Chapter 28 - Pharynx and Esophagus (CHERI NOTES) Flashcards
The _____ ; also called a ___ ;is a barium examination of the alimentary tract from the pharynx to the ligament of treitz. (p.734)
UPPER GASTROINTESTINAL (UGI)SERIES (aka BARIUM MEAL)
A ____ or _____ is a study more dedicated
to the evaluation of swallowing disorders and suspected
lesions of the pharynx and esophagus. (p.734)
BARIUM SWALLOW or ESOPHAGOGRAM
Distention of the pharynx is provided by
having the patient ____. (p.734)
PHONATE
Distention of the esophagus is attained by
having the patient __.
(p.734)
HAVE THE PATIENT INGEST GAS-PRODUCING
CRYSTALS
___ views are collapsed views of the bariium-coated
esophagus. (p.734)
MUCOSAL VIEWS
TRUE OR FALSE.
CT is poor at evaluating the musosa and
generally cannot differentiate inflammatory and
neoplastic conditions. (p.734)
TRUE
MR is preferred over CT for evaluation of the
nasopharynx and is an alternative to CT for
demonstrating the extent of disease.
____ is useful for demonstration of tumor
penetration of the esoophageal wall. (p.734)
ENDOSCOPIC SONOGRAPHY
7 symptoms of abnormal oral or pharyngeal
swallowing. (p.737)
- Difficulty initiating swallowing
- Globus sensatuib (lump in throat)
- Cervical Dysphagia
- Nasal Regurgitation
- Hoarseness
- Coughing
- Choking
4 symptoms suggesting ESOPHAGEAL
DYSFUNCTION. (p.737)
- HEARTBURN
- DYSPHAGIA
- “INDIGESTION”
- CHEST PAIN
___ is defined as the awareness of swallowing
difficulty during the passage of solids or liquids
from mouth to stomach. (p.734)
DYSPHAGIA
- odynophagia (painful swallowing)
TRUE OR FALSE.
In Esophageal Motility disorders; the patient’s
subjective assessment of the location of the
abnormality is not reliable. (p.737)
TRUE
4 signs of PHARYNGEAL DYSFUNCTION
p.737
- PHARYNGEAL STASIS
- LARYNGEAL PENETRATION
- ASPIRATION
- NASAL REGURGITATION
- LARYNGEAL PENETRATION and tracheobronchial ASPIRATION are associated with increased risk of developing pneumonia especially in hospitalized patients.
_____; indicative of impaired pharyngeal transport;
is seen as increased residual volume of swallowed
material filling the valleculae and piriform sinuses.
(p.737)
PHARYNGEAL STASIS
____ is defined as entry of barium into the laryngeal
vestibule without passage below the vocal cords.
(p.737)
LARYNGEAL PENETRATION
____ implies barium passage below the vocal cords
p.737
ASPIRATION
____ occurs when the soft palate does not make a
good seal against the posterior pharyngeal wall.
(p.737)
NASAL REGURGITATION
-causes include neurologic impairment;
muscular dystrophies; and structural
defects in the palate.
______ is attibutable to failure of complete relaxation
of the UES ; commonly resulting in dysphagia and
aspiration. (p.737)
CRICOPHARYNGEAL ACHALASIA
In CRICOPHARYNGEAL ACHALASIA;
barium swallo demonstrates a shelf-like impression
(CRICOPHARYNGEAL BAR) on the barium column
at the pharyngoesophageal junction at the level
of ____. (p.737)
C5-C6 level
- the pharynx is distended and barium may overflow
into the larynx and trachea.
Narrowing of the lumen greater than ___ %
is generally accepted as a definite cause of dysphagia
(p.737).
greater than 50%
- cricopharyngeal dysfuntion is commonly associated
with neuromuscular disorders of the pharynx.
_____ of the esophagus is a disease of unknown
eitology characterized by:
1. absence of peristalsis in the body of the esophagus
2. marked increase in resting pressure of the LES
3. failure of the LES to relax with swallowing
(p.737)
ACHALASIA
- the abnormal peristalsis and LES
spasm result in a failure of the
esophagus to empty - pathologically; cases show a deficiency
of ganglion cells in the myenteric plexus
(Auerbach plexus) throughout the esophagus. - clinical presentation is insidious;
usually at 30 to 5 years; with dysphagia;
regurgitation; foul breath and aspiration.
5 Radiographic signs of
ACHALASIA (p.738)
1. Uniform dilatation of the esophagus; usually with an air-fluid level present 2. Absence of peristalsis; with tertiary waves common in the early stages of the disease 3. Tapered "beak" deformity at the LES because of failure of relaxation 4. Findings of esophagitis including ulceration 5. Increased incidence of Epiphrenic Diverticulum and Esophageal CA
- treatment of Achalasia is BALLOON DILATION
or HELLER MYOTOMY
3 Diseases that may mimic
Esophageal Achalasia. (p. 738)
- Chagas Disease
- Carcinoma of the GEJ
- Peptic Strictures
\_\_\_\_\_ is caused by the destruction of ganglion cells of the esophagus due to a neurotoxin released by the protozoa; Trypanosoma cruzi; endemic to South America; esp. eastern Brazil. (p.738)
CHAGAS DISEASE
- The radiographic appearance of the esophagus is identical to achalasia.
