2 ESOPHAGUS Flashcards
What is Achalasia? (Cardiospasm)
An esophageal motility disorder involving the smooth muscle layer of the esophagus, and the lower esophageal sphincter (LES)
What is Achalasia characterized by?
- Incomplete relaxation of LES - It’s increased tone - Lack of peristalsis of esophagus
What is Primary Achalasia?
MC** Characterized by failure of distal esophageal inhibitory neurons - The Auerbach’s plexus (myenteric plexus)
What does the Auerbach’s plexus (or myenteric plexus) provide?
Motor innervation to both layers of the muscular layer, having both para and sympathetic output
What is special about Meissner’s plexus?
It has ONLY parasympathetic fibers and provides secretor innervation to the mucosa nearest the lumen of the gut
What could secondary Achalasia result from?
Cancer of esophagus or upper stomach
What else could Secondary Achalasia result from?
Infection with Protozoa (Trypanosoma Cruzi) which causes destruction of the myenteric plexus of the esophagus with its dilation
Achalasia caused by Tripansoma cruzi is known as _____
***Chaga’s Disease SECONDARY ACHALASIA
What are the signs and symptoms of Achalasia?
- Dysphasia 2. Regurgitation 3. Chest pain 4. Coughing 5. Aspiration of food or liquid
What is “Dysphagia” associated with Achalasia?
Difficulty in swallowing of solid or liquid food
What is “Regurgitation” associated with Achalasia?
Backflow of undigested food
Why would you have chest pain with Achalasia?
BEHIND THE STERNUM With radiation to the neck or armS* (NOT JUST ONE ARM) Can be extremely painful and gets worse AFTER eating
Why would there be “Coughing” with Achalasia ?
Cough when you’re in a HORIZONTAL position especially at night
What will you see on X- Ray with Achalasia?
Use contrast liquid swallowing shows the narrowing of the distal part of esophagus
What is the radiographic sign apparent with Achalasia?
“Bird’s Beak” or “Rat’s Tail” sign** Along with dilation above
How is there a diagnosis of Achalasia?
Upper Endoscopy (Gastroscopy)
What are the 3 complications of Achalasia?
- Aspiration pneumonia or airway obstruction 2. Lower esophageal diverticulum 3. Esophageal Cancer (in 5% of patients)
What do you recommend to patients with Achalasia ?
- Eat slowly - Avoid eating near bed time - Avoid ketchup, citrus, chocolate, caffeine - Physician consultation
What is a Hiatal Hernia of the esophagus?
Protrusion of the upper part of stomach into thorax through the space between the muscular Curran’s of the diaphragm (hiatus)
What are the different forms of Hiatal Hernia?
- Sliding MC* 2. Rolling or Paraesophageal
What happens during a Sliding Hernia?
Where the gastroesophageal junction together with the stomach move above the diaphragm
What type of dilation do you see with a sliding hernia?
Bell Shaped* MC form of hiatal hernia
What is a rolling or paraesophageal hernia?
When a separate portion of the stomach, usually along the greater curvature, enters the thorax through the widening foremen
What is condition can be an etiology of Hiatal Hernia?
Kyphoscoliosis
What are the etiologies associated with Hiatal Hernia?
- Increased pressure within the abdominal cavity - Congenital diaphragmatic weakness - Obesity, trauma
Hiatal Hernia is known as
Great mimic disease
What do most cases of Hiatal Hernia do?
Does not cause any symptoms or specific symptoms
Signs and Symptoms of the Hiatal hernia:
- Dull pain in chest - Shortness of breath - Heartburn (typical for sliding hernia) - Heart Palpitation (tachycardia)
How do you diagnose Hiatal Hernia?
X ray with liquid Barium salt, or upper endoscopy
What are the differential diagnosis of the Hiatal Hernia?
- Ischemic heart disease (chest pain) - GERD because of heartburn - Lung disease (short breath)
Ulcer in the esophagus is a complication of what disease?
Hiatal Hernia
What is there a stricture of in the complication of a Hiatal Hernia?
Stricture of esophagus
What can the complication of Rolling Hernia be?
Development of venous infarction due to its possible strangulation by the diaphragm *** EMERGENCY ***
What are the recommendations by the chiropractor with Hiatal hernia?
- Restrict activities that raise intra abdominal pressure - Avoid eating near bed time - Diet modification: small frequent bland food
What is Gastroesophageal Reflux Disease (GERD)?
A chronic syndrome resulting in mucosal damage caused by stomach acid coming up from the stomach into the esophagus
Why does GERD usually happen?
Because the LES opens at the wrong time or does not close properly
Failure of the lower esophageal sphincter can be due to:
- CNS depressants - Hypothyroidism - Pregnancy - Alcohol or Tobacco exposure
Sliding hernia might be etiology for:
GERD
What are some visceral things that are an etiology of GERD?
