3/15 Esophageal Disease - Corbett Flashcards
tracheoesophageal fistula
newborn drooling, not tolerating first feed, unable to pass nasogastric tube
esophagus anatomy
SEGMENTS
blood supply
venous drainage
cervical esophagus (C6 to T1)
- begins below cricopharyngeus muscle (upper esoph sphincter)
- separates pharynx from esoph
- normally closed
- blood: inf thyroid a
thoracic esoph
- blood: bronchial aa, thoracic aorta, R iintercostal a
lower esoph
- lower esoph sphincter: high pressure zone 3-5cm long at lower esoph → fx: prevents refulx
- blood: L gastric artery, short gastrics (splenic), L inferior phrenic a
venous drainage?
- shared w other organs → extensive submucosal longitudinal latticework of collateral vv
- lower esoph venous drainage → PORTAL SYSTEM
porto systemic venous anastomosis
L gastric vein (aka coronary v) & short gastric v
portal HTN → can lead to esoph varices
- imp cause of upper GI bleeds
lymphatic drainage of esophagus
very comprehensive network in submucosa travelling longitudinally
- lymphatics can carry neoplastic cells for long distances in either direction
- tx for esoph cancers is usually total esophagectomy
organization of gut
in esoph…striated and smooth mm
upper 1/3 : two layers of striated
middle 1/3 : smooth muscle deep to striated muscle
lower 1/3 : two layers of smooth muscle (circular, longitudinal)
*esoph has NO serosal layer → only adventitia as outermost connective tissue
heartburn / pyrosis
- “burning sensation” behind sternum from epigastrium, can radiate to neck
- intermittent (post eating, during exercise, lying flat)
- relieved w water or antacids
esophageal disorders
general categories x5
- motility disorders
- inflammatory disorders
- GERD
- eosinophilic esophagitis (aka allergic esophagitis)
- infectious esophagitis
- iatrogenic (lye, pill)
- cancer
- structural disorders
- mechanical injury
chest pain
why feels similar to cardiac pain?
esophagus and heart share a nerve plexus! → chest pain is common sx with esoph issues
sensation of pressure in midchest, radiating to midback/arms/jaw
- due to esoph distension, chemostim (acid)
dysphagia as an ALARM sx
subjective sensation of difficulty or abnormality of swallowing
imp questions:
1. timing?
helps determine location:
-
oropharynx : diff initiating swallow → coughing, choking, nasopharyngeal regurg, aspiration
- aka “TRANSFER” DYSPHAGIA
- due to structural or propulsive issues
- esophagux : diff swallowing AFTER initiating swallow (several seconds post) → food “getting stuck”
2. solids? liquids? both? (including progression of sx)
-
dysmotility problem (motor disorder) : both solids and liquids at onset
- intermittent → primary or secondary esoph motility disorder
-
progressive
- chronic heartburn → scleroderma
- regurg and/or resp sx and/or wt loss → achalasia
- mechanical problem : solids progressing to liquids
Zenker diverticulum
altered esoph motility due to failure of relaxation of upper esoph sphincter
- M>F, incr incidence w age
- unclear etiology
UES is too tight → incr pressure in proximal esoph → diverticulum forms through weak spot in wall
- false diverticulum : does NOT contain all layers of wall! just mucosal lining (doesn’t incl muscular layers)
sx: halitosis/regurg of undigested food, nocturnal aspiration, weight loss
dx: barium swallow
achalasia
likely autoimmune etiology
- inf w T. cruzi mimics achalasia
immune mediated ganglionitis → loss of neurons in myenteric plexus
- loss of inhibitory (NO-producing neurons) leads to dysregulation of peristaltic activity, LES tone
- cholinergic neurons continue to regulate muscle tone → high LES tone → sphincter fails to relax
so see reduced amplitude or ABSENT PRIMARY PERISTALSIS & failure of LES to relax
sx:
- high resting LES pressure w failure to relax
- absent peristalsis w addtl neuron loss
- loss of UES relaxation with esoph distension
- esoph dilation
- clinically: dysphagia for solids/liquids, regurg of undigested food
achalasia chart
diffuse esoph spasm
uncommon
pathophys
- impaired inhibitory neuron innervation
- problem with NO synthesis
when swallow → simultaneous or premature rapidly propagating peristaltic contractions
- mostly involving distal esoph
- normal sphincter + GER
sx
- dysphagia to liquids and solids
- w or w/o retrosternal chest pain
Nutcracker esophagus
uncommon
pathophysiology
overactivity of excitatory (cholinergic) neurons
- sequential peristaltic contractions of v high amplitude
- primarily distal esoph
- normal sphincter + GER
- dysphagis to liquids/solids, otherwise maybe asymp
GERD
etiology
pathogenesis
risk factors
common (10% experience symptoms daily)
etiology: excessive reflux of acid-containing gastric secretions and/or bile into esoph and/or impaired clearance of secretions
pathogenesis: esophageal or gastric factors affecting mucosal defense and LES fx