- Associated abnormalities include cardiomyopathy;
megaduodenum; megaureter and megacolon
\_\_\_\_\_ may mimic achalasia but tends to involve a longer (> 3.5 cm) segment of the distal esophagus; is rigid; and tends to show more irregular tapering of the distal esophagus and mass effect. (p.738)
CARCINOMA OF THE GEJ
When findings of achalasia are present on barium studies; it is important to evaluate the \_\_\_\_\_\_\_\_\_\_\_\_ and \_\_\_\_to rule out an underlying malignant tumor at the GEJ as the cause of these findings. (p.738)
GASTRIC CARDIA and FUNDUS
- The cardia and fundus is however not adequately evaluated radiographically in all patients because of delayed emptying of barium from the esophagus. - Therefore; it is important to be aware of the limitations of barium studies in evaluating the cardia and fundus in patients with suspected achalasia.
\_\_\_ strictures are usually associated with normal primary esophageal peristalsis. A hiatal hernia is usually present. (p.738)
PEPTIC STRICTURES
\_\_\_\_ is a syndrome of unknown cause characterized by multiple tertiary esophageal contractions; thickened esophageal wall; and intermittent dyphagia and chest pain. (p.738)
DIFFUSE ESOPHAGEAL SPASM
- primary peristalsis is usually present but contractions are infrequent. - Most patients are middle-aged - The LES is frequently dysfunctional and the conditions commonly improves with injection of Clostridium botulinum toxin at the GEJ wth endoscopic balloon dilatation of the LES.
\_\_\_ is characterized on barium studies by intermittently absent or weakened primary esophageal peristalsis with simultaneous; nonperistaltic contractions that compartmentalize the esophagus; producing a classic corkscrew appearance. (p.738)
DIFFUSE ESOPHAGEAL SPASM
- CT reveals circumferential thickening
(5 to 15 mm) of the wall of the
distal 5 cm of the esophagus in
20% of patients.
______ disorders are a common
cause of abnormalities of the
oral; pharyngeal; or esophageal
phases of swallowing. (p.738)
NEUROMUSCULAR disorders
The most common cause
of neurologic dysfunction is
_____ and ____. (p. 738)
CEREBROVASCULAR DISEASE and
STROKE
- additional causes include Parkinsonism;
Alzheimer disease; multiple sclerosis;
neoplasms of the CNS and posttraumatic
CNS injury.
Diseases of the striated esophageal muscle; such as muscular dystrophy; myasthenia gravis; and dermatomyositis; predominantly affect the \_\_\_ and \_\_\_\_\_\_ of the esophagus. (p.738)
PHARYNX and PROXIMAL THIRD
(striated muscle portion) of the
esophagus.
\_\_\_\_ is a systemic disease of unknown cause characterized by progressive atrophy of smooth muscle and progressive fibrosis of affected tissues. (p.739)
SCLERODERMA
- women are most commonly affected; usually aged 20 to 40 years at the onset of disease. - the esophagus is affected in 75% to 80% of patients
4 Radiographic findings of
Scleroderma (p.739)
1. Weak to absent peristalsis in the distal two-thirds (smooth muscle portion) of the esophagus. 2. Delayed esophageal emptying 3. A stiff dilated esophagus that does not collapse with emptying 4. Wide gaping LES with free gastroesophageal reflux.
- despite free reflux; tight strictures
of the distal esophagus are uncommon.
TRUE OR FALSE. Postoperative states; including surgery for malignancy of the tongue;larynx and the pharnyx; commonly impair swallowing function as well as alter the morphology.
TRUE
- surgical resection is aimed at providing
at least a 1-cm margin free of tumor and
often results in removing large blocks of
tissue and functionally altering the
structures that remain.
\_\_\_\_ frequently results in abnormal esophageal motility and esophageal motility and visualization of tertiary esophageal contractions. (p.739)
ESOPHAGITIS
\_\_\_\_ occurs as a result of incompetence of the LES. The resting pressure of the LES is abnormally decreased and fails to increase with raised intraabdominal pressure. (p.739)
GASTROESOPHAGEAL REFLUX
DISEASE (GERD)
- as a result; increases in intraabdominal
pressure exceed LES pressure;
and gastric contents are allowed to
reflux into the esophagus. - GERD is classified as a spectrum of
conditions: nonerosive reflux disease;
erosive esophagitis; and Barett esophagus.
3 symptoms of GERD.
p.739
1. SUBSTERNAL BURNING PAIN
("heartburn")
2. POSTURAL REGURGITATION
(in supine position)
3. DEVELOPMENT OF
REFLUX ESOPHAGITITS;
DYSPHAGIA AND ODYNOPHAGIA.3 complications of GERD (p.739)
- REFLUX ESOPHAGITIS
- STRICTURE
- DEVELOPMENT OF BARRETT
ESOPHAGUS
TRUE OR FALSE. Thhe radiographic diagnosis of GERD may be difficult because 20% of normal individuals show spontaneous reflux on UGI examination; and patients with pathologic GERD may not demonstrate reflux without provocative tests. (p.739)
TRUE
5 Findings associated with
GERD on barium esophagrams.