SLE, asthma, gallbladder stones, and laryngitis
What infection is an etiology of GERD?
Helicobacter Pylori
Does obesity cause GERD?
YES
What are the signs and symptoms of GERD?
- Heartburn - Regurgitation - Dysphagia - Increased salivation - Nausea - Chest pain (radiates to arms and neck)
How do you diagnose GERD?
- X-ray with liquid Barium salt - Upper endoscopy
What is a differential diagnosis of GERD?
- Heart diseases (chest pain) - Hiatal Hernia
What is a major complication of GERD?
Reflux esophagitis necrosis (ulcer near the junction between stomach and esophagus)
Is esophageal stricture complication of GERD?
YES
What are the 3 complications of GERD?
- Barrett Esophagus - Aspiration Pneumonia - Esophageal Cancer
What are life style modifications for GERD?
- Eating not later than 3-4 hours before going to bed - Avoid coffee, alcohol, chocolate, sour, and spicy food - Increased fluid intake - Ginger tea
What is Barrett Esophagus?
An abnormal change (metaplasia) in the cells of the lower portion of esophagus
What happens to the cells in Barrett Esophagus?
The squamous epithelial cells of the esophageal mucosa are replaced by columnar epithelial cells with **Goblet mucus producing cells
What is the etiology of Barrett Esophagus?
- GERD - Central Obesity - Smoking
What are the signs and symptoms with Barrett Esophagus?
- Heartburn - Hematemesis - Painful eating - Dysphagia (in case of complication by stricture)
How do you diagnose Barrett Esophagus?
Upper endoscopy with biopsy
What are complications of Barrett Esophagus?
Bleeding, stricture, and frank esophageal adenocarcinoma
How is treatment done with Barrett Esophagus ?
ONLY MEDICAL
What is Mallory Weiss Syndrome?
Lacerations - Bleeding from longitudinal tears in the mucosa (not muscular layer) at the esophagogastric junction
5-10% of Mallory-Weiss Syndrome have:
Upper GI bleeding episodes
What is the pathogenesis of Mallory Weiss Syndrome?
Inadequate relaxation of the musculature of the lower esophageal sphincter during vomiting, with stretching and tearing of the esophageal junction during propulsive expulsion of gastric contents
What is the MC etiology of Mallory Weiss Syndrome?
Alcoholism, after frequent severe retching and vomiting
What are the different etiologies of Mallory-Weiss Syndrome?
- Hiatal Hernia - Overdose of NSAIDs - Severe vomiting in pregnancy
What are signs and symptoms of Mallory Weiss Syndrome?
Episodes of vomiting with bright blood
What is the Diagnosis method for Mallory Weiss Syndrome?
Upper Endoscopy
What are the complications of Mallory Weiss Syndrome?
- Severe bleeding - Esophageal Rupture (known as BOERHAAVE SYNDROME***)
Action of Mallory Weiss Syndrome in an office =
CALL 911
What is an esophageal Varicies?
Extremely dilated submucosa veins in the low 1/3rd of the esophagus
What is the Etiology of Esophageal Varicies?
Portal Hypertension
What does Portal Hypertension cause?
- Posthepatic (suprahepatic) 2. Hepatic (Intrahepatic) 3. Prehepatic (Infrahepatic)
What is Post Hepatic (suprahepatic) associated with?
- Chronic right sided heart failure - Budd-Chiari Syndrome
What is Budd Chiari Syndrome?
Endophlebitis of the liver veins, or obstruction of the hepatic vein
What is Hepatic (Intrahepatic) associated with?
- Liver cirrhosis (MC) - Liver tumors - Amyloidosis
Prehaptic (infrahepatic) is associated with,
- Portal vein thrombosis - Portal vein sclerosis - Portal vein congenital stenosis or atresia
Esophageal Varicies appear in 65% of patients with ______
Liver cirrhosis
What are manifestations of Esophageal Varicies?
- Varicies produce no symptoms until they rupture, and the hemorrhage develops (hematemesis)
What is the diagnosis of Esophageal Varicies?
Upper Endoscopy and CT scan
What is the treatment for Esophageal Varicies?
This is life threatening situation and requires immediate hospitalization
What is an esophageal diverticuli?
A Diverticulum is an outpouching of the alimentary tract organ wall that contains all visceral layers
What are the forms of Esophageal Diverticulum?
- Zenker’s Diverticulum aka Pharyngoesophageal Diverticulum 2. Midesophageal, aka Traction Diverticulum 3. Epiphrenic Diverticulum
What is Zenker’s Diverticulum aka Pharyngoesophageal Diverticulum?