risk factors
- abd obesity
- pregnancy
- gastric hypersecretion
- delayed gastric emptying
- disruption of esoph peristalsis
sx
- heartburn, regurg
- substernal chest pain
- dysphagia
- cough, adult asthma
dx: EGD, 24hr pH probe
rx: lifestyle mod (avoid food that drop LES pressure → fatty food, alc, spearmint, etc), PPI med
GERD complications
things that affect LES pressure
(potential causes of GERD)
- anatomic position
- SMC tone
- LES length
esophagitis
erosive esophagitis
benign stricture
excessive reflux of acid and pepsin → necrosis of surface layers of esoph mucosa → erosions, ulcers
- persistent? can result in fibrosis, neoplasia
benign stricture : short in length, often contiguous with GE jx (gastroesoph jx)
Barrett esophagus
intestinal metaplasia within esophageal squamous mucosa
- can be either low grade or high grade dysplasia
- incr risk of esoph adenocarcinoma
eosinophilic esophagitis
etiology: immunologic
- Th2 cell-mediated, NOT IgE
- induced by antigen exposure (poss dietary?) → food exposures triggers Th2 cell-mediated cytokine response
- environmental exposures
pathophysiology
- IL13 and IL5 production → eosinophil recruitment
histo: see eosinophils and broken down cell-cell contacts
clinical pres:
- dysphagia (solid food)
- episodes of food impaction
- central chest pain
- GERD sx; refractory heartburn
- kids: nonspecific (difficulty feeding, n/v), heartburn, failure to thrive
endoscopic finding: stacked rings
tx: food adjust, PPI, topical glucocorticoids, dilation
infectious esophagitis
1. candida albicans
- ODYNOPHAGIA
- most common in HIV (also chemotx, radiation tx)
- often w thrush
- white mucosal plaque-like lesions
2. herpes simplex
- ODYNOPHAGIA
- most common in organ transplat recipients
- reactivation w spread via vagus n
- affects distal esophagus
- well-circ ulcers with “volcano” appearance
“pill” esophagitis
mech: esophageal hypomotility or incorrect method of taking med
clinical ft:
- acute onset of chest pain
- severe odynophagia
- acute severe heartburn
causes
- antibiotics (tetracycline, doxycycline, direct tox)
- bisphosphonates (alendronate → caustic alk solution)
- NSAIDs
- KCl → hyperosmolar solution
caustic ingestion
alkali ingestion → liquefactive nectosis →→ full thickness injury
- esoph most affected
- 30% develop strictures
acid ingestion → coagulative necrosis w limited superficial necrosis
- mostly damages stomach
esophageal cancer
two pathologic types w similar presentation but diff causative factors
-
SQUAMOUS CELL CARCINOMA of esoph
- arises in cervical and thoracic esophagus
- distinct risk factors: smoking, alc, hot tea, nitrates, fungal tox, iNJURY, esoph webs, achalasia
-
ADENOCARCINOMA of esoph
- assoc with GERD and Barrett esoph, tobacco, irrad
- arises in distal esophagus
- associated with dysplastic columnar epithelium
- p53 mutation
- 15% overexpress HER2/NEU
- not assoc w Heliobacter (Heliobacter may actually reduce risk)
esoph dysphagia → solids only → mech obstruction
- nonprogressive
- progressive
sets of sx and dxs
nonprogressive
- esophageal ring/eosinophilic esophagitis : eosinophilic esophagitis
progressive
- chronic heartburn : peptic stricture (GERD)
- elderly, wt loss, and/or anemia : esoph/cardia cancer
structural disorders
-
webs/rings : thin, non-circumferential mucosal fold protruding into lumen, covered with sq epithelium
- most in cervical esoph → focal narrowing in post-cricoid area
- Plummer Vinson Syndrome (Fe def anemia, dysphagia, cervical esoph web)
- hiatus hearnia__
- paraesophageal hernias
- other diverticular
hiatus hernias
two types
Type 1 (>95%): sliding hiatus hernia → everything slides up
- hiatus widens, stomach and GE jx slide into chest
- no hernia sac, structures stay in posterior mediastium
- over 505 of pt with GERD → type I hiatus hernia
Type 2: paraerophageal hernia → GE jx intact, but portion of stomach has herniated upward
gastric volvulus
rotation of stomach within chest
Borchardt triad
- sudden severe pain in epigastrium or chest
- persistent retching but scant vomitus
- inability to pass nasogastric tube
three types of diverticulum
1. Zenker diverticulum (propulsion issue)
2. traction diverticulum
- tethering force assoc with cancer or granulomatous inf
3. epiphrenic diverticulum (propulsion issue)
- forms prox to GEJ
- assoc with HTNive LES
- +/- achalasia
esophageal syndrome
Boerhaave syndrome
- spontaneous esophageal rupture assoc with vomiting
- most common in L distal esoph
clinical ft:
- excruciating retrosternal chest pain with hx of emesis
- possible air in mediastinum/chest
Mallory Weiss tear
self limited cause of upper GI bleed
- hematemesis
- epigastric or back pain
- hx of emesis, retching, or coughing
tear in mucosa of lower esoph
dx: EGD
overarching algorithm: esoph disorders