(p.739)
1. HIATAL HERNIA; associated with presence of reflux esophagitis 2. SHORTENING OF THE ESOPHAGUS; a finding of importance to treating GERD surgically 3. IMPAIRED ESOPHAGEAL MOTILITY 4. GASTROESOPHAGEAL REFLUX; often demonstrated by provocative maneuvers such as Valsalva; leg raising; and cough 5. Prolonged clearance time of refluxed gastric contents.
- low volume reflux is not considered a
significant finding.
Most sensitive means of
diagnosing abnormal GERD
(p.739)
MONITORING OF ESOPHAGEAL pH for
24 hours in an ambulatory patient.
- GERD is managed medically with agents
that inhibit gastric acid production or
surgically with fundoplication
___ hernia is often considered
synonymous with GERD. (p.739)
HIATUS hernia
- most patients with hiatus hernia do not have gastroesophageal reflux or evidence of esophagitis. - Hiatus hernia is therefore NOT LIKELY as a PRIMARY CAUSE OF REFLUX. - However; up to 90% of patients with GERD have a hiatus hernia. - The presence of hiatus hernia delays the clearance of reflux and promotes development of RE.
Simply defined as protrusion
of any portion of the stomach
into the thorax. (p.740)
HIATUS hernia
- highly prevalent affecting
40% to 60% of adults.
3 types of hiatal hernia (p.740)
- SLIDING HIATUS HERNIA
- PARAESOPHAGEAL HIATUS HERNIA
- MIXED OR COMPOUND HIATAL
HERNIA
Most common type of hiatal hernia (95%).
p.740
SLIDING HIATUS HERNIA
Type of hiatal hernia where the the GEJ is displaced more than 1 cm above the hiatus. The esophageal hiatus is often abnormally widened to 3 to 4 cm. (p.740)
SLIDING HIATUS HERNIA
- the gastric fundus may be displaced above
the diaphragm and present as a
retrocardiac mass on chest radiographs. - the presence of an air-fluid level in the
mass suggests the diagnosis. - small; sliding hiatus hernias commonly
reduce in the upright position. - the function of the LES and the presence
of pathologic gastroesophageal reflux
are the crucial factors in producing
symptoms and causing complications.
The upper limit of normal hiatal
width is __ mm; most easily
measured by CT. (p.740)
15 mm
type of hiatal hernia where the the GEJ remains in normal location; while a portion of the stomach herniates above the diaphragm. (p.740)
PARAESOPHAGEAL HIATUS HERNIA
\_\_\_\_\_is the most common type of paraesophageal hernia. The GEJ is displaced into the thorax with a large portion of the stomach; which is usually abnormally rotated.
MIXED OR COMPOUND HIATAL HERNIA
TRUE OR FALSE. Paraesophageal hernis; esp. when large with most of the stomach in the thorax; are at risk for volvulus; obstruction and ischemia. (p.740)
TRUE
___ are protrusions of pharyngeal
mucosa through areas of
weakness of the lateral
pharyngeal wall. (p.741)
LATERAL PHARYNGEAL DIVERTICULA
Most common regions of
Lateral Pharyngeal Diverticula.
(p.741)
TONSILLAR FOSSA and the
THYROHYOID MEMBRANE
These condition reflects
increased intrapharyngeal pressure and are seen most
commonly in wind instrument
players. (p.741)
LATERAL PHARYNGEAL DIVERTICULA
\_\_\_\_ arises in the hypopharynx just proximal to the UES. It is located in the posterior midline at the cleavage plane, known as Killian dehiscence; between the circular and the oblique fibers of the crico- pharyngeus muscle. (p.741)
ZENKER DIVERTICULUM
- the diverticulum has a small neck that is higher than the sac; resulting in food and liquid being trapped within the sac. - the distended sac may compress the cervical esophagus - symptoms include dysphagia; halitosis and regurgitation of food.
\_\_\_\_\_ diverticula which originate on the anterolateral wall of the proximal cervical esophagus in a gap just below the cricopharyngeus and lateral to the longitudinal tendon of the esophagus (i.e. the Killian- Jamieson space). (p.741)
KILIAN-JAMIESON DIVERTICULA
- less common and considerably smaller than Zenker diverticulum and appear on pharyngoesophagography as persistent left-sided or; less frequently; bilateral outpouchings from the proximal cervical esophagus below the cricopharyngeus.
- less likely to cause symptoms
and are less likely to be associated with
overflow aspiration or gastroesophageal
reflux than is Zenker Diverticulum
Midesophageal diverticula
may be ___ or ___ diverticula.
(p.742)
PULSION or TRACTION DIVERTICULA
- midesophageal diverticula have large
mouths; empty well and are usually
asymptomatic
____ diverticula occur as a result
of disordered esophageal
peristalsis. (p.742)
PULSION DIVERTICULA
\_\_\_\_ diverticula occur because of fibrous inflammatory reactions of adjacent lymph nodes and contain all esophageal layers. (p.742)
TRACTION DIVERTICULA
_____ diverticula occur just above
the LES; usually on the right side.
