No serosa; mucosa is strongest layer (in small bowel, submucosa is strongest)
Central input initiates swallow which elicits primary peristalsis, distention then elicits secondary peristalsis. Sphincters are contracted at rest. Normal LES tone = 15-25 mmHg (length 4cm)
Swallowing order of events: soft palate closes nasopharynx, larynx up, larynx closes, UES relaxes, pharyngeal contraction
Zencker's diverticulum: occurs in Killian's triangle, due to incr pressure (pulsion tic), need myotomy and diverticulectomy/pexy. Approach via left cervical incision
Paraesophageal hernia: always operate since risk of incarceration, strangulation (Every Year)
Diffuse esophageal spasm: medical treatment (Ca channel blockers)
Esophageal rupture (Boerhaave's) key to survival is early Dx (85% dead if > 36 hours)
Achalasia: decr ganglion cells in Auerbach's plexus, absence of peristalsis and esophageal dilation. Bird's beak on Ba swallow; manometry shows no peristalsis, high LES pressures/failure to relax. Rx: laparoscopic or thoracoscopic Heller myotomy
Barrett's esophagus: metaplasia from squamous to columnar cells. 1-2% get adenocarcinoma (30-100 x risk) P53 associated (tumor suppresor gene)
Achalasia and chemical ingestion also incr risk of esophageal CA
AdenoCA now #1 esophageal cancer over squamous (also true for lung CA)
R gastroepiploic artery is main supply to stomach when used to replace esophagus
Leiomyoma: if symptomatic or > 5cm excise by enucleation via thoracotomy (R if middle, L if lower esophagus). Do not biopsy on EGD.
Adenoid Cystic Carcinmoa: #1 malignant salivery tymor of the submandibular/mino glands
Pleomorphic adenoma = mixed parotid tumor = #1 benign tumor, do not enucleate, needs superficial parotidectomy (spare CN7); if malignant, take whole parotid w/CN7; If high grade (anaplastic), need radical neck dissection
Warthin's tumor (adenolymphoma) #2 benign salivary tumor. 10% bilateral. 70% of bilateral parotid tumors are Warthin's tumor. Rx: superfiical parotidectomy.
Radical neck dissection takes CNXII, SCM, IJ, submandibular gland. Most morbid = CN XII
Juvenile Nasopharyngeal Angifirboma: benign, in teen males, present w/obstruction, epistaxis. Rx embolize (internal maxillary a), then extirpate
Hepatocellular CA is #1 CA worldwide. May have high alpha-FP.
Chronic Hep B and C is #1 cause; also assoc w/any cirrhosis (EtOH, hemochromatosis, primary biliary cirrhosis, alpha-1 antitrypsin deficiency), clonorchis sinensis (flukes), aflatoxin, Fibrolamellar variant has better Px.
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Peripheral nerve injuries:
Neuropraxis = focal demyelination, improves
Axonotmesis = loss of axon continuity (nerve and sheath intact). Regenration 1 mm/day.
Neurotmesis = loss of nerve continuity, surgery required for nerve recovery
ADH produced when high osmolarity is sensed at supraoptic nucleus of hypothalamus
Causes incr free H2O absorption at the distal tubules and collecting ducts
Alcohol and head injury inhibit ADH release = Diabetes Insipidus
DI = high urine output, low urine SG, high serum osmolarity/Na
May also see SIADH with CHI = oliguric, high urine osmolarity, low serum osmo/Na (Every Year)
AVM's: congenital, bleed age 40-60; aneurysms younger (age 20-59), are a/w HTN
Most adult brain tumors are malignant, spinal cord tumors are 60% benign (extradural likely malignant/met)
Acoustic neuroma: CN8 at the cerebello-pontine angle (cps)
13% of patients with head injury have a spinal injury
Subdural hematoma: crescent shape, conforms to brain; 50% mortality