B45 pathology of the esophagus

Question 1

What are the major types of pathologies in the esophagus?

(5)

Answer 1

1. Malformations
2. Motor disorders
3. Esophagitis
4. Varices and bleeding
5. Cancer

Question 2

What are the malformations of the esophagus?

Answer 2

Congenital malformations:

• Atresia, when part of it is not canalized and totally blocked. Usually accompanied by a fistula.
• Congenital Tracheo-esophageal fistula. A connection between the esophagus and trachea, and interruption of the esophagus.
  
  • Causes regurgitation if the upper half of the esophagus ends in a blind pouch, and causes sucking air into the stomach on breathing, balooning of the abdomen.
  • or can cause aspiration and suffocation if the upper end is connected to the esophagus and the lower half is a blind pouch. Detected immediately on eating and must be quickly fixed surgically.

Question 3

What is Achalasia?

What causes it?

Consequences?

Answer 3

Achalasia is the failure of smooth muscle to relax.

In the esophagus, Achalasia is associated with increased Lower Esophageal Sphincter tone, impaired relaxation during swallowing, and decreased/failed esophageal peristalsis.

Causes difficulty swallowing, dysphagia, and can cause massive dilation of the esophagus with possible diverticula formation due to food buildup.

Additionally the food buildup will cause inflammation, can lead to ulceration, perforation, and chronic inflammation increases risk of esophageal cancer

Causes:

• primary achalasia, is idiopathic, failure of inhibitory neurons in the LES.
• Chagas disease
• Diabetic autonomic neuropathy
• Dorsal motor nuclei lesions
  
  • sarcoidosis
  • malignancy
  • polio
• Degenerative or traumatic damage to the vagus nerve or dorsal motor nucleus of vagus.

Question 4

What kind of developmental rest is common in the esophagus?

Answer 4

Formation of ectopic gastric mucosa

Can secrete acid and lead to dysphagia, barret esophagus, and increased risk of adenocarcinoma (barret’s leads to adenocarcionma: mucinous gland metaplasia then adenocarcinoma)

Question 5

What are the acquired malformations of the esophagus?

Answer 5

Acquired trachoe-esophageal fistulas occur accidentally during surgery, or can occur as a result of esophageal cancers invading the trachea.

Stenosis. Forms due to thickening from inflammation and scarring. from chronic GERD or irradiation.

Diverticula

• ​True diverticula, malformations, contain all 3 layers, also called traction diverticula. Formed from inflammation of the surrounding tissue of the esophagus, and adhesions pulling the outer layers. for example from tuberculosis or other mediastinal inflammations.
• False diverticula, acutally herniation of the mucosa layer through weak points in the muscular layer. also called pulsion diverticula from the mucosal layer pulling through.
  
  • Occur in 3 points:
    
    • Above the upper esophageal sphincter at the cricopharyngeal muscle: Zanker diverticulum
    • In the middle of the esophagus
    • Above the lower esophageal sphincter, epiphrenic diverticulum.

Herniation of the stomach

• sliding hernia: 95% of the cases. The whole lower esophageal sphincter is shifted upwards from the diaphragm, and a circular portion of the stomach cardia moves upward with it, dilating above the diaphragm
• paraesophageal hernia: 5% The LES remains in its normal position within the diaphragm, but part of the stomach slides out to the side, forming an outpouching.
• These herniated regions can become ulcerated or perforated

Question 6

What are the causes of esophagitis?

Answer 6

1. Reflux esophagitis, results in:
   
   • ​​Strictures, scarring and fibrosis of the lower esophagus with narrowing of the lumen.
   • Leukoplakia, precancerous lesion to squamous cell carcinoma
   • Barret esophagus, columnar epithelial metaplasia with goblet cells.
2. Infectious esophagitis:
   
   • ​​Candidial esophagitis,
     
     • in diabetic females
     • immunosuppressed patients
     • HIV patients
   • CMV esophagitis
     
     • In HIV patients
3. Eosinophilic esophagitis
   
   • ​​usually seen in people with atopic dermatitis, atopic asthma, allergic rhinitis
   • idiopathic and defined by lots of eosinophils and inflammation in the esophagus.
   • assumed to be caused by some food allergen the patient is allergic to.
4. Chemical/corrosive esophagitis. ​

Question 7

What are the causes and consequences of esophageal varicies?

Answer 7

Caused by Portal Hypertension

Prehepatic causes:

• Portal vein thrombosis
• Malignancies causing compression, ex pancreatic cancer

Intrahepatic:

• Cirrhosis, which is the most common cause
• Schistosomiasis
• Wilson disease, excessive copper accumulation in the liver

Posthepatic:

• Budd chiari syndrome, hepatic vein thrombosis
• Right sided heart failure
• Constrictive Pericarditis

Consequences:

• Rupture and esophageal bleeding.
• Swallowed blood may lead to occult blood in stool
• Vomitting blood
• Rapid hypovolemic shock and death.

Question 8

What are the esophageal cancers?

Answer 8

1. Squamous cell carcinoma. Most common. about 90% of all esophageal cancers worldwide, BUT in the western world, adenocarcinoma has been increasing, and now these two are about 50% each.
   
   • caused by tabacco and alcohol.
   • or by HPV 16 and 18. These variants have better prognosis, justl ike in oral s.c.c.
   • usually occurs in the upper 2/3rds of the esophagus.
   • Preceeding by squamous dysplasia, carcinoma in situ, or leukoplakia.
   • More prevalent in men, usually in smokers, drinkers, over 45 years.
   • 6 times more common in blacks than whites.
   • Has a much higher incidence in Asia and South America than in the US/europe.
   • 75% 5yrS if there is no spread, drops to 10% if lymph nodes are involved.
2. Adenocarcinoma
   
   • ​​Occurs in the lower 1/3
   • Preceeded by Barret esophagus.
   • Caused by gastric reflux.
   • 7 times more prevalent in men
   • more common in whites
   • Sometimes found by regular observation of GERD/Barett esophagus
   • Otherwise presents with dysphagia, weight loss, chest pain, or vomiting. and has usually spread to lymphatics. 5yrS is less than 25% once spread has occured. and 80% if it is limited to the mucosa and submucosa.

Question 9

What are Mallory Weiss tears, what is Borhave syndrome?

Answer 9

Both are caused by severe bouts of vomitting and are longitudinal rips in the esophagus. Difference is the location.

Mallory Weis tears: occur across the gastric/esophageal junction, are usually superficial, and heal rapidly

Borhave syndrome: Occurs in the middle esophagus and causes mediastinitis, can be very severe and dangerous.

Question 10

What are the major complications of the esophageal cancers (besides metastasis)

Answer 10

Constriction, Stricture formation in the esophagus and dysphagia.

Ulcers and bleeding

Perforation, mediastinitis and sepsis

Tracheo-esophageal fistula formation and aspiration of food