They are rare and usually found
with esophageal motility disorders.
- because of a small neck;
higher than the sac; they may trap
food and liquids and cause symptoms
(p.742)
EPIPHRENIC DIVERTICULA
____ are small outpouchings
of the esophagus that
usually occur as a sequela of
severe esophagitis. (p.742)
SACCULATIONS
- thought to result from the healing and scarring of ulcerations - tend to change in size and shape during fluoroscopic observation - smooth contours help to differentiate sacculations from ulcerations
\_\_\_\_\_ are the dilated excretory ducts of deep mucous glands of the esophagus. - they appear as flask-shaped barium collections that extend from the lumen or as lines and flecks of barium outside the esophageal wall. (p.742)
INTRAMURAL PSEUDODIVERTICULA
- tend to occur in clusters and in
association with strictures.
- linear tracks of barium ("intramural
tracking") commonly bridge adjacent
pseudodiverticula.
7 radiographic signs of
ESOPHAGITIS (p.743)
1. Thickened esophageal folds (>3 mm) 2. Limited esophageal distensibility (asymmetric flattening) 3. Abnormal motility 4. Mucosal plaques and nodules 5. Erosions and ulcerations 6. Localized stricture 7. Intramural pseudodiverticulosis (barium filling of dilated 1 to 3 mm submucosal glands)
____ are a hallmark finding of
esophagitis. (p. 743)
ULCERS
- CT usually reveals non-specific findings
of :
1. thickening of the wall (>5 mm)
2. target sign with hypoattenuating thickened wall
and high attenuating enhancing mucosa
SMALL ULCERS (< 1 cm) are found with \_\_\_\_\_(give 5). (p.743)
- reflux esophagitis
- herpes
- acute radiation
- drug-induced esophagitis; and
- benign mucous membrane pemphigoid
LARGER ULCERS (>1 cm) are characteristic of \_\_\_. (give 4). (p. 743)
- CYTOMEGALOVIRUS
- HIV
- BARETT ESOPHAGUS
- CARCINOMA
____ is the result of esophageal
mucosal injury owing to exposure
to gastroduodenal secretions.
(p.743)
REFLUX ESOPHAGITIS
- severity depends on the concentration
of the caustic agent and duration of the
contact with the esophageal mucosa.
The findings of reflux esophagitis
is always most prominent in the
___ and _____. (p.743)
DISTAL ESOPHAGUS and GEJ
Early changes of REFLUX ESOPHAGITIS include \_\_\_\_; which is manifest as granular or nodular pattern of the distal esophagus. (p.743)
MUCOSAL EDEMA
TRUE OR FALSE. In contrast to the distinct borders of Candida plaques and nodules; REFLUX ESOPHAGITIS nodules have poorly defined borders.
TRUE
Inflammatory exudates and
pseudomembrane formation
may mimic fulminant ____
esophagitis. (p.743)
- patient has symptoms of reflux
rather than severe odynophagia.
CANDIDA esophagitis
____ is the most common cause
of esophageal ulcerations. (p.743)
REFLUX ESOPHAGITIS
- ulcers appear as discrete linear;
punctate;or irregular collections of
barium; usually surrounded by a
radiolucent mound of edema. (p.743)
TRUE OR FALSE. Prominence of ulcerations in the DISTAL rather than proximal or midesophagus is the key to differentiating reflux esophagitis ulcers from those of herpes or drug-induced esophagitis. (p.743)
TRUE
4 Complications of reflux
esophagitis. (p.743)
- Ulceration
- Bleeding
- Stricture
- Barett esophagus
\_\_\_\_ is an acquired condition of progressive columnar metaplasia of the distal esophagus caused by chronic gastroesophageal reflux.
BARRETT ESOPHAGUS
- Columnar rather than squamous epithelium lines the distal esophagus. - PREMALIGNANT; with 30 ro 40-times increased risk of developing adenocarcinoma; resulting in a 15% prevalence of adenocarcinoma in patients with Barrett esophagus. - AdenoCA may develop at any age
The prevalence of Barrett Esophagus in patients with RE is about \_\_%; but increases to \_\_ % in patients with scleroderma. (p.743)
BARRETT ESOPHAGUS prevalence:
10 % (RE)
37% (Scleroderma)
The characteristic radiographic
appeaerance of BARRETT
ESOPHAGUS is a ___.
(p.743)
HIGH (MIDESOPHAGEAL) STRICTURE
OR DEEP ULCER IN A PATIENT WITH
GERD
- a reticular mucosal pattern of the esophageal mucosa; resembling areae gastricae of the stomach; is also suggestive. - the diagnosis is confirmed by endoscopy and biopsy
___ esophagitis is found most
commonly in patients with
compromised immune system.
(p.743)
INFECTIOUS esophagitis
- increasingly common because of the
use of steroids and cytotoxic drugs
and because of the increasing
prevalence of AIDS
____ is by far th most common
cause of infectious esophagitis
and is highly prevalent in patients
with AIDS. (p.744)
CANDIDA ALBICANS
- additional risk factors include
malignancy; radiation; chemotherapy
and steroid treatments.
