Motility Disorders
Anatomy
more motility
Diverticulum
Barrett's
200
Achalasia is caused by what?
- There is an irreversible loss of inhibitory ganglion in the esophageal myenteric plexus (Auerbach plexus). The cause of this selective neurodegeneration is unknown but is suspected to be autoimmune.
200
What are the layers of the esophagus?
Mucosa, submucosa, muscular propria
No Serosa
200
What are the expected manometry findings in patients with hypertensive LES
1. high basal LES pressure
2. complete LES relaxion
3. normal peristalsis
200
What causes a Zenker's diverticulum and is it a true or false pulsing diverticulum?
False
dysfunction of the superior esophageal sphincter muscles causing increased intraluminal pressure
200
What is Barrett's esophagus
intestinal metaplasia od the lower esophagus from squamous to columnar
400
Describe "bird's beak" appearance on esophagram and in what motility disorder you would expect to see this
Achalasia; dilated esophagus with narrowing to small LES
- Esophageal dilation
400
What is the bloody supply to the esophagus? Cervical, thoracic and abdominal
1. inferior thyroid artery
2. vessels directly off aorta
3. left gastric and inferior phrenic arteries
400
What are operative and nonoperative management options for hypertensive LES?
1. non operative - CCB, nitrates
2. Heller myotomy
400
After finding low grade dysplasia on a patient with Barrett's esophagus, what should be the next step in management?
Repeat EGD in 6 months
600
What manometric findings would you expect in achalasia?
1. high or normal LES basal pressure
2. incomplete relaxation of the LES
3. hypotonic or absent peristalsis
600
What is the most likely location for a Zenker's diverticulum to form?
Killian's triangle - triangular area located superior to the cricopharyngeus muscles and inferior to the inferior constrictor muscles
600
What are the expected manometry findings in patients with diffuse esophageal spasm?
1. normal LES pressure and relaxation
2. high amplitude, uncoordinated esophageal contractions
600
What is the management of a Zenker's diverticulum? surgical, endoscopic, size?
>3cm - endoscopic division of the upper esophageal sphincter
<3cm need open myotomy +/- diverticulectomy
600
What is the next step in management of a patient with high grade dysplasia (with known Barrett's) confirmed on biopsy?
1. Endoscopic mucosal resection
800
What are some nonoperative treatment choices for achalasia?
- Medications (nitrates or calcium channel blockers). Poor efficacy and a significant side-effect profile make these an undesirable choice for most patients.
- Botulinum toxin injections of the LES
- This can provide substantial symptom relief.
- Between 10% and 15% of patients have no response.
- Response is transient (weeks to months) and declines with each subsequent injection procedure.
- Pneumatic dilation
- This has less efficacy and durability than POEM or Heller myotomy.
- It may last months to years.
- The perforation rate is reported to be 1% to 5%.
800
What is the most common location of an iatrogenic esophageal perforation
cricopharyngeus
800
What are the manometry findings expected in someone with nutcracker syndrome?
1. normal LES pressures and relaxation
2. high amplitude, coordinated esophageal contractions
800
What kind of diverticulum is an epiphanic esophageal diverticula and what is its management?
pulsion diverticulum
diverticulectomy and treatment of underlying motility disorder - usually need Heller myotomy
800
What is the management of esophageal leiomyomas?
<5cm - endoscopic resection or enucleation
>5cm - surgical resection
1000
What is the ideal surgical management for achalasia?
Heller myotome with partial fundoplication
Extend your myotome 6cm onto the esophagus and 2cm onto the stomach.
1000
What are the surgical approaches for the different areas of the esophagus? (3)
1. proximal third - cervical incision along left SCM
2. Middle third - right posterolateral thoracotomy
3. distal third - left posterolateral thoracotomy
1000
What is the recommending surveillance interval of a patient with Barrett's?
annual EGD with biopsies
4 quadrant biopsies every 1-2cm of involved segment
if 2 consecutive years are negative for dysplasia can switch EGD to every 3 years