( due to post treatment reflux Barretts epithelium) RESPIRATORYAspiration pneumonia, empyema, lung abscess, fibrosis, bronchiectasisDyspnea due to extrinsic tracheal compression PSYCHOSOCIALUnable to eat in publicwithdrawn

  • What is the treatment for Achalasia?Chronic condition, no cure for itAim of Treatment: relieve distal esophageal functional obstructionChoices of treatment:Pneumatic Balloon dilatation, initial success rate of 80% decreases to 50% at 10 years; esophageal perforation risk of 5%Intra-sphincteric injection of Botox, symptomatic relief of 60% decreases to 30% at 2.5 yearsDistal esophagomyotomy and partial fundoplication gives the best sustained result of 90%, postoperative reflux is about 15% over time

  • Distal Esophago-Myotomy and Partial Fundoplication

  • Distal Esophageal Spasm

  • Distal Esophageal SpasmThe lower part of the esophagus (smooth muscle) of patients with diffuse esophageal spasm is simultaneously and firmly contracted for an abnormally long time

    Severe pain, dysphagia, and presence of esophageal diverticulae

    TreatmentReassurance in most casesSurgical treatment cannot correct the functional disorderLong Esophagomyotomy to lower amplitude of waves and resting pressure; add Partial Fundoplication

  • Distal Esophageal Spasm

  • Nutcracker esophagus

    High Amplitude, Peristaltic Esophageal Contractions> 180 mmHg amplitudeLong duration contractions > 6 secLES is normal

    TreatmentReassurance in most casesMust exclude myocardial ischemia Long Esophagomyotomy in selected cases; add Partial Fundoplication

  • Nutcracker Esophagus

  • Gastroesophageal Reflux Disorder WHAT IS IT?Frequent retrograde flow of gastric contents across the GE junction into the esophagus

    WHAT IS THE REASON?Loss of barrier function of the LES, either continuous or intermittent WHAT ARE THE TWO TYPES OF REFLUX?PhysiologicalPathological GERD

    REFLUXATEAcid or Alkaline refluxHCL, Pepsin, Bile, Bile salts

  • What are the properties of LES?Major barrier to reflux HIGH PRESSURE ZONEPhysiological sphincterLocated in the last 2 to 4 cm of esophagusNormal resting tone 15 to 30 mm. HgRelaxation is coordinated with primary peristalsisLES pressure is decreased by estrogen, progesterone, nitroglycerine, calcium channel blocker, cigarette smoking, alcohol, fat rich meals, gastric distension, coffee, chocolates, vagotomy, distal esophagomyotomy

  • Lower esophageal sphincter has become incompetent in GERDWHAT ARE THE CAUSES OF PATHOLOGIC GERD?Idiopathic - majorityAfter pneumatic dilatation or esophagomyotomy for AchalasiaSclerodermaFixed large hiatus herniaGastric outlet obstructionProlonged nasogastric tube insertion

    WHAT ARE THE TYPICAL SYMPTOMS?Unpleasant and intense substernal burning sensationSubsternal chest painPostural and/or postprandial regurgitationWater brashFlatulenceIntermittent difficulty with swallowing

  • Complications of Pathologic Gastroesophageal Reflux DisorderESOPHAGUS - reflux esophagitis: inflammation, erosion and ulceration chronic blood loss and iron deficiency anemia, fibrosis and peptic stricture, Barretts epithelium dysplasia adenocarcinomaUES SPASM Zenkers diverticulumMOUTH - teeth decay and loss of enamelPROXIMAL AIRWAY -laryngitis, wheezing, coughLUNGS - aspiration pneumonia lung abscess, pulmonary fibrosis, bronchiectasis, empyema

  • Reflux and Esophageal Damage

  • How is the diagnosis of GERD made?Barium swallow and UGI series radiologic reflux, hiatus hernia, esophageal stricture, aspiration, spasm in UESUpper GI endoscopy esophagitis (erythema, erosions, ulcerations, stricture formation), columnar-lined esophagus Esophageal manometry decreased LES, ineffective esophageal peristalsis24-hour esophageal pH monitoringMost sensitive test for acid reflux: number of reflux episodes, duration of reflux, upright vs. supine

  • What is the treatment for GERD?FIRST MEDICAL THERAPYDietary modificationSmall meals, avoid eating for 2 hrs before going to bedElevate head of the bedAbstain from coffee, alcohol, trigger foodsDrugs: Antacids, PPI, H2- blockers

    SURGICAL THERAPY IS BY FUNDOPLICATIONWhen GERD is refractory to optimal medical therapy given for a minimum of 6 monthsWhen GERD is associated with complications of hiatus hernia, complications in the airway

  • An elderly patient in the ER complaining of central chest pain radiating into left shoulder, retching, and coffee ground emesis. Barium study from 12 months ago for similar complaint is shown

    What condition is shown?How does it affect the patient?What serious problem can occur?

  • Complications of Hiatus Hernia 1. Incarceration strangulation ischemic perforation death2. Anemia chronic blood loss due to mucosal congestion3. Dyspnea large hernia4. Cardiac Arrhythmias extrinsic pressure 5. Volvulus obstruction 6. Perforation7. Massive Bleeding

  • Type IType IIType III

  • Type IV hiatus herniaIntrathoracic stomach with risk of volvulus, associated herniationof transverse colon, small bowel

  • Management of Hiatus Hernia

  • A barium study is finally given to a patient whose complaint for difficulty swallowing was for ignored for 5 months What are the clinical features of this condition?What is the differential diagnosis?What investigations should be undertaken?What treatments are available?

  • Esophageal CancerWHAT ARE THE TWO MAIN CELL TYPES?AdenocarcinomaSquamous cell carcinoma

    WHAT IS THE MOST COMMON HISTOLOGY?Worldwide: squamous cell carcinoma 95%Western world: adenocarcinoma

  • Squamous Cell Cancer what are the etiological factors? Strong association with excess cigarette smoking and alcohol consumptionThree dietary factors are high intake of nitrosamines (food preservatives), low intake of both vitamin A and nicotinic acid, and chronic iron deficiencyLong standing achalasia, accidental caustic ingestionTylosis palmaris et plantarisCeliac diseaseSilica in wheat Previous radiation therapy to the mediastinum

  • Adenocarcinoma what is the cause?Incidence of adenocarcinoma