1 Flashcards
segment of the stomach protrude above the diaphragm
Hiatal hernia , over 50 years old
- More common in women than men
Hiatal hernia Two anatomic patterns:
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
congenital connection between the esophagus and trachea
- Most common congenital anomaly of esophagus
Characteristics of the most common type:
Tracheoesophageal fistula
(1) Proximal esophagus ends blindly .
(2) Distal esophagus open in the trachea
Tracheoesophageal fistula
Clinical findings
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
Plummer-Vinson syndrome
triad of :
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
These are saccular outpouchings of the esophageal wall. True or False
entrapped food →
diverticulitis
Esophageal diverticulum
Types diverticulum
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
Longitudinal mucosal tears in the esophagus at the gastroesophageal junction produced by severe prolonged vomiting ……….
Mostly occur in…..
Lacerations (Mallory-Weiss Syndrome)
chronic alcoholics after a bout of severe vomiting
Lacerations (Mallory-Weiss Syndrome)
Presentation, Gross
hematemesis,
Gross: linear lacerations at the gastroesophageal junction
inadequate relaxation of the lower esophageal sphincter during vomiting → ↑ed pressure →with stretching & mucosal tearing
Esophagitis
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
Reflux Esophagitis (Gastro Esophageal Reflux Disease) (GERD)
Etiology,
Etiology: Reflux may be due to: 1- Incompetence of lower esophageal sphincter (LES): the common cause or
2- Hiatus hernia
Reflux Esophagitis (Gastro Esophageal Reflux Disease) (GERD)
Gross, Microscopy
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).
Reflux Esophagitis (Gastro Esophageal Reflux Disease) (GERD)
Presentation, Diagnostic tests:
Complications
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
replacement of stratified squamous epithelium of lower (distal) esophagus by metaplastic columnar epithelium containing goblet cells due to chronic exposure to gastric secretions
Barrett esophagus
Increased risk of high-grade dysplasia and development of → esophageal adenocarcinoma
dilated, tortuous esophageal veins in the submucosa of the lower third of esophagus.
Esophageal Varices
Etiology
Esophageal Varices
Diagnosis, Presentation
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
Esophageal Obstruction
1- Organic Causes:
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
Esophageal Obstruction
Functional Causes: cand ta
Achalasia of lower esophageal sphincter (Achalasia of the Cardia):
- incomplete relaxation of lower esophageal sphincter (LES) in
response to swallowing
inadequate relaxation of lower esophageal sphincter (LES) in response to swallowing
Achalasia of lower esophageal sphincter (Achalasia of the Cardia):
Achalasia of lower esophageal sphincter (Achalasia of the Cardia):
Etiology, Pathogenesis
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
Achalasia of lower esophageal sphincter
Gross, Microscopic
Microscopic:
- Loss of ganglion cells in the myenteric plexus
Gross: -Dilatation of esophagus proximal to (above) the lower esophageal sphincter but peristalsis is absent
Achalasia of lower esophageal sphincter Presentation, Diagnosis, Complication
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%)
Squamous cell carcinoma of the esophagus (SCC)
Predisposing (Risk) Factors: , Sites, Presentation
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
Adenocarcinoma of the esophagus
Predisposing Factors, Micro ,Site
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
