Q 13 Not true about the etiology of Achalasia cardia
a) It is a familial disease
b) Allgrove's disease is a rare condition associated with achalasia
c) HSV-1, HSV-2, Polio virus
d) Assciation with class II MHC antigen
Q14. True about the role of medical therapy in Barrett's Esophagus
a) There is direct evidence that medical treatment prevents development of Barrett's esophagus in patients with GERD
b) The end point of treatment in Barrett's esophagus is control of reflux
c) COX 2 inhibitors have a role in prevention of Adenocarcinoma in patients with Barrett's Esophagus
d)
Q15. One of the following is not a hallmark of end stage Achalasia Cardia
a) Severe dysphagia or regurgitation
b) Hypertensive Lower esophageal sphincter tone
c) Mega esophagus or sigmoid esophagus
d) Reduction of ganglion cells with fibrosis of Myenteric plexus
Answers
11) d
For tumors in the upper thoracic esophagus, obtaining a sufficient proximal resection margin dictates an anastomosis placed in the neck.
McKeown approach--- In this procedure a right thoracotomy is first carried out to mobilize the thoracic esophagus together with lymphadenectomy, and this is followed by abdominal and neck incisions for the mobilization of the esophageal substitute placing the anastomosis in the neck.
For middle 1/3rd thoracic esophageal tumors Lewis Tanner approach is used. The operation begins with an abdominal phase, in which the stomach is prepared; a right thoracotomy and resection of the tumor together with lymphadenectomy follows this. The stomach is then brought up into the chest for anastomosis with the proximal esophagus at the apex of the pleural cavity.
Isolated Left Thoracotomy and not a right thoractomy maybe an option. Through a left thoracotomy and incision in the diaphragm, both the esophagus and stomach can be mobilized and resection carried out, and the stomach delivered into the chest for anastomosis, either below or above the aortic arch.
A transhiatal approach, whereby the thoracic part of the esophagus is mobilized by blunt and often blind dissection through the enlarged esophageal hiatus, and the mobilized stomach is then delivered to the neck and anastomosed to the cervical esophagus, is advocated especially for distal esophageal tumor or early-stage tumors of other parts of the esophagus.
Ref Maingot 11th edition
12. d
Achalasia cardia is a motor disorder of the esophagus characterised by difficulty in swallowing. Manometry is the gold standard for diagnosing it.
manometric findings include
Hypertonic LES (lower esophageal sphincter) with pressure more than 35 mm Hg. Normal is 18-24
13. a
Familial Achalasia constitues 1% of all cases of Achalasia. Allgrove's disease or the AAA syndrome includes, Achalasia, Alacrima and ACTH (Adrenocortico trophic Hormone ) resistant adrenal insufficiency.
The etiology and pathogenesis of Achalasia Cardia s not known fully and various hypothesis have been put forward:-
Pathology includes
Inflamation and selective losss of inhibitory myenteric neurons in the Auerbech's plexus. Auerbech's plexus normally secretes Nitric Oxide and VIP.
As a result of this there is faiure of lower esophageal sphincter to relax leading to aperistalsis and dilatation of esophagus
Although herpes simplex virus type 1 (HSV-1), HSV-2, polio, human papillomavirus, and measles have all been proposed as candidates in initiating the immune response, no infectious pathogens have been convincingly isolated from tissue samples either by electron microscopy or by polymerase chain reaction amplification.
Certain class II major histocompatibility complex (MHC) antigens such as HLA-DQw1, HLA-DQB1, and HLA-DRB1 have been also associated with achalasia
Chagas disease of esophagus caused by Trypanosoma cruzi has similarities in clinical presentation, manometry and radiology to achalasia however subtle differences are there
1. Chagas disease is having denervation of both excitatory and inhibitory myenteric neurons
2. LES (Lower Esophageal Sphincter) hypotonic
14 c
There is Indirect evidence that medical treatment prevents Barrett 's esophagus
1. Long duration of GERD Symptoms lead to barrett Odds ratio is 6.4 after 10 years of symptoms as compared to symptoms of less than 1 day
2. Prevalence of Barrett in general population is between 5-15%
The end point of medication is control of symptoms like heartburn and regurgitation. Reflux is not controlled.
Another thing which can be improved is the elevation of intraesophagel ph
COX 2 inhibitors are used in chemoprevention
SCHCKELFORD's Surgery Alimental CAnal 6th edition
15) b
Traditionally treatment of end stage achalasia is esophageal resection.
Hypertensive LES is not a end satge achalasia and is seen is 30-40% patients of achalasia
All others signify end satge achalasia