Candida of the oropharynx
p.744
THRUSH
- odynophagia is a prominent symptom
- discrete plaque-like lesions demonstrated
by double-contrast esophagrams are most
characteristic - plaques appear as longitudinally oriented
linear or irregular discrete filling defects
etched in white with intervening normal-
appearing mucosa. - the lesions may be tiny and nodular or giant
and coalescent with pseudomembranes - ulcers tend to be small (<1 cm) and may
be punctate; round; oval or linear. - fulminant disease produces the “foamy
esophagus” with a pattern of tiny bubbles
at the top of the barium column
____ esophagitis begins as
discrete vesicles that rupture to
to form discrete mucosal ulcers.
(p.744)
HERPES SIMPLEX ESOPHAGITIS
- ulcers may be linear; punctate or
ring-like and have a characteristic
radiolucent halo.
Discrete ulcers on a background
of normal mucosa involvong
the midesophagus are most
characteristic of ____. (p. 744)
HERPES
- nodules and plaques are
usually absent
___ is cause of fulminant
esophagitis in patients with
AIDS. (p.744)
CYTOMEGALOVIRUS
- CMV esophagitis is is characteristically manifest as one or more large; flat mucosal ulcers - endoscopic biopsy or culture confirms the diagnosis
____ esophagitis causes giant
ulcers and severe odynophagia.
(p.744)
HIV esophagitis
- the ulcers are large; flat and usually
in the midesophagus
The ___ is the least common
portion of the GI tract to be
involved by tuberculosis.
(p.744)
ESOPHAGUS
- manifestations of esophageal TB:
ulceration; stricture; sinus tract and
abscess formation
\_\_\_\_ esophagitis is the result of intake of oral medications that produce a focal inflammation in areas of contact with mucosa. (p.744)
DRUG-INDUCED ESOPHAGITIS
- drugs that cause this condition include:
tetracycline; doxycyclne; quinidine;
aspirin; indomethacin; ascorbic acid;
potassium chloride and theophylline. - radiographic appearance may be
identical to herpes esophagitis;
with discrete ulcers separated by
normal mucosa in the midesophagus. - history is suggested by a history of
recent drug ingestion
Healing of drugi-induced
esophagitis occurs within
__ to __ days of discontinuing
the offending medication. (p.744)
7 to 10 days
____ ingestion usually occurs
as an accident in children or a
suicide attempt in adults.
(p.744)
CORROSIVE ingestion
- alkaline agents (liquid lye)
produce deep (full thickness)
coagulation necrosis. - acid agents tend to produce
more superficial injury - ulceration; esophageal
perforation and mediastinitis
may complicate the acute
injury. - late complications are fibrosis long
or multiple strictures
___ may rarely manifest as
discrete apthous ulcers in the
esophagus. (p.744)
CROHN DISEASE
- involvement of the small
or large bowel by CROHN DISEASE
is virtually always present.
TRUE OR FALSE. Crohn disease of the esophagus should not be considered unless Crohn disease of the bowel is already evident. (p.744)
TRUE
____ esophagitis occurs in
patients with a history of
thoracic radiation therapy
for malignant disease. (p.745)
RADIATION ESOPHAGITIS
- acute radiation may cause shallow or deep ulcers in the area of involvement. - with the development of fibrosis; the peristaltic wave is interrrupted and a long smooth stricture may develop within the radiotherapy field. - UGI shows a variable length segment of esophageal narrowing multiple discrete ulcers or a granular mucosal pattern within the radiation field.
Higher radiation dose in the
range of ___ to ____ R
is associated with development
of strictures. (p.745)
4500 to 6000 R
- simultaneous radiotherapy and doxorubicin hydrochloride (Adriamycin) chemotherapy greatly accentuates esophageal inflammation.
__ defined as any persistent
intrinsic narrowing of the
esophagus. (p.745)
STRICTURES
The most common causes of
esophageal strictures are ____.
(p.745)
FIBROSIS induced by INFLAMMATION
AND NEOPLASM
- because radiographic findings are not
reliable in differentiating benign from
malignant strictures; all should be
evaluated endoscopically.
DISTAL ESOPHAGEAL
STRICTURES are caused by
__ (give 3). (p.745)
- GERD
- SCLERODERMA
- PROLONGED NASOGASTRIC
INTUBATION
UPPER AND MID-ESOPHAGEAL
STRICTURES most commonly
results from ____ (give 4).
(p.745)
- BARRETT ESOPHAGUS
- MEDIASTINAL RADIATION
- CAUSTIC INGESTION
- SKIN DISEASES associated with
mucosal ulceration such as pemphigoid;
erythema multiforme and epidermolysis
bullosa dystrophica
BENIGN vs MALIGNANT
ESOPHGEAL STRICTURES
(p.745)
BENIGN STRICTURES
- typically show smoothly tapering
concentric narrowing
MALIGNANT STRICTURES - are characteristically abrupt; assymetric; eccentric narrowings with irregular; nodular mucosa - tapered margins may occur because of the ease of submucosal spread of tumor
TRUE OR FALSE.
