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Esophageal Emergencies. Tintinalli chapter 75. Anatomy/Physiology. Muscular tube 20-25 cm long Majority in mediastinum, post/lat to trachea Outer longitudinal & inner circular muscles Upper 1/3 striated muscle, lower half all smooth muscle

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esophageal emergencies

Esophageal Emergencies

Tintinalli chapter 75

anatomy physiology
Anatomy/Physiology
  • Muscular tube 20-25 cm long
  • Majority in mediastinum, post/lat to trachea
  • Outer longitudinal & inner circular muscles
  • Upper 1/3 striated muscle, lower half all smooth muscle
  • Two sphincters; UES cricopharyngeus muscle, LES lower 1-2 cm of esophagus
anatomy physiology3
Anatomy/Physiology
  • Three anatomic constrictions:
    • Cricopharyneus
    • Aortic arch/left mainstem bronchus
    • Gastroesophageal junction
anatomy physiology4
Anatomy/Physiology
  • Innervation mirrors cardiac, a convergence of somatic and visceral stimuli; cardiac and esophageal chest pain similar.
  • Blood supply; inferior thyroid artery, branches from thoracic aorta, branches from left gastric and inferior phrenic arteries.
anatomy physiology5
Anatomy/Physiology
  • Venous; submucosal plexus drains into plexus outside of esophagus
  • Outer plexus to :
    • Inferior thyroid
    • Azygos
    • Coronary
    • Gastric venous system
dysphagia
Dysphagia
  • Defined; difficulty swallowing
    • Majority will have organic process
  • Two types:
    • Transfer dysphagia; early in swallowing process
    • Transport dysphagia; impaired movement down esophagus through LES, perceived later in process, feeling of food “getting struck”
dysphagia7
Dysphagia
  • Transfer:
    • 80 % neuromuscular; CVA,scleroderma, myasthenia gravis, parkinsons, lead poisoning, thyroid disease
    • Risk of aspiration
    • Discoordinated food bolus transfer to esophagus
    • Symptoms; gagging, coughing, nasal regurg.
dysphagia8
Dysphagia
  • Transport:
    • 85 % obstructive disease; foreign body, carcinoma, webs, strictures, thyroid enlargement, vessel abnormalities, diverticuli
    • Less aspiration risk
    • Improper transfer from esophagus to stomach
    • symptoms; food sticking, retrosternal fullness, odonophagia
dysphagia9
Dysphagia
  • History
    • Acute vs. chronic
    • Solids vs. liquids
    • Intermitent or progressive
    • Feeling of “something stuck”
  • Physical exam; focus on head and neck and neuro, helpful to watch pt swallow sip of water. Physical exam often normal.
dysphagia10
Dysphagia
  • ED work-up: AP & lat neck x-rays. CXR.
    • Diagnosis often made outside ED. Barium swallow usually first test. Ultimately best worked up with video-esophagography.
structural obstructive causes
Structural/Obstructive causes
  • Neoplasm: common cause of both types.
    • 95 % squamous cell
    • Male : female , 3:1
    • Fast progression from solids to liquid dysphagia
    • Pts >40 yo with dysphagia assume neoplasm. Need expedient work up to rule out malignancy
structural obstructive causes12
Structural/Obstructive causes
  • Esophageal stricture: results from scaring from GERD
    • Generally distal esophagus, may interfere with LES
    • Symptoms develop over years, usually only solids
    • Must rule out malignancy
structural obstructive causes13
Structural/Obstructive causes
  • Schatzki ring: most common cause of intermittent dysphagia with solids