Immediately above the upper esophageal sphincter (FALSE Diverticulum)
Midesophageal aka Traction Diverticulum =
Near the midpoint of the esophagus
What does Midesophageal aka Traction Diverticulum results from:
Mediastinal Lymphadenitis (as from TB)
Where is Epiphrenic Diverticulum?
Immediately above the lower esophageal sphincter
What are the signs and symptoms of Esophageal Diverticuli ?
- Zenker’s diverticulum 2. Traction diverticulum 3. Epiphrenic diverticulum
What is Zenker’s Diverticulum?
Food regurgitation in the absence of Dysphagia, can be complicated by aspiration pneumonia
What is Traction Diverticulum?
Usually asymptomatic
What is Epiphrenic Diverticulum?
Gives rise to nocturnal regurgitation
How do you diagnose Esophageal Diverticuli?
- X-ray with contrast liquid - Upper endoscopy
What is the treatment of Esophageal Diverticuli?
Surgery
What are the different types of Benign tumors of Esophagus?
- Leiomyomas 2. Polyps 3. Fibromas 4. Lipomas 5. Hemangiomas 6. Neurofibromas 7. Squamous Papillomas
What are benign tumors of esophagus?
Mostly mesenchymal in origin and usually lie within the esophageal wall
What is a leiomyoma?
MC benign tumor of esophagus, originates from smooth muscle cells
Where do Benign tumors most commonly locate ?
Distal 2/3rd of the esophagus, usually they are multiple
What are Polyps?
Usually composed of a combination of fibrous, vascular, or adipose tissue, covered by an intact mucosa
What age/gender do Benign tumor of esophagus occur?
Occur between 20-50, and have NO gender preference **The potential for malignancy for these tumors is very low
What is the rule for signs and symptoms of benign tumors of esophagus?
They are usually asymptomatic, silent, and undetected - Their size is more than 5 cm in diameter, they can come to the clinical attention
What are the signs and symptoms of Benign tumors of the Esophagus?
- Dysphagia (meat and bread) 2. Pain while swallowing (less common) 3. Food regurgitation 4. Bleeding or hematemesis
When does bleeding or hematemesis of Benign tumor result from?
Bleeding or hematemesis result from ulceration or necrosis of benign tumors (These manifestations are very rare)
What is the diagnosis for Benign tumor of esophagus ?
- Upper endoscopy with biopsy - Ultrasound endoscopy - CT scan - X-ray with Barium liquid
How do you treat Benign tumors of Esophagus?
- Removal of polyps through endoscopy - Surgery
What are the MC malignant esophageal tumors?
Squamous cell carcinoma and adenocarcinoma
Squamous cell Carcinoma represents ______ of esophageal cancer world wide
90-95%
Where does squamous cell carcinoma arise from?
The squamous epithelium
Adenocarcinoma represents ______ of esophageal cancer in the US?
50-80%
What does Adenocarcinoma arise from?
Metaplastic columnar epithelium
Where does squamous cell carcinoma usually occur?
In the proximal 2/3rd of esophagus
Where does Adenocarcinoma usually occur?
In the distal 1/3rd of esophagus or gastroesophageal junction
What is squamous cell carcinoma in direct correlation with?
- Celiac disease - Hot tea with increased concentration of tannins - Tylosis (palmar/plantar hyperkeratosis)
What is adenocarcinoma in direct correlation with?
- GERD - Barrett Esophagus - Scleroderma - Zollinger-Ellison syndrome
What are the risk factors for both cancers of esophagus ?
- Tobacco smoking and chewing - Alcohol overconsumption - Age after 60-65 y/o - male:female 5:1
What are the clinical manifestations for both cancers of esophagus?
- Dysphagia - Weight loss
Why is there pain with Malignant tumors of esophagus?
Usually more late symptom, the pain locates behind sternum or epigastrium, could be severe, and is worsened by swallowing of any food
Why is there coughing with Malignant esophageal tumors?
Unusual hoarseness, due to involving of the recurrent laryngeal nerve
Why are there hiccups of Malignant tumors of esophagus?
Phrenic nerve involvement
What are the more severe manifestations of malignant tumors of esophagus?
- Nausea, vomiting, regurgitation of food - due to disruption of normal peristalsis - Bleeding, hematemesis
How do you diagnose malignant tumors of esophagus?
Endoscopy with biopsies - Ultrasound endoscopy
What are the 3 special imaging choices for Malignant tumors of esophagus?
- CT scan of chest, abdomen and pelvis, especially if looking for METS 2. PET (Positron Emission Tomography) for estimation of stage, Mets of the cancer 3. Xrays with Barium liquid for esophageal motility studies
Where do malignant tumors of the esophagus metastasize to?
- Regional lymph nodes - Aorta - Liver and lungs - Mediastinum
What is the treatment for Malignant tumors of the esophagus?
- Surgery - Chemotherapy - Radiotherapy