Acute and chronic findings of
esophagitis commonly overlap.
(p.745)
TRUE
- Chronic inflammation induces
progressive firbrosis that eventually
narrows the esophageal lumen
___ (____) is the most common
cause of esophageal stricture.
(p.745)
REFLUX ESOPHAGITIS (GERD)
- reflux strictures are usually confined to the DISTAL ESOPHAGUS - may be tapered; smooth and circumferential (the classic appearance) or assymetric and irregular - small smooth sacculations and fixed transverse folds are characteristic and caused by scarring.
Long segment esophageal
stricture may be induced by
long-term_____ . (p.745)
long-term NASOGASTRIC INTUBATION
- nasogastric tubes prevents closure of the LES; resulting in continuous bathing of the distal esophagus with acid reflux from the stomach - Zollinger-Ellison syndrome can lead to severe reflux esophagitis because of the high acid content of refluxed gastric contents.
A \_\_\_\_\_ is pathologic ring-like esophageal stricture at the level of the B ring; caused by reflux esophagitis. (p.745)
SCHATZKI RING
TRUE OR FALSE. BARRETT ESOPHAGUS strictures tend to be high in the midesophagus and may be smooth and tapered or ring-like narrowings. (p.745)
TRUE
- the high position is because of a tendency for strictures to occur at the squamocolumnar junction; which has been displaced to a position well above the GEJ
TRUE OR FALSE.
CORROSIVE STRICTURE are long
and symmetrical. They commonly develop years
after the initial injury. (p.745)
TRUE
___ esophagitis may occur
in patients who have undergone
partial or total gastrectomy. (p.745)
ALKALINE REFLUX ESOPHAGITIS
- reflux of bile or pancreatic secretions into the esophagus results in the development of severe alkalkine reflux esophagitis and distal esophageal strictures whose length and severity increase rapidly over a short period of time.
Performing a \_\_ reconstruction at the time of surgery helps prevent reflux of bile and pancreatic secretion into the esophagus. (p.745)
ROUX-EN-Y reconstruction
TRUE OR FALSE. An alkaline reflux stricture should be suspected when barium examination performed in patients who have undergone partial or total gastrectomy or gastrojejunostomy reveals a long stricture in the distal esophagus. (p.745)
TRUE
\_\_\_ esophagitis is an increasingly common diagnosis made most often in young men with a history of allergies. (p.745-746)
EOSINOPHILIC ESOPHAGITIS
- some have a peripheral eosinophilia - patients present with a long- standing history of dysphagia and food impaction
DIAGNOSIS? Barium studies demonstrate smooth long-segment narrowing of the esophagus or a series of ring-like strictures; called the "RINGED ESOPHAGUS" (P.746)
EOSINOPHILIC ESOPHAGITIS
- biopsy reveal eosinophilic infiltration of the wall of the esophagus - the cause may be related to ingested food allergens - treatment is STEROIDS
Radiation strictures are confined to the radiotherapy field. They are smooth and tapered and usually in the \_\_\_ or \_\_\_ -esophagus. (p.746)
UPPER or MID-ESOPHAGUS
An irregular; ulcerated; circumferential narrowing with nodular shoulders is most typical of \_\_\_ esophageal stricture. (p.746)
MALIGNANT stricture (esophageal)
- infiltrative tumors may cause smooth; rigid narrowing of the esophagus without a clear zone of transition - the mucosa may not be altered until tumor spread is substantial
TRUE OR FALSE. Because longitudinal spread of tumor along the length of the esophagus is typical; long-segment strictures caused by carcinoma are common. (p.746)
TRUE
___ are thin (1 to 2 mm);
delicate membranes that
sweep partially across the
esophageal lumen. (p.746)
ESOPHAGEAL WEBS
- they occur in both the pharynx esophagus and are commonly multiple. - most are incidental findings; however; they occasionally cause sufficient obstruction to result in dysphasia.
Pharyngeal webs arise most
commonly from the ____ wall
of the hypopharynx. (p.746)
ANTERIOR wall of the hypopharynx
Esophageal webs may occur
anywhere; but they are most
common in the _____. (p.746)
CERVICAL ESOPHAGUS just distal
to the cricopharyngeus impression
TRUE OR FALSE. Malignancy or inflammation in the mediastinum may encase the esophagus and narrow its lumen. (p.746)
TRUE
- causes of esophageal extrinsic compression include Lung CA; Lymphoma; metastatsis to mediastinal nodes; TB and histoplasmosis.
TRUE OR FALSE.
Thick folds occur most commonly
with reflux esophagitis. (p.746)
TRUE
- additional findings associated with
esophagitis ; such as ulcerations and nodules; are commonly present.
\_\_\_ appear as serpiginous filling defects that change in size with changes in intrathoracic pressure and that collapse with esophageal peristalsis distension. (p.746)
ESOPHAGEAL VARICES
Esophageal varices are best
best demonstrated on UGI
with ___ views. (p.746)
MUCOSAL REFIEF VIEWS.
