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Z - SURGERY
Esophagus
| Question | Answer |
|---|---|
| Boerhaave Syndrome | Spontaneous esophageal rupture |
| Is esophageal perforation a surgical emergency? | Yes |
| Spontaneous esophageal performation comprises what percentage of all causes of esophageal perforation? | 15%; most of the time, esophageal perforations are iatrogenic from a procedure |
| Acute onset of CP after vomitting | typical of Boerhaave Syndrome |
| Sx's of Boerhaave Syndrome (5) | 1. Acute onset of CP after vomiting, 2. shoulder pain, 3. dyspnea, 4. midepigastric pain; 5. pleural effusion (75%) |
| Signs of systemic infection (3) | tachycardia, fever, leukocytosis |
| Most spontaneous esophageal ruptures occur in the distal third of esophagus about GR jxn. What side pleural effusion more common? | L |
| In esophageal perforation - what is the timeline of CP? | immediate and persistent; most common presenting sx |
| In esophageal perforation - what is the timing of subQ emphysema? | 1h after perforation - may not be present wth lower esophageal perforation |
| In esophageal perforation - what is the timing of pleural effusion? | Can be immediate or after 6h; happens in 75% of cases; mostly on L |
| In esophageal perforation - when would you see fever and leukocytosis? What would it be from? | >4h from sepsis from mediastinitis |
| In esophageal perforation - what is the chance of death? | If dx <24h, 15%; if dx > 24h, >40% |
| In esophageal perforation - what is the best initial diagnostic test? | Water soluble contrast esophagogram - ID in 90% of cases |
| In esophageal perforation - What position should pt be in when getting esophagogram? | R lateral decubitus |
| What is the most common presenting sx of esophageal rupture? | CP |
| subcutaneous emphysema | air is present in the subcutaneous layer of the skin; characteristic crackling feel to the touch, like Rice Krispies;[2] crepitus. |
| Initial tx of esophageal perforation (4) | ABC's, IVF, abx, chest tube |
| Tx principles for spontaneous esophageal perforation (4) | 1. surgical drainage, 2. debridement, 3. repair, 4. diversion |
| What kind of surgery is done for spontaneous esophageal perforation? | chest thoracotomy (R posterolateral) --> exposure of tear, debridement, primary suture repair, reinforcement (with flap), drainage |
| What is the follow up for spontaneous esophageal perforation? | restudy with esophagogram in 1 week for presence of leak |
| achalasia | esophageal motility disorder: smooth muscle layer of esophagus loses normal peristalsis, & LES fails to relax properly in response to swallowing. Characterized by difficulty swallowing, regurgitation, and sometimes chest pain |
| pt w CP after vomiting, subQ emphysema on exam, and Lsided pleural effusion | spontaneous esophageal perforation |
| Where do most spontaneous esophageal ruptures occur? | Distal third of esophagus |
Created by:
christinapham
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