Esophagus
Motility disorders, GERD/Barrett, benign lesions, and esophageal cancer/perforation for the Surgery Shelf.
Sources: extracted/STEP2CK-Surgery.md (Esophagus); First Aid 2026 (first-aid-usmle-bible).
High-Yield Points
- The esophagus has no serosa (contributes to anastomotic leaks). Upper ⅓ = striated muscle, lower ⅔ = smooth muscle.
- Zenker diverticulum = false, pulsion diverticulum through Killian triangle (above cricopharyngeus) from failure of UES relaxation → dysphagia, regurgitation, halitosis. Dx barium esophagram; avoid endoscopy (perforation risk). Tx: cricopharyngeal myotomy ± diverticulectomy.
- Achalasia = failure of LES relaxation + aperistalsis from myenteric ganglion loss (idiopathic, or Chagas). Dysphagia to solids AND liquids. Manometry is the gold standard; barium shows bird's beak. Always endoscope to exclude pseudoachalasia (GEJ cancer). Tx: pneumatic dilation or laparoscopic Heller myotomy + partial fundoplication (POEM also). Late risk of squamous cell carcinoma.
- GERD from decreased LES resting pressure. PPI is first-line; long-standing → endoscopy for Barrett. Best diagnostic test = 24-h pH probe (DeMeester >14.7). Surgery (Nissen 360° fundoplication) for refractory/complicated disease; use partial wrap if dysmotility.
- Barrett esophagus = metaplasia squamous → columnar with goblet cells; risk of adenocarcinoma (~<1%/yr). No dysplasia → PPI + surveillance q3–5 y; HGD → endoscopic resection + RFA.
- Esophageal cancer: adenocarcinoma (most common in US, lower ⅓, from Barrett/GERD) vs squamous cell (upper ⅔, from alcohol/tobacco/achalasia/caustic). Chest/abd CT best for resectability; neoadjuvant chemo-XRT (cisplatin + 5-FU) for T2+.
- Boerhaave = full-thickness rupture from forceful emesis, left posterolateral distal esophagus → pneumomediastinum, crepitus, left effusion. Dx water-soluble (Gastrografin) swallow — never barium first. Early (<24 h) thoracic → operative repair.
- Caustic injury: alkali → liquefaction necrosis (worse) > acid coagulation necrosis. CT for perforation, then endoscopy within 12 h; no neutralizing agents; esophagectomy for grade 3b/4.
Key Tables / Differentials
Esophageal motility disorders (manometry)
| Disorder | Manometry | Buzzword | Treatment |
|---|---|---|---|
| Achalasia | ↑LES, fails to relax; aperistalsis | Bird's beak | Pneumatic dilation / Heller + partial wrap |
| Diffuse esophageal spasm | High-amplitude, uncoordinated contractions | Corkscrew | CCB / TCA; Heller if refractory |
| Nutcracker | High-amplitude waves, normal peristalsis | Chest pain mimicking cardiac | CCB; Heller if refractory |
| Scleroderma | ↓LES, fibrous replacement of smooth muscle | Massive reflux | PPI + metoclopramide |
Adenocarcinoma vs squamous cell carcinoma
| Adenocarcinoma | Squamous cell | |
|---|---|---|
| Location | Lower ⅓ | Upper ⅔ |
| Risk | Barrett/GERD, obesity | Alcohol, tobacco, achalasia, caustic |
| Mets to | Liver | Lung |
| Chemo-XRT response | Poorer | Favorable |
Board Pearls
- Retching → vomiting blood, bleeding stops on its own = Mallory-Weiss (partial thickness, lesser curve/GEJ); EGD confirms.
- Dysphagia + iron-deficiency anemia + esophageal web = Plummer-Vinson (SCC risk).
- Dysphagia from an aberrant right subclavian artery = dysphagia lusoria (± Kommerell diverticulum).
- Submucosal mass, mucosa intact, do NOT biopsy = leiomyoma (most common benign tumor) → enucleation.
- UGI bleed in a cirrhotic = esophageal varices → ABCs + abx + octreotide + band ligation.
- Most common site of iatrogenic (endoscopic) perforation = cricopharyngeus.
Classic Vignette Triggers
- "Bad breath, regurgitates undigested food, gurgling neck mass" → Zenker diverticulum.
- "Dysphagia to solids and liquids, bird's beak" → achalasia (manometry, then exclude cancer).
- "Forceful vomiting then severe chest pain, subcutaneous emphysema, left effusion" → Boerhaave → Gastrografin swallow.
- "Heartburn for years, then dysphagia/weight loss, salmon-colored mucosa with goblet cells" → Barrett → adenocarcinoma.
- "Alcoholic smoker with progressive solid-food dysphagia, upper esophagus" → squamous cell carcinoma.
- "Child/young adult drank drain cleaner" → alkali liquefaction injury → CT then early endoscopy.