TRUE OR FALSE. CT with bolus contrast enhancement demonstrates varices as enhancing vascular structures within and adjacent to esophageal wall near the GEJ. (p.746)
TRUE
- MR is also effective in demonstrating
varices as vascular spaces; with signal
void because of flowing blood.
___ varices refer to the porto-
systemic veins that enlarge
because of portal HTN. (p.746)
UPHILL VARICES
- coronary vein collaterals connect
with gastroesophageal varices that
drain into the inferior vena cava through
the azygos system. (p.746)
Uphill varices are usually only
present in the ___ esophagus.
(p.746)
DISTAL esophagus
\_\_\_ varices are formed as a result of obstruction of the superior vena cava with drainage from the azygous system through esophageal varices to the portal vein. (p.748)
DOWNHILL VARICES
Downhill varices usually
predominate in the ____
esophagus. (p.748)
PROXIMAL esophagus
TRUE OR FALSE.
Lymphoma may infiltrate the
submucosa and thicken the
folds. (p.748)
TRUE
- lymphoma rarely involves the
esophagus directly and is virtually
never primary in the esophagus.
p.748
___carcinoma causes thick;
tortuous; longitudinal folds
that resemble varices but
are rigid and persistent. (p.748)
VARICOID carcinoma
TRUE OR FALSE.
Pharyngeal carcinoma are well
demonstrated by double
contrast pharyngography. (p.748)
TRUE
DIAGNOSIS? (pharynx) Radiographic signs include: 1. intraluminal mass seen as a filling defect; abnormal luminal contour; or focal increased density. 2. mucosal irregularity owing to ulceration or mucosal elevations 3. asymmetrical distensibility due to infiltrating tumor or extrinsic nodal mass.
PHARYNGEAL CARCINOMA
Most pharyngeal tumors are \_\_\_\_\_ that may arise on the base of the tongue; palatine tonsil; posterior pharyngeal wall or the piriform sinus. (p.748)
SQUAMOUS CELL CARCINOMAS
- LARYNGEAL tumors may impress
on the pharynx or extend into it. - Staging is best performed by
CT or MR.
____ are benign lesions that
typically involve the valleculae
and should not be mistaken for
phargyngeal neoplasms.(p.748)
- arise from dilatation of mucus
glands caused by chronic inflammation.
PHARYNGEAL RETENTION CYSTS
- appear as small; smooth; well-defined;
round or oval-filling defects best
appreciated on frontal views. - they are NEVER MALIGNANT.
____ usually manifest as a large;
bulky tumor of the lingual or
palatine tonsils. (p.748)
LYMPHOMA OF THE PHARYNX
- Lymphoma constitutes 15% or
oropharyngeal tumors
TRUE OR FALSE. Esophageal CA is squamous cell CA in 85% to 90% of cases; and the remainder are adenoCA arising in Barrett esophagus.; undifferentiated; or miscellaneous cell types. (p.748)
TRUE
- because of rapid spread to adjacent structures; esophageal CA is deadly; with a 5-year survival of only 5% for advanced disease. - early stage disease treated surgically has a 5-year survival of 50% to 80%.
4 basic radiographic patterns of
ESOPHAGEAL CA. (p.748)
1. ANNULAR CONSTRICTING LESION; appearing as an irregular ulcerated stricture (MOST COMMON) 2. POLYPOID PATTERN causes an intraluminal filling defect 3. INFILTRATIVE VARIETY grows predominantly in the submucosa and may simulate a benign stricture 4. ULCERATED MASS (LEAST COMMON)
Give 4 risk factors for ESOPHAGEAL CA (p.748)
- CIGARETTE SMOKING
- ALCOHOL ABUSE
- CORROSIVE INGESTION
- CARCINOMA OF THE HEAD
AND NECK
-typical patient is a 65 year old man
TRUE OR FALSE.
Esophageal CA tumor spreads
quickly by direct invasion into
the adjacent tissues. (p.748)
TRUE
- because of the lack of a serosal covering on the esophagus. - Lymphatic spread may go to nodes in the neck; mediastinum; or below the diaphgragm; depending on the location of the primary tumor in the esophagus.
Hematogeneous spread of
Esophageal CA is to __; __ and
___. (p.748)
- LUNG
- LIVER
- ADRENAL GLAND
TRUE OR FALSE. CT and endosopic US are used primarily to define the extent of disease and determine surgical resectability of esophageal CA. (p.748)
TRUE
- findings include irregular thickening of the esophageal wall (>5mm); eccentric narrowing of the lumen; dilation of the esophagus above the area of narrowing; invasion of periesophageal tissues; and metastases to mediastinal lymph nodes and the liver.
- obliteration of the fat space between the aorta; esophagus; and vertebral body is highly predictive of invasion of the aorta.
TRUE OR FALSE. GASTRIC ADENOCA spreads from the fundus and GEJ into the distal esophagus. (p.748)
TRUE
- AdenoCA of the distal esophagus
may be either primary gastric or
primary esophageal ; arising in
Barrett esophagus.
