1

Question 1

segment of the stomach protrude above the diaphragm

Answer 1

Hiatal hernia , over 50 years old
- More common in women than men

Question 2

Hiatal hernia Two anatomic patterns:

Answer 2

Two anatomic patterns:
1- Sliding hernia:
- The most common type - Protrusion of the proximal stomach above the diaphragm through widened diaphragmatic esophageal hiatus (→ incompetence of the LES)
C/P: - Heartburn and
- nocturnal epigastric distress from acid reflux accentuated by positions favoring reflux (bending forward, lying supine) & obesity.
Complications: mucosal ulceration, bleeding (Hematemesis) (vomiting blood)
2- Paraesophageal (rolling) hernia: (1%) - Portion of stomach herniates (bulges) into the thoracic cavity alongside the essophegu distal esophagus.
- Gastroesophageal junction remains at the level of the diaphragm.
- Rarely induce reflux

Question 3

congenital connection between the esophagus and trachea
- Most common congenital anomaly of esophagus
Characteristics of the most common type:

Answer 3

Tracheoesophageal fistula

(1) Proximal esophagus ends blindly .
(2) Distal esophagus open in the trachea

Question 4

Tracheoesophageal fistula

Clinical findings

Answer 4

Difficulty with feeding :
- Food regurgitates out of the mouth
- may develop chemical pneumonia from aspiration
Abdominal distention in newborn : Air in the stomach from tracheal fistula

Question 5

Plummer-Vinson syndrome
triad of :

Answer 5

triad of :1- Chronic iron deficiency
2- Glossitis
3- Dysphagia due to the presence of esophageal web or
mucosal fold in upper ⅓ of esophagus (post-cricoid region) → Produces dysphagia for solids but not liquids

Question 6

These are saccular outpouchings of the esophageal wall. True or False
entrapped food →

Answer 6

diverticulitis

Esophageal diverticulum

Question 7

Types diverticulum

Answer 7

True diverticulum:
Outpouching lined by mucosa, submucosa, muscularis propria, and adventitia
False, or pulsion diverticulum:
into Outpouching of mucosa and submucosa into area of muscle wall weakness

Question 8

Longitudinal mucosal tears in the esophagus at the gastroesophageal junction produced by severe prolonged vomiting ……….
Mostly occur in…..

Answer 8

Lacerations (Mallory-Weiss Syndrome)

chronic alcoholics after a bout of severe vomiting

Question 9

Lacerations (Mallory-Weiss Syndrome)

Presentation, Gross

Answer 9

hematemesis,
Gross: linear lacerations at the gastroesophageal junction

inadequate relaxation of the lower esophageal sphincter during vomiting → ↑ed pressure →with stretching & mucosal tearing

Question 10

Esophagitis

Answer 10

Reflux Esophagitis (Gastroesophageal reflux disease, GERD)
- due to reflux of gastric contents
2- Infectious esophagitis
- Usually a complication of AIDS - Pathogens: Herpes simplex virus, Cytomegalovirus, Candida
3- Corrosive esophagitis
- Ingestion of strong alkali (e.g., lye NaOH, KOH) or acid (e.g., HCl) - Complications: Stricture formation,
ai fibrosis invasion
4- Others: prolonged gastric intubation, ingestion of irritant substance

Question 11

Reflux Esophagitis (Gastro Esophageal Reflux Disease) (GERD)

Etiology,

Answer 11

Etiology: Reflux may be due to: 1- Incompetence of lower esophageal sphincter (LES): the common cause or
2- Hiatus hernia

Question 12

Reflux Esophagitis (Gastro Esophageal Reflux Disease) (GERD)

Gross, Microscopy

Answer 12

Gross: Redness and superficial erosions of the lower esophageal mucosa. (depend on duration and severity of the exposure)
Microscopy:
- Mucosal epithelial hyperplasia with intraepithelial inflammatory cells (eosinophils and ± neutrophils).