    • Fibrous stricture near GE junction in 15 % of population
    • Pts frequently present with food impacted after poorly chewed meat
    • Treatment is dilatation
structural obstructive causes14
Structural/Obstructive causes
  • Esophageal webs: thin structures of mucosa and submucosa
    • Often mid or proximal esophagus
    • Congenital or acquired
    • Plummer-Vinson syndrome, with iron deficiency anemia
    • Tx is dilatation
structural obstructive causes15
Structural/Obstructive causes
  • Diverticula: can be found throughout esaphagus
    • Zenker; progressive outpouching of pharyngeal mucosa above UES. d/t increased pressure when swallowing.
    • Usually seen after age 50
    • Halitosis
    • Feeling of a neck mass
motor lesion causes
Motor lesion causes
  • Neuromuscular disorders; misdirection of food bolus,
    • liquid > solids.
    • Symptoms intermittent.
    • CVA #1 cause
    • Polymyositis/Dermatomyositis #2 causes
motor lesion causes17
Motor lesion causes
  • Achalasia; dysmotility disorder,
    • unknown cause.
    • Impaired LES relaxation,
    • absence of esophageal peristalsis.
    • Patients 20-40 yo.
    • Symptoms; regurgitation, weight loss, odonophagia
motor lesion causes18
Motor lesion causes
  • Diffuse esophageal spasm;
    • dysphagia intermittent and does not progress.
    • Tx =control any reflux present
chest pain of esophageal origin
Chest Pain of Esophageal Origin
  • Differentiating esophageal from ischemic pain very difficult. Often not done in ED.
  • Pain at night, spontaneous onset, regurgitation, odynophagia, dysphagia, meal induced= can be seen in both
  • High admission rate of chest pain found not to be cardiac is appropiate.
  • 20-60% of chest pain is esophageal and normal coronary arteries.
slide20
GERD
  • 25% of adults
  • Weak or transient relaxing of LES is primary cause
  • Other causes= high fat diet, nicotine, ETOH, caffeine, pregnancy, meds(nitrates, Ca channel blockers, estrogen, progesterone)
  • Heartburn is classic symptom
slide21
GERD
  • Other symptoms= odynophagia,dysphagia, acid regurgitation, hyperslivation. Asthma exac, dental erosions, frequent URI’s, vocal cord ulcers, laryngitis, hoarseness, chronic cough
  • Postural changes in pain= increasing intraabdominal pressure can increase pain
  • Relief with antacids
slide22
GERD
  • Complications= strictures, esophageal inflammation, Barrett esophagus (columnar epith replaces strat squamous) premalignant.
  • Pain; squeezing, pressusre-like, onset with exertion, diaphoresis, pallor, nausea, vomiting, radiation to arms and neck, shoulder and back. All similar to cardiac pain
slide23
GERD
  • TX;
    • Avoid exacerbating agents
    • Elevate head of bed 30 degrees
    • Don’t eat 3 hours before going to bed
    • H2 blockers or PPI’s
esophagitis
Esophagitis
  • Inflammatory: can progress to ulceration, scarring, stricture
    • Reflux induced- aggressive tx. with acid suppression
    • Med induced-NSAIDs, KCL, doxy, clinamycin, tetracycline
  • Infectious: immunosuppression; AIDS
    • Candida #1, HSV, CMV, aphthous ulceration
    • Fungal, vericella, EBV.
esophageal motility disorders
Esophageal Motility Disorders
  • Chest pain, dull/achy, at rest, 5th decades, intermittent dysphagia
  • Esophageal dysmotility: excessive, uncoordinated contraction
  • Achalasia & diffuse es. spasm as above
  • Ineffective esophageal motility
  • Hypertensive LES
