Chapter 17-Esophagus Flashcards
What is the embryological derivation of the esophagus
Cranial portion of the forget
What is nutcracker esophagus
High amplitude contraction of the distal esophagus due to the loss of normal coordination of the inner circular layer and outer longitudinal smooth muscle contraction
What is diffuse esophageal spasm
Repetitive, simultaneous contractions of the distal esophageal smooth muscle
What is the cause of lower esophageal sphincter dysfunction
-high resting pressure of incomplete relaxation
What can esophageal dysmotility result in
Development of small diverticula (epiphrenchic)right above the lower esophageal sphincter
What is the cause of Zenker diverticulum
Impaired relaxation and spasm of the cricopharyngeus after swallowing, which results in increased pressure within the distal pharynx
What is another name for Zenker diverticulum
Pharyngoesophageal diverticulum
Where do Zenker diverticulum develop
-Above the upper esophageal sphincter in the pharynx
What is the age group commonly to have Zenker diverticulum
Over 50
What is the cause of benign esophageal stenosis
Narrowing of the lumen caused by fibrous thickening of the submucosa due to atrophy of the muscularis propia due to GERD, irradiation
What are the physical side effects seen in patients with benign esophageal stenosis
Usually maintain the appetitive and weight
What are esophageal mucosal webs
Ledge like protrusions of mucosa and are composed of fibrovascular connective tissue overlying epithelium
What conditions are associated with esophageal mucosal webs
GERD, chronic graft versus host, blistering skin diseases
What conditions will accompany esophageal mucosal webs
- Iron deficiency Anemia
- Glossitis
- Cheilosis
What is the name of the condition that has esophageal webs along with the anemia
Paterson Brown Kelly or PLummer-Vinson syndrome
What is the main symptom of esophageal webs
Nonprogresive dysphagia with incomplete chewed food
What are Schatzki rings
Similar to Webs but are thicker and include mucosa, submucosa, and hypertropic muscularis propria
What is the location and make up of A rings
Distal esophagus, above the gastroesophageal junction, and contain squamous mucosa
What are the location and make up of B rings
Located at the squamocolumnar junction of the lower esophagus and contain gastric cardia-type mucosa
What is the triad that is characteristic of alchalasia
- Incomplete LES relaxation
- Increased LES tone
- aperistalsis of the esophagus
What are the symptoms of achalasia
- Difficulty swallowing both liquids and solids
- Difficulty burping
- chest pain
What is the cause of primary alchalasia
Distal esophageal inhibatory neurons, aka ganglion degeneration
-can be of the extraesophageal vagus nerve or the dorsal motor nucleus of the vagus
What are some causes of achalasia like diseases
- Diabeteic autonomic neuropathy
- malignancy or amyloidosis
- downsyndrome
- Allgrove syndrome (triple A)
What is algrove syndome aka triple A syndrome
Autosomal recessive
- Alchalasia
- Alacrima
- adrenocorticotripic hormone resistant adrenal insufficiency
What are Mallory Weiss tears associated with
Vomiting secondary to vomiting, especially with alcohol toxicity
What are the symptoms of Boerhaave syndrome
Causes mediastinitis
Severe chest pain, tachycardia, shock, and present as a MI
-Can also be causing vomiting of blood/hematemsis due to esophageal perforation.
