21 d Esophagectomy

There is a recent term Endoscopically suspected Esophageal metaplasia (ESEM) seen with white light high resolution endoscopy. Management is PPI and repeat evaluation after 6-12 months

Once Barrett's esophagus is diagnosed, the further management depends on weather its a low grade or high grade dysplasia.

No dysplasia and barrett's segment < 3 cm - Endoscopic surveillance 5 yearsNo dysplasia and barrett's segment > 3 cm - 3 year surveillance with four quadrant biopsy every 2 cm

Indefinite dysplasia - Biopsy repeat 3-6 months

Low grade dysplasia - 6-12 months  endoscopic surveillance

HIgh grade dysplasia/Early esophageal cancer-

Special cases

i) age younger than 30 years at the time of Barrett's diagnosis

ii) a family history of Barrett's esophagus or esophageal cancer, 

iii) a segment of circumferential Barrett's esophagus greater than 6 cm

Endoscopic ablative therapy can be considered

Dysplasia and Invasive carcinoma

1. No submucosal invasion - EMR followed by ablative management
2. T1b or more (submucosal invasion) -Esophagectomy

EMR, PDT and APC can be done for T1a lesion

22)  d

 Nutcracker esophagus is a hyper contractile disorder of the  esophagus in which there is excessive contractility of the esophagus. There are high amplitude peristaltic contractions in the body of esophagus.

It is the most common motility disorder of the esophagus.

It can occur in all age groups and is of equal distribution in both sex.

Nutcracker esophagus symptoms

1. Chest pain
2. Dysphagia
3. Painful deglutition (Odynophagia)

Acording to the Chicago classification 

 There is  subjective complaint of chest pain with at least one swallow showing a distal contractile integral greater than 8000 mm  Hg with single or multi­peaked contractions on HRM. The LES pressure is normal, and relaxation occurs with each wet swallow

Management

1. Avoid trigger inducing foods such as caffeine
2. Calcium channel blockers, Nitrates, Antispasmodics
3. Esophageal dilatation in some cases

23. c

Nissen fundoplication is only an abdominal procedure in which total fundoplication is done. it is a 360 degree wrap. It might have short term dysphagia but is durable in the long run. 

Gas bloat syndrome is a very common complication in which belching is not possible. If gas bloat is excessive and disabling conversion to a partial fundoplication is done.

24. d

The golden period of repair for esophagus perforation is 24-48 hours. after 48 hours there starts contamination of mediastinal structures with signs of systemic sepsis.

Primary repair principles -

With in 24-48 hours

Expose the defect clearly with myotomy above and below

Closure of mucosa, muscle and with pedicled flap if available

Esophagus diversion  principles      

 After mediastinal contamination        

MOre than 48 hours

 Esophagus resection

Associated diseases such as achalasia,  reflux strictures, malignancy     

Conservative      

Cameron criteria

1. Early diagnosis  intramural perforation
2. Transmural perforation of mediastinum or neck with free drainage back to the esophagus on esophagogram
3. Absence of any other esophagus disease
4. No symptoms/Sepsis     

Ref: Shackelford - 482

25 d) 

Oropharyngeal dysphagia is characterized by difficulty in transferring food out of the mouth into the esophagus,
nasal regurgitation, aspiration, or any combination of these symptoms.

Poor coordination plus hypopharyngeal stasis results in laryngeal and tracheal aspiration

Cricopharyngeal myotomy is a recognized treatment of patients with dysfunction of the pharyngoesophageal
junction secondary to neurologic conditions. Conservative treatment fails

Water braasch and Regurgitation are seen in GERD and not in this disease