  • Nutcracker esophagus; high amplitude, long duration contractions LES, >180 mmHg
  • Tx with NTG, Ca channel blockers
esophageal perforation
Esophageal Perforation
  • Iatrogenic 75%
    • endoscopy #1 cause
  • Boerhaave syndrome 10-15%
    • ETOH
    • emesis
esophageal perforation27
Esophageal Perforation
  • Trauma 10%
    • Blunt rare
    • Penetrating wounds more common, often masked by more critical wounds in the area
  • FB ingestion; perforation usually at anatomic narrowings. d/t pressure necrosis(coin), penetrating from sharp object(pin), chemical irritant(battery)
esophageal perforation28
Esophageal Perforation
  • Esophageal contents to ;
  • Mediastinum-fulminant necrotizing mediastinitis and polymicrobial infection to shock
  • Pleural/peritoneal space- rapidly progressive infection/shock
  • Most spontaneous perfs through left post-lat wall in distal esophagus. Proximal perfs with instrumentation
esophageal perforation29
Esophageal Perforation
  • Pain- acute, severe, unrelenting, diffuse, chest neck and abdomen.
  • May radiate to back and shoulders
  • Exacerbated by swallowing
  • Dysphagia, dyspnea, hematemesis, cyanosis may all be present
  • Confused w/(MI, PE, ulcer, aortic catastrophe, acute abd.)= delays in dx.
esophageal perforation30
Esophageal Perforation
  • Physical; abd rigidity, hypotension, fever, tachycardia, tachypnea all common.
  • Cervical sub-q emphysema if cervical perf
  • Mediastinal emphysema takes longer
  • “Hammon crunch” air in mediastinum being moved by beating heart
  • Pleural effusion in 50% w/ intrathoracic perfs.
esophageal perforation31
Esophageal Perforation
  • CXR=suggestive
  • CT=confirms
  • Endoscopy= confirms
  • Pleural fluid aspirate= high amylase
esophageal perforation32
Esophageal Perforation
  • High mortality rate regardless of cause
    • Location, etiology, time until dx all affect outcome
  • Rapid aggressive mgt is key
    • Tx shock
    • Surgical consult
esophageal bleeding
Esophageal Bleeding
  • General approach:
  • UGIB= airway mgt., NG tube, gastric lavage, blood if needed, GI consult
  • 60% vericeal bleeds resolve w/ supportive care. 80% if bleed is not vericeal.
  • If continue to bleed= early endoscopy
  • Pharmacologic= somatostatin analogs
  • Balloon tamponade= last resort
esophageal bleeding34
Esophageal Bleeding
  • Varices:
  • Seen in chronic liver ds & portal HTN
  • 60% of pts with chronic liver ds.
    • 25-30% experience hemorrhage
  • Varices from ETOH abuse have higher risk of bleeding
    • 2/3 that bleed have recurrent hemorrhage
esophageal bleeding35
Esophageal Bleeding
  • Varices:
  • Endoscopy first line to control bleeding
  • Sclerotherapy and ligation are alternatives
  • Despite tx, mortality remains high
esophageal bleeding36
Esophageal Bleeding
  • Mallory-Weiss syndrome:
  • Arterial bleeding from longitudinal mucosal lacs. of distal esoph/prox stomach
  • 5-15% of UGIB
  • 4th – 6th decades
  • Acute onset of UGIB
  • Overall low relative incidence of surgical intervention or adverse outcomes is seen
esophageal bleeding37
Esophageal Bleeding
  • Mallory-Weiss syndrome:
  • Initial tx = supportive, most stop spontaneously
  • Ongoing bleeding= electrocoagulation, sclerotherapy, laser photocoagulation, angiographic embolization, surgery.
esophageal bleeding38
Esophageal Bleeding
  • Esophageal Cancer:
  • Heme-positive stools
  • Uncommon cause of significant UGIB or LGIB
swallowed foreign bodies

