ESOPHAGEAL OBSTRUCTION - rEMERGs

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‣ Complications ‣ Perforation 2% ‣ Airway obstruction ‣ Mediastinitis ‣ Fistulas ‣ Extraluminal migration ‣ Esophageal strictures MANAGEMENT ‣ Food Bolus ‣ Never use papain: increased perforation rate ‣ Glucagon 1.0 mg iv (decreases LES tone, may cause vomiting); only useful for lower esophageal impaction (no smooth muscle in upper esophagus); contraindicated in sharp FB, upper esophageal FB, insulinoma, pheochromocytoma, Zolinger-Ellison syndrome ‣ COKE for gas forming properties: works 60% of the time (Tartaric acid + sodium bicarb has also been used - produces carbon dioxide) ‣ Expectant managment: observe for 24 hours and then endoscopy prn; should not leave > 24hrs ‣ Endoscopic removal Emergent for airway obstruction Urgent for failure of above, > 24 hours Indicated for suspected strictures, carcinoma, webs, rings, etc Emergent Endoscopy ‣ Airway obstruction ‣ Can’t handle secretions ‣ Must come out regardless of location b/c of risk of erosion ‣ Only one you could potentially watch is right at the GE junction ‣ Concerns of both foreign body and caustic ingestions ‣ Contains metal salt and a variety of caustic alkaline substances: sodium and potassium hydroxide ‣ Majority pass uneventfully in stool and most within 4 - 7 days ‣ Rare fatal complications: esophageal - aorta fistula ‣ Airway assessment is key initial management ‣ Radiographic localization via chest or abdominal Xrays ‣ Airway or lower respiratory tract location are usually symptomatic and require bronchoscopy ‣ Intact batteries past esophagus: d/c home and watch stool, return if problems ‣ Children < 6yo + battery > 15mm: unlikely to pass pyloris thus must re- evaluate in 48hrs with repeat Xrays to visualize: endoscopic removal if not past pyloris ‣ Esophageal location requires endoscopic removal ‣ Other foreign bodies ‣ Watch if at lower esophagus ‣ Endoscopy if at upper esophagus ‣ ED removal with sedation and foley catheter has been described for upper esophageal foreign bodies ‣ Emergent endoscopy: AWO, can’t handle secretions ‣ Urgent endosocpy: upper esophagus, button batteries, > 24hr duration, sharp objects
<strong>ESOPHAGEAL</strong> PERFORATION INTRODUCTION ‣ Most rapidly fatal perforation of GIT; was uniformly fatal ‣ Mortality now 30% depending on MOI, Pmhx, esoph pathology PATHOPHYSIOLOGY ‣ NO serosal covering of the esophagous :. direct access to mediastinum ‣ Upper esophageal perforation drains into the retropharyngeal space b/c of fascial planes that extend from the base of the skull to the bifurcation of the trachea ‣ Thin mediastinal pleura rarely prevents drainage into pleural cavity ‣ Massive chemical and bacterial mediastinitis ‣ Sepsis, volume loss, obstructive shock, resp failure, death ‣ Inherent wkness of left posterior esoph leads to it being the MC emesis induced rupture site ‣ Esophageal pathology can alter sites ‣ Rupture secondary to FB occurs at three areas of narrowing .... ‣ Cricopharyngeal muscle near the esoph intoitus ‣ Espophageal crossing of the left mainstem bronchus and aortic arch ‣ GE junction ETIOLOGY ‣ Iatrogenic (MC) ‣ Endoscopy: MCC, 0.5% of endoscopy, rigid > flexible, inc w/ corrosives ‣ NG/OG tubes: MCC in ED, perforates pyriform sinus ‣ Foreign Bodies ‣ Lacerations, pressure necrosis ‣ Usu in cervical esoph unless tumor/stricture in lower esoph ‣ Kids < 4yo: cricopharyngeal narrowing is MC location ‣ Caustic Burns ‣ Alkali: liquefaction necrosis, more commonly causes perf than acids ‣ Acids: coagulation necrosis, less perforation ‣ Must have endoscopy ‣ Penetrating Trauma ‣ 5 - 30% of all esoph perfs ‣ Penetrations of neck, chest, or abd ‣ Blunt Trauma ‣ Rarely isolated injury; tracheal injury is MC associated injury ‣ Cervical esoph is MC location ‣ Commonly overlooked b/c of dramatic tracheal injury ‣ Xrays: blood/air in retropharyngeal space on lateral C-spine ‣ Has been assoc w/ C-spine # ‣ Spontaneous Rupture ‣ Bourhaave’s syndrome, Postemetic perforation ‣ worst prognosis b/c massive seeding of mediastinum ‣ Longitudinal left posterolateral tear MC b/c of inherent wkness ‣ 80% male, middle aged a/f +++ food and EtoH ‣ Neonatal has occurred ‣ May occur in normal or pathological esoph
Page 1: ESOPHAGEAL OBSTRUCTION ANATOMY ‣
Page 5 and 6: DYSPHAGIA DEFINITIONS ‣ Dysphagia
Page 7 and 8: INVESTIGATIONS ‣ Neck Xrays: look
Page 9 and 10: ‣ Resp Complications: recurrent c
Page 11 and 12: GASTROESOPHAGEAL REFLUX DISEASE Int
Page 13 and 14: ABDO PAIN: GASTRIC OR DUODENAL ORIG
Page 15 and 16: ‣ ‣ May present w/ Complication
Page 17 and 18: NSAID INDUCED ULCERS EPIDEMIOLOGY
Page 19 and 20: MEDICATION OPTIONS ‣ Gastric Acid
Page 21 and 22: ‣ urease splits urea and produces

ESOPHAGEAL OBSTRUCTION - rEMERGs

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