What is pill induced esophagitis
Pill is taken, but dissolves in the esophagus rather than making it to the stomach
What are esophagus infection in healthy individuals caused by
HSV, but is very rare
What are the histological and morphological findings of herpes virus in the esophagus
Punched out ulcers
Nuclear viral inclusions within the rim of degeneration
What are the histological and morphological findings of CMV in the esophagus
Shallow ulcers with nuclear and cytoplasmic inclusions within the capillary endothelium and stromal cells
What are the some of the factors that can increase the chances of GERD
Alcohol Tabacco Obesity CNS depressants Pregnancy Hiatal herniation
Which population of patients is GERD most common
Older than 40
What is the taste in patients with GERD
Tasting of sour tasting gastric contents
What are the treatments for patients with GERD
Proton pump inhibators
What is a condition that resembles GERD and what is it characterized by
Hiatal hernias cause similar symptoms, but are caused by speration of the diaphragmatic crura and protrusion of the stomach into the thorax
What is the characteristic finding in eosinophilia esophagus
Large number of intraepithelial eisinophils superficially
What are the symptoms that helps to differentiate GERD from eiosinphilic esophagitis
- Increased eiosinophils
- No acid reflex
- High doses of PPI does not work
What are the conditions that are associated with eosinophilia esophagitis
Atopic dermatitis
Allergic rhinitis
Asthma
Following portal hypertension, what is the next most common cause of varices
Hepatic schistosomiasis
What are the treatments used to treat esophageal varices
Splanchnic vasoconstriction
Sclerotherapy (injection of thrombin agents)
Ballon tamponade
Varicella ligation
What is the main risk factor that needs to be addressed in patients with esophageal varices
The size and past history of bleeding
- Large tend to bleed and recurrent bleeding
- Small tend to not bleed
What is the typical patient group at risk for Barrett esophagus
White males between 40 to 60
What is the greatest risk associated with Barrett esophagus
Adenocarcinoma
The presence of dysplasia in Barrett esophagus is correlated with which things
- prolonged symptoms
- longer segment length
- increased patient age
- Caucasian race
What is the change seen in Barrett esophagus
-squamous esophageal epithelium replaced with goblet cells
What are the histological stain findings with Barrett esophagus
Mucous vacuole that stain blue with an H and E stain, leading to the shape of a wine goblet to the remaining cytoplasm
What is the most common esophageal tumor in the US and worldwide
Adenocarcinoma
What is the most common esophageal tumor in the world
Squamous cell carcinoma
What is the majority of benign tumors of the esophagus
Mesenchymal, so include smooth muscle cells
Which risk factors increase the risk of adenocarcinoma
Barrett esophagus
Tabacco use
Radiation
Lack of fresh fruits and vegetables
How does H pylori actually decrease the risk of adenocarcinoma
Causes gastric atrophy and the subsequent decrease in acid leads to decreased risk of Barrett esophagus
What is the patient group most commonly affected by adenocarcinoma
White Caucasian males
What are the mutations assocaited in the early transition from Barrett esophagus to adenocarcinoma
- TP53
- CDK2NA
What are the mutations assocaited in the late transition from Barrett esophagus to adenocarcinoma
EGFR ERBB2 MET Cyclin D1 Cyclin E
The adenocarcinomas that from from Barrett esophagus typically produce what
Forms glands and secrete mucin
What are the clinal presentations of esophageal adenocarcinomas
Pain/difficulty swallowing Progressive weight loss Hematemesis Chest pain Vomiting
Where doe the tumor general spread in adenocarcinomas of the esophagus
Submucosa lymphatic Vessels
What is the population group that is affected by squamous cell carcinoma of the esophagus
African amaerican (8x more likely) Males (4x) older than 45 years
What are the risk factors for developing squamous cell carcinoma
- Alcohol and tobacco
- achalasia
- tylosis
- Plummer-Vinson syndrome
- Lacking fruits and vegetables
- Very hot beverages*
Which cancer of the esophagus is increased via radiation and when does it typically present
-Squamous cell carcinoma, occurring 5 to 10 years after exposure
Which regions dent to have a higher risk for developing squamous cell carcinomas
- Rural and underdeveloped areas
- Western Kenya
- Iran, China, Hong Kong
Where is Africa is there a higher rate of squamous cell carcinoma and what is the cause
Western Kenya, due to consumption of mursik, which contains acetalaldehyde
What is the majority of squamous cell carcinomas of the esophagus due to in the US and western countries
Alcohol and tobacco use (synergistic)
What are the mutations associated with increased risk of squamous cell carcinoma of the esophagus
-SOX2
-Cyclin D1
TP53
-E Cadherin
-NOTCH1
Where in the esophagus do adenocarcinomas occur
Distal 1/3
Where in the esophagus do squamous cell carcinomas occur
Middle 1/3
How do squamous cell carcinomas begin
As squamous dysplasia (aka intraepithelial neoplasm/carcinoma in situ)
What are some locations of complications of squamous cell carcinomas and their spreading in the cavity
- Respiratory tree leading to pneumonia
- aorta leading to exsanguination
- Mediastinum and pericardium
What is the location of Squamous cell carcinoma of the esophagus if it spread to the cervical lymph nodes
Upper 1/3
What is the location of Squamous cell carcinoma of the esophagus if it spread to the paratracheal lymph nodes
Middle 1/3
What is the location of Squamous cell carcinoma of the esophagus if it spread to the gastric and celiac lymph nodes
Lower 1/3
What are the clinical presentations of squamous cell carcinoma of the esophagus
Dysphagia Odynophagia (pain on swallowing) Obstruction Change in eating from solid to liquid Weight loss Iron loss
What is commonly a first symptom of squamous cell carcinoma
Aspiration of food via the tracheoesophageal fistula
What is associated with the poorer prognosis in esophageal squamous cell carcinoma
LN metastasis