Question 13

Reflux Esophagitis (Gastro Esophageal Reflux Disease) (GERD)

Presentation, Diagnostic tests:

Complications

Answer 13

Presentation:
- recurrent heartburn, (= attacks of noncardiac chest pain) im
- indigestion
- regurgitation
- Nocturnal cough, nocturnal asthma

Diagnostic tests:
- Esophageal pH monitoring for 24 hours: Sensitivity/specificity 80% to 90%
- Esophageal endoscopy
- Manometry: LES pressure <10 mm Hg

Complications m
1- Peptic ulceration, bleeding and development of fibrous stricture.
2- Barrett’s esophagus:
is precancerous (metaplasia → dysplasia → adenocarcinoma

Question 14

replacement of stratified squamous epithelium of lower (distal) esophagus by metaplastic columnar epithelium containing goblet cells due to chronic exposure to gastric secretions

Answer 14

Barrett esophagus

Increased risk of high-grade dysplasia and development of → esophageal adenocarcinoma

Question 15

dilated, tortuous esophageal veins in the submucosa of the lower third of esophagus.

Answer 15

Esophageal Varices

Question 16

Etiology

Esophageal Varices

Diagnosis, Presentation

Answer 16

Portal hypertension seen in cases of:1- Cirrhosis, 2- Bilharzial hepatic fibrosis

Presentation:Asymptomatic (Varices produce no symptoms until they rupture)or massive hematemesis when ruptured

Diagnosis: Endoscopy
Complication: potentially fatal hemorrhage

Question 17

Esophageal Obstruction

1- Organic Causes:

Answer 17

1- Organic Causes:
- Lumen obstruction: by tumor, foreign body
- Wall stricture:
a) congenital
b) Acquired: as post inflammatory (particularly corrosive
- Outside compression:
by mediastinal tumors, enlarged L nodes, esophageal diverticulum

Question 18

Esophageal Obstruction
Functional Causes: cand ta

Answer 18

Achalasia of lower esophageal sphincter (Achalasia of the Cardia):
- incomplete relaxation of lower esophageal sphincter (LES) in
response to swallowing

Question 19

inadequate relaxation of lower esophageal sphincter (LES) in response to swallowing

Answer 19

Achalasia of lower esophageal sphincter (Achalasia of the Cardia):

Question 20

Achalasia of lower esophageal sphincter (Achalasia of the Cardia):

Etiology, Pathogenesis

Answer 20

Etiology: Unknown in most cases.
Pathogenesis:
1- Incomplete relaxation of LES (? loss of intrinsic inhibitory innervation of the LES) cab
(?degeneration in the vagus nerve fibres)
2- Absent ganglion cells in myenteric plexus in the body of the esophagus → →↓ proximal smooth muscle contraction

Question 21

Achalasia of lower esophageal sphincter
Gross, Microscopic

Answer 21

Microscopic:
- Loss of ganglion cells in the myenteric plexus

Gross: -Dilatation of esophagus proximal to (above) the lower esophageal sphincter but peristalsis is absent

Question 22

Achalasia of lower esophageal sphincter Presentation, Diagnosis, Complication

Answer 22

Progressive dysphagia
- Nocturnal regurgitation of undigested food
- Nocturnal cough from aspiration may occur.

Abnormal barium swallow:
Dilated, aperistaltic esophagus with a beak-like tapering at distal end
- Abnormal esophageal manometry:
- Detects aperistalsis failure of LES relaxation (↑ resting tone of the LES).
Complication:
In prolonged cases → Increased risk of esophageal carcinoma (5%)

Question 23

Squamous cell carcinoma of the esophagus (SCC)

Predisposing (Risk) Factors: , Sites, Presentation

Answer 23

Males > females; age usually >50
- Chronic esophagitis due to
heavy smoking,
excess alcohol intake,
achalasia of the lower esophageal sphincter

Sites: - 20% arise in the upper third of esophagus,
- 50% in the middle third, and
- 30% in the lower third.

Presentation
Often asymptomatic until late in the course → Progressive dysphagia (due to esophageal obstruction) (for solids initially ), bleeding (hematemesis), weight loss and axis anorexia. Painless enlarged supraclavicular nodes

Question 24

Adenocarcinoma of the esophagus

Predisposing Factors, Micro ,Site

Answer 24

usually associated with Barrett esophagus and dysplasia
- The degree of dysplasia is the strongest predictor of the progression to cancer

Micro
most tumors are mucin-producing glandular tumors showing intestinal-type features

Site: usually in the distal third of the esophagus