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GI/Nutrition > Diseases of the Esophagus Pt. 2 > Flashcards

Diseases of the Esophagus Pt. 2 Flashcards

1
Q

What kind of epithelium is present in the esophagous? How is this beneficial?

A

Non-keratinized stratified squamous epithelium - resistant to abrasion from foods but is sensitive to acid

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2
Q

What structures in the proximal and distal esophagous contribute to mucosal protection?

A

Sub-mucosal glands

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3
Q

What type of epithelium is present in the stomach?

A

Columnar epithelium

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4
Q

What is the difference between mucosa in the stomach and the esophagus?

A
  • Esophageal mucosa is made for transportation
  • Stomach mucosa is for protection against acids
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5
Q

What are some mechanisms of epithelial defense against acidity?

A
  • Intracellular buffering by negatively charged proteins and bicarbonate ion
  • H+ extrusion processes for regulation of pH
  • Also apical cell membrane and intracellular junctional complex
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6
Q

What is the most important barrier against reflux?

A

The constant LES tone (prevents reflux of acidic gastric contents which are under positive abdominal pressure)

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7
Q

In addition to acid, _____ ____ reflux may exacerbate mucosal injury

A

Dudodenal bile

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8
Q

How does inflammation lead to a reduction of LES tone?

A
  • Inflammation induces the production of IL-6 which leads to an increase of H2O2 in the muscle
  • H2O2 is the main cause of increase in platelet activating factor and PGE2 which reduce ACh release and LES tone
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9
Q

What is incompetent LES and how does it happen?

A
  • Incompetent is LES is when the gastroesophageal junction barrier is defective
  • It may occur through transient LES relaxation (majority), strain (may be caused by exercise/crural diaphram contraction), or a hypotonic LES
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10
Q

Transient LES relaxation is a part of the _____ reflex

A

Belch

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11
Q

What leads to transient LES relaxation?

A

The efferent pathway is in the vagus nerve and NO is the postganglionic neurotransmitter

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12
Q

What type of hernia is associated with incompetent LES?

A

Hiatal hernia - Protrusion of the stomach into the thorax through the gap between the diaphragmatic crura and LES

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13
Q

What are the two types of hiatal hernia and which is more common?

A
  • Sliding and para-esophageal
  • Sliding hiatal hernia is more common and asymptomatic (90% of the time)
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14
Q

The morphology of mucosa in acid reflux shows basal zone hyperplasia exceeding __% of total thickeness and also the presence of ____ in the squamous mucosa

A

20%; eosinophils (followed by neutrophils)

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15
Q

What may be seen in reflux esophagitis endoscopically?

A

Simply hyperemia (redness) and possible mucosal breaks (erosions)

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16
Q

What are risk factors and symptoms of reflux esophagitis?

A
  • Most common in adults > 40yrs
  • Obesity is a risk factor
  • Symptoms:
    • Heartburn
    • Regurgitation
    • Dysphagia (less common)
    • (May also see atypical chest pain, chronic cough, or hoarseness)
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17
Q

What are three modalities for diagnosis of reflux esophagitis?

A
  • Endoscopy (90% specific in GERD but only 50% sensitivity)
  • Ambulatory reflux monitoring (70% sensitivity)
  • Radiography

*note: symptoms do not necessarily correlate with degree of mucosal damage

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18
Q

What alarm symtoms indicate the need for an endoscopy in a patient experiencing GERD?

A
  • Dysphagia
  • Anemia
  • Weight loss
  • Abdominal Mass
  • Vomiting
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19
Q

What lifestyle modifications can be done to help with GERD?

A
  • Weight loss (for overweight patients)
  • Elevation of bed
  • Avoiding late meals (patients with nocturnal symptoms)
  • Avoiding trigger foods (ETOH, caffeine, chocolate)
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20
Q

What pharmacologic therapies can be used for GERD?

A
  • Anti-secretory drugs (healing esophagitis and symptomatic relief)
  • Proton pump inhibitors are more effective than histamine blockers
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21
Q

What operative therapies can be used to manage GERD?

A
  • Fundoplication (surgery)
  • Substitution of devices to enforce LES
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22
Q

What are some complications of GERD?

A
  • Esophageal ulcer
  • Esophageal stricture
  • Bleeding
  • Barrett’s esophagus
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23
Q

Stricture is most often due to ______ and ______

A

inflammation and scarring

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24
Q

What can cause esophageal stricture (3)?

A
  • Chronic gastroesophageal reflux
  • Radiation
  • Caustic injury
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25
Q

Narrowing with esophageal strictures is generally caused by…

A
  • Fibrous thickening of the submucosa
  • Atrophy of the muscularis propria
  • Secondary epithelial damage
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26
Q

What is Eosinophilic Esophagitis (EOE)?

A

Epithelial infiltration by large numbers of eosinophils, particularly superficially

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27
Q

How can you differentiate EOE from GERD?

A

Abundance of eosinophils and location far from GE junction

28
Q

What is the clinical presentation of EOE in adults vs. children?

A
  • Adults: predominantly dysphagia
  • Children: nausea, burning and food intolerance
29
Q

What is the general clinical presentation of EOE?

A
  • Failure of the acid suppressive treatment and the absence of acid reflux
  • Personal or family history of atopia
30
Q

EOE involves ______ whicih leads to eosinophil infiltration and activation

A

T-cell (mediated hypersensitivity)

31
Q

How does eosinophil infiltration in EOE lead to change in the mechanical properties of the esophagus?

A

Cascade of cytokine release from esoinophils and deposition of major basic protein and increased expression of IL-5 and IL-13 within the affected esophageal epithelium - leads to tissue remodeling and fibrosis

32
Q

Histologic confirmation of > __ eosinophils per HPF (high power field) in esophageal mucosa is needed

A

15

33
Q

What type of diet is used to treat EOE?

A

Elimination diet - avoid seafood, wheat, soy, nuts, milk, and eggs

34
Q

Aside from diet, how else is EOE treated?

A
  • Topical steroids
  • Systemic steroids
  • Endoscopic dilation
35
Q

What other types of esophagitis (aside from EOE) exist?

A
  • Chemical
  • Infectious
  • Iatrogenic
  • Skin Disorder associated
36
Q

What types of irritants can cause chemical esophagitis?

A
  • Corrosive acid
  • Corrosive alkali
  • Alcohol
  • Excessively hot fluids
  • Heavy smoking
  • Medicinal pills (may lodge and dissolve in esophagus)
37
Q

What symptoms are associated with chemical esophagitis?

A
  • Generally causes only self-limited pain
  • Odynophagia - pain with swallowing
  • Hemorrhage, stricture, or perforation may occur
38
Q

Infectious esophagitis is most frequent in those who are ___________

A

immunosuppressed

39
Q

Viral Esophagitis is often due to which types of viruses? What appearance is associated with each?

A
  • Herpes simplex virus: punched-out