Swallowed Foreign Bodies

Tintinalli

Chapter 76

swallowed fb
Swallowed FB
  • Peds 80% of all cases
  • Prisoners, psych, edentulous adults
  • Adults=meat and bones
  • Peds = coins, toys, crayons, pen caps
  • Psych and prisoners = unlikely objects, spoons, razors
pathophysiology
Pathophysiology
  • Most pass spontaneously
  • 10-20% require some intervention
  • 1% surgical
  • Most are at “anatomic narrowings”
    • Peds: cricopharyngeal(C6) most common, thoracic inlet(T1), aortic arch(T4), tracheal bifurcation(T6), hiatal narrowing(T10-11)
pathophysiology42
Pathophysiology
  • Once object passes pylorus, usually passes out with stool.
  • Irregular or sharp edges may lodge anywhere though.
clinical presentation
Clinical Presentation
  • Objects in esophagus:
  • Anxiety, discomfort, retrosternal pain, retching, vomiting, dysphagia, choking, coughing.
  • In peds= refusal to eat, vomiting, gagging, choking, stridor, neck or throat pain, increased salivation, inability to swallow.
clinical presentation44
Clinical Presentation
  • Physical exam:
  • Nasopharynx, oropharynx, sub-q tissue for air.
  • Laryngoscopy (direct or indirect)
  • Objects warrenting endoscopy consult:
    • Sharp/elongated, multiple FB, button batteries, evidence of perf, child w/ coin at cricopharyngeous, airway compromise, FB for >24 hours
ed management
ED Management
  • General Care:
  • Expectant once FB past pylorus
  • If FB obstructs esoph, insert tube above FB to remove unswallowed material
  • Locate FB:
    • Standard x-ray
    • Endoscopy= locates and removes FB, procedure of choice
    • Esophagogram- consult endoscopist prior to contrast
ed management46
ED Management
  • Type of contrast:
  • Perf expected= water soluble contrast, Gastrografin
  • Aspiration is possible use Barium, Gastrografin is pulmonary irritant
  • Perf and aspiration possible: use nonionic contrast
ed management47
ED Management
  • Monitor FB progress w/ x-rays 2-4 hrs apart
  • Frequent abd exams for peritonitis should perf occcur
ed management48
ED Management
  • Food impaction:
  • Meat= time and sedation allow meat to pass. Do not allow in esoph >12 hrs
  • Endoscopy #1
  • Glucagon 1 mg IV, repeat 2 mg IV in 20 min, relaxes esoph smooth muscle
  • Nifedipine 10 mg sub lingual, reduces LES pressure
  • DO NOT use meat tenderizer d/t complications including perforation
ed management49
ED Management
  • Coin injestion: (usually children)
  • 35% are asymptomatic
  • Coins lie in frontal plane in esoph, = flat side visible on AP films
  • Coins in trachea in sagittal plane
  • Foley catheter removal if <24 hrs
    • Secondary to endoscopy
    • Protect airway first = ET tube
ed management50
ED Management
  • Button Battery:
  • True emergency, rapid action of alkaline on mucusa, burns in 4 hrs, perfs in 6hrs.
  • Lithium cells= bad outcomes
  • Mercury containing= get blood and urine mercury levels
ed management51
ED Management
  • Locate battery on x-ray
  • In esophagus get endoscopy
  • Past esophagus: asymptomatic don’t remove. Remove if not past pylorus > 48hrs
  • Most pass through body in 48-72 hrs
  • Pts with s/s of GI tract injury need surgical consult
ed management52
ED Management
  • Sharp Objects:
  • Longer than 5cm, wider than 2 cm rarely able to pass stomach.
  • Large objects(above) and extremely pointed (safety pins) must be removed prior to passing stomach. 15-35% will perf intestines.
ed management53
ED Management
  • Initial radiograph on all.
  • Symptomatic or sewing needle FB= surgical consult
  • Sharp object and asymptomatic= expectant w/ serial radiographs
    • Not passing stomach=water soluble contrast
    • First sign of perf or object not passing= surgical consult
ed management54
ED Management
  • Cocaine Ingestion:
  • Packet = condom, holds 5 grams
  • Rupture of one packet can be fatal
  • Surgery not endoscopy recommended.
  • If packet passing intact through intestinal system, may be able to wait and watch.
questions
Questions
  • 1. GERD symptoms include:
    • A)pressure pain
    • B)diaphoresis
    • C)nausea
    • D)pain radiation to arm/neck
    • E)all of the above
  • 2. common causes of Trasport dysphagia include all of the following except:
    • A)carcinoma
    • B)thyromegally
    • C)CVA
    • D)strictures
questions56
Questions
  • 3. Esophageal perforation is most commonly due to:
    • A)Iatrogenic
    • B)ETOH use
    • C)Boerhaave syndrome
    • D)blunt trauma
  • 4. Of the anatomic narrowings in children the most common spot for FB’s to lodge is:
    • A)cricopharyngus
    • B)aortic arch
    • C)tracheal bifurcation
    • D)hiatal narrowing
questions57
Questions
  • 5. Treatment for meat impaction includes all of the following except:
    • A) endoscopy
    • B)glucagon
    • C)Nifedipine
    • D)meat tenderizer
answers
Answers
  • 1. E
  • 2. C (CVA is a cause of transfer dysphagia)
  • 3. A
  • 4. A
  • 5. D