Chapter 15: Esophagus

Question 1

Achalasia is a form of esophageal dysmotility. What is it characterized by?

Answer 1

A triad of incomplete lower esophageal sphincter (LES) relaxation, increased LES tone and esophageal aperistalsis.

Question 2

What is meant by ectopic tissues?

Answer 2

Ectopia is growth of normal tissue in the incorrect anatomic position and, in relation to the lung, comprises either nonpulmonary tissues being present in the lung or lung tissue outside the thoracic cavity.

Question 3

What can cause esophageal varices?

Answer 3

Diseases that impede portal blood flow cause portal hypertension, which can lead to the development of esophageal varices/

Question 4

What happens when portal hypertension occurs that can lead to the formation of varices?

Answer 4

It induces development of collateral channels that allow portal blood to shunt into the caval system (anastomosis). However, these collateral veins enlarge the subepithelial and submucosal venous plexi within the distal esophagus. These vessels are termed varices.

Question 5

What else can happen to the esophagus (besides varices)?

Answer 5

Laceration of the esophagus, mucosal injury and infection.

Question 6

What are common esophageal lacerations called?

Answer 6

Mallory-Weiss tears, which are often induced by severe stretching or vomiting. This happens when the esophagus isn’t able to relax before contraction (before vomiting for example), causing the wall to stretch (and tear).

Question 7

Mallory-Weiss tears heal quickly, which lacerations can result in mediastinitis, are catastrophic and require prompt surgical intervention?

Answer 7

Transmural esophageal tears (Boerhaave syndrome)

Question 8

Just read about the different forms of esophagitis (because I don’t think we need to know this)

Answer 8

• Pill-induced esophagitis, medicinal pills adhere to the esophageal lining and dissolve in the esophagus rather than passing to the stomach.
• Esophagitis due to chemical injury generally causes only self-limited pain (odynophagia; pain with swallowing).
• Infectious esophagitis is most frequent in debilitated or immunosuppressed individuals.
• Bacterial or fungal esophagitis can be primary of complicate a preexisting ulcer.

Question 9

What is a key component of the development of mucosal injury in gastroesophageal reflux disease (GERD) and what can exacerbate the damage?

Answer 9

Reflux of gastric juices, reflux of duodenal bile.

Question 10

What are conditions that decrease eosphageal sphincter tone or increase abdominal pressure that contribute to mucosal injury in gastroesophageal reflux disease (GERD) ? (don’t learn this by heart)

Answer 10

Alcohol, tobacco, obesity, central nervous system depressants, pregnancy, hital hernia, delayed gastric emptying and increased gastric volume.

Question 11

What are morphological characterizations are there for mucosal injury in gastroesophageal reflux disease (GERD) ?

Answer 11

Hyperemia evident as redness. In more significant disease, eosinophils are recruited into the squamous mucosa, followed by neutrophils.

Question 12

What is eosinophilic esophagitis?

Answer 12

A chronic immunologically mediated disorder.

Question 13

What are symptoms of eosinophilic esophagitis?

Answer 13

Food impaction and dysphagia in adults and feeding intolerance or GERD-like symptoms in children.

Question 14

How is the distinction made between GERD and eosinophilic esophagitis?

Answer 14

In eosinophillic esophagitis there’s epithelial infiltration of large numbers of eosinophils. There are also evident rings in the upper and mid portions of the esophagus..

Question 15

What is a complication of chronic GERD?

Answer 15

Barret esophagus that is characterized by intestinal metaplasia within the esophageal squamous mucosa.

Question 16

What risk increases in Barret esophagus?

Answer 16

Development of esophageal adenocarcinoma.

Question 17

What is a defining feature of intestinal metaplasia and a feature of Barret esophagus?

Answer 17

The presence of goblet cells, which have distinct mucous vacuoles that stain pale blue.

Question 18

Molecular studies suggest that the progression of Barrett esophagus to adenocarcinoma occurs over an extended period through the stepwise acquisition of genetic and epigenetic changes. This model is supported by the observation that epithelial clones identified in nondysplastic Barrett metaplasia persist and accumulate mutations during progression to dysplasia and invasive carcinoma. What kind of mutations are these?

Answer 18

Chromosomal abnormalities and TP53 mutation, these are often present in the early stages of adenocarcinoma. Additional genetic changes and inflammation are thought to contribute to tumor progression.

Question 19

What can be seen from this picture?

Answer 19

Esophageal adenocarcinoma growing back-to-back glands.

Question 20

What are clinical symptoms of esophageal adenocarcinoma?

Answer 20

Difficulty swallowing, progressive weight loss, chest pain or vomiting.

Question 21

Why is the prevalence of esophageal squamous cell carcinonomas highest in Europe and the US?

Answer 21

Because of the use of alcohol and tobacco which synergize to increase risk.

Question 22

Fill in: In contrast to the … (1) location of most adenocarcinomas, half of squamous cell carcinomas occur in the … (2) third of the esophagus

Answer 22

1. distal 2. middle

Question 23

How do squamous cell carcinomas develop?

Answer 23

They begin as an in situ lesion in the form of squamous dysplasia. Over months to years they grow into tumor masses that may be polypoid and protrude into and obstruct the lumen.

Question 24

So squamous cell carcinoma beginst as an in situ lesion and eventually will grow into tumor masses that can protrude and obstruct the lumen. They don’t nessecarily have to protrude the lumen, what else can happen to the tumor?

Answer 24

Tumors that are either ulcerated or diffusely infiltrative lesions that spread within the esophageal wall, where they can cause thickening, rigidity and luminal narrowing.

Question 25

Are most squamous cell carcinomas differentiated?

Answer 25

Yes, they are moderately to well-differentiated.

Question 26

What are clinical manifestations of squamous cell carcinoma?

Answer 26

Dysphagia (difficulty swallowing), odynophagia (pain on swallowing) and obstruction.

Question 27

Inflammation of the esophagus can result in adenocarcinoma. Here, it starts with esophagitis which results in intestinal metaplasia. Followed by dysplasia, esophagitis changes into an adenocarcinoma. What happens during (reflux) esophagitis?

Answer 27

Inflammation, seen by hyperemia and granulocytes (and in severe cases ulceration).

Question 28

Inflammation of the esophagus can result in adenocarcinoma. Here, it starts with esophagitis which results in intestinal metaplasia. Followed by dysplasia, esophagitis changes into an adenocarcinoma. What happens during metaplasia and (chronic) inflammation?

Answer 28

Because of the chronic inflammation metaplasia occurs. Here, differentiated cells are replaced by another differentiated cell type.

Question 29

What is seen in this picture?

Answer 29

Intestinal metaplasia

Question 30

What is meant by dysplasia? And what is cytonuclear atypia?

Answer 30

Dysplasia is any of various types of abnormal growth or development of cells. Cytonuclear atypia are cells with large nuclei, irregular shape of nuclei and coarse chromatin pattern due to dysplasia.

Question 31

How can adenocarcinoma of the oesophagus be recognized?

Answer 31

Because adenocarcinomas form tubular structures and these tubular structures invade deeper layers. Furthermore an adenocarcinoma can be recognized through cytonuclear atypia (but also irregular tubular structures).

Question 32

If tubular structures are only present in the mucosa, it is called…

Answer 32

dysplasia

Question 33

What is the difference between adenocarcinoma and squamous cell carcinoma?

Answer 33

Adenocarcinoma is a result from inflammation, metaplasia and dysplasia. Squamous cell carcinoma is a result from dysplasia of squamous epithelium.