\_\_\_; while; is still the most common benign neoplasm of the esophagus; accounting for 50% of all benign esophageal neoplasms. (p.748)
LEIOMYOMA
- the tumor is firm; well-encapsulated and arises in the wall. - Ulceration is rare. - Most cause no symptoms and are discovered incidentally. - Men aged 25 to 35 years are affected most commonly (male-to-female ratio=2:1)
TRUE OR FALSE.
GI stromal tumor (GISTs)
(748-749)
are RARE in the esophagus.
TRUE
TRUE OR FALSE. LEIOMYOSARCOMA of the Esophagus is exceedingly rare; accounting for less than 1% of the esophageal malignancy. (p.749)
TRUE
TRUE OR FALSE.
Fibroepithelial or fibrovascular
polyps are a rare cause of
esophageal filling defect. (p.749)
TRUE
- They appear as a large ovoid or
elongated intraluminal masses in the
upper esophagus.
\_\_\_ cysts are congenital abnormalities that are usually incidental findings presenting without symptoms. - most (60%) occur in the LOWER ESOPHAGUS. (p.749)
ESOPHAGEAL DUPLICATION CYSTS
- CT shows a well-defined cystic mass
- Barium examination will show
extrinsic or intramural compression
due to close contact with the esophagus. - differential diagnosis include
bronchogenic and neurenteric
cyst
3 extrinsic lesions that may
invade the esophagus or
simulate an esophageal mass
or filling defect. (p.749)
- Mediastinal adenopathy
- Lung CA
- Vascular structures
___ artery which arises from the
aorta distal to the left
subclavian artery. (p.749)
- to reach its destination; it must
cross the mediastinum
behind the esophagus.
ABERRANT RIGHT SUBCLAVIAN artery
- it causes a characteristic upward-
slanting linear filling defect on the
posterior aspect of the esophagus.
More than half of ESOPHAGEAL
PERFORATION cases are related to
______. (p.749)
ESOPHAGEAL INSTRUMENTATION
- bleeding can be profuse and infection is a great risk in esophageal perforations - conventional radiographs demonstrate subcutaneous; cervical or mediastinal emphysema within 1 hour of perforation - chest radiographs may show widened mediastinum and pleural effusion or hydropneumothorax.
Key imaging finding in the
diagnosis of ESOPHAGEAL
PERFORATION. (p.750)
FOCAL OR DIFFUSE EXTRAVASATION
OF CONTRAST OUTSIDE THE ESOPHAGUS
- CT demonstrates fluid collections;
extraluminal contrast and air in the
mediastinum. (p.750)
TRUE OR FALSE. Blunt trauma may tear the esophagus by an explosive increase in intraesophageal pressure. (p.750)
TRUE
____ syndrome refers to the
rupture of the esophagus wall
as a result of forceful vomiting.
(p.750)
BOERHAAVE syndrome
- the tear is virtually always in the LEFT POSTERIOR WALL near the left crus of the diaphragm - esophageal contents usually escape into the left pleural space or into the potential space between the parietal pleura and the left crus. - tears may result in intramural dissections and hematomas in the wall of the esophagus.
_____ tear involves only the
MUCOSA and not the full
thickness of the esophagus.
(p.750)
MALLORY-WEISS TEAR
- endoscopy usually identifies the lesion - the lesion is commonly missed on UGI. - when seen; the tear appears as a longitudinally oriented barium collections; 1 to 4 cm in length; in the distal esophagus. - it may be a cause of copious hematemesis.
Mallory-Weiss tears are usually
caused by ____. (p.750)
VIOLENT RETCHING
TRUE OR FALSE. Foreign body impaction in adults is usually attributable to bones or boluses of meat. (p.750)
TRUE
- childeren may ingest any foreign
object including toys, coins and
jewelry.
IN FOREGN BODY IMPACTION:
Bones usually lodge in the
____; most often near the
_____ muscle. (p.750)
PHARYNX; CRICOPHARYNGEUS
muscle.
IN FOREGN BODY IMPACTION:
Meat impacts in the ____ or
___ esophagus (p.750)
DISTAL or MIDESOPHAGUS
IN FOREGN BODY IMPACTION: Perforation occurs in only 1% of cases, but the risk increases if impaction persists of more than \_\_ hours. (p.750)
MORE THAN 24 HOURS
TRUE OR FALSE. Bones in the pharynx are difficult to differentiate from calcification of the thyroid and cricoid cartilages. (p750)
TRUE
Contrast studies show
nonopaque foreign bodies as
___. (p750)
FILLING DEFECTS
- impacted foreign bodies may be removed by use of a Foley balloon catheter or wire basket or by gaseous distention of the esophagus with gas- producing crystals. - CT demonstates the nature of the foreign body and frequently any associated pathology that predisposed to impaction. (p.751)
UGI and CT findings in LEIOMYOMA (p.749)
UGI: most appear as smooth; well-defined wall lesions; although rarely they may be pedunculated or polypoid. - coarse calcifications are occasionally present and strongly indicative of leiomyoma
CT: demonstrates a smooth; well-defined
mass of uniform soft tissue density.
The esophageal wall is eccentrically
thickened.
