贲门失弛缓症的处理.ppt
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1、贲门失弛缓症ACHALASIA,Anatomy- esophagus,- Muscular tube - Conduit from the pharynx to the stomach - Length is defined anatomically, from cricoid cartilage to the gastric orifice - Distance from the incisor 40-45 cm (actual length: M 22-28cm F 2cm shorter) - Passes behind aortic arch and left main bronchu
2、s. - Enters abdomen through esophageal hiatus 2-4 cm below the diaphragm,Course of the esophagus - Neck and upper esophagus: left of midline - Mid-esophagus: right of midline - Lower esophagus: left of midline Three area of normal constrictions: - Cricopharangeal - Behind the aortic arch - LES (thic
3、kening of the Circular muscles 4cm),- Fixed in position at two places: . Upper: firmly attached to the cricoid cartilage . Lower: Phreno-esophageal ligament to the esophagus which provides an air- tight seal between the thoracic and abdominal cavity. (lack of fixation throughout its length allows bo
4、th transverse and longitudinal mobility),Vascular supply,ARTERIAL SUPPLY Upper superior and inferior thyroid artery Middle Bronchial arteries and esophageal branches directly from aorta Lower L inferior phrenic and gastric VENOUS SUPPLY Upper esophageal venous plexus to azygos vein Lower esophageal
5、branches of the coronary vein, a tributary of the portal vein,Structure,- Consists of 3 layers: muscularis externa, submucosa, mucosa,Achalasia-historical note,First described more than 300yrs ago Referred to as cardiospasm Thomas Willis (1621-1675) Described a pt starving and unable to swallow Conc
6、lusion was due to lower esophageal narrowing Constructed the first dilator-made of whale bone and sponge First successful treatment of achalasia,Achalasia-historical note,1914: Ernst Heller (1877-1964) - First successful cardiomyotomy Anterior and posterior myotomies Extending 8cm or more into esoph
7、agus and stomach,Achalasia-historical note,1918: De Brune Groenveldt and Zaaijer performed modified Heller myotomy anterior only Original technique was to excessive,Achalasia,- Uncommon (0.5-1 in 100,000) - No sex predilection M=F - Majority between ages 20-50s - Ineffective relaxation of the LES co
8、mbined with loss of esophageal peristalsis impaired esophageal emptying and gradual dilatation - Decrease or loss of myenteric ganglion cells - Slight increase risk of esophageal carcinoma (approx. 10yrs earlier than the general population),Achalasia - Presentation,- Dysphagia - delayed and progress
9、ive presentation (mean 2 years) - Exacerabated by emotional stress or cold fluid - 60-90% report spontaneous or forced regurgitation of undigested food - 10% will have pulmonary complication - Chest pain ( heartburn) - 30-50% resolves with Myotomy,Achalasia - Diagnosis,-CXR: air fluid levels - Bariu
10、m swallow: dilated esophagus with Birds beak deformity. (pseudoachalasia from extrinsic mass may mimic the classic achalasia appearance) - Manometry: gold standard . Elevated LES pressure (greater than 35mmHg) . Incomplete sphincter relaxation . Complete absence of peristalsis - Endoscopy: dilated e
11、sophagus with tightly closed LES gentle pressure will admit the scope with a “pop“.,Achalasia,Achalasia,Achalasia - Treatment,Palliation of dysphagia is the key relieve functional obstruction of distal esophagus - pharmacotherapy - botulinum toxin - esophageal dilation - operative myotomy,Achalasia-
12、 algorithm,Achalasia - Treatment,Pharmacotherapy: (poorly absorbed and short lived, best reserved as adjunct to other therapies) - Nitrates - Ca+ channel blockers - Anticholinergics - Opiods,Botulinum Toxin Therapy,Achalasia - Treatment,Botox injection: - Bind to cholinergic nerves and irreversibly
13、inhibit Acetyl Choline release - 60-85% of patient get relief but 50% get recurrent symptoms within 6 months. - Endoscopically injected - For pt who are not candidates for other therapies,Achalasia - Treatment,Botox injection cont. - Advantages: safety, ease of administration, minimal side effects -
14、 Disadvantages: expensive, need for multiple injections, and efficacy decreased with repeated injection - Cause obliteration of the dissection planes between submucosa and muscular layer which will make subsequent surgery more difficult and increase risk of perforation.,Pneumatic Dilator,Achalasia -
15、 Treatment,Esophageal dilation (under fluroscopy) -Standard nonoperative therapy -Break the muscle fibers -For pts with limited life expectancy -Can have repeated dilatation -60-80% success rate, 5yr recurrence rate 50% -Efficacy is decreased after second dilatation -Perforation rate 2% -PPI reduces
16、 the need for repeat dilatation,Esophageal myotomy,Achalasia Surgical treatment,- Excellent results in 90-95% - Gold standard - 1914 - Ernest Heller- double myotomy - Modified by Zaaijer- single myotomy - Worlds largest experience -Brazil, Chagas disease-endemic -1 in 8 inhabitants, in which 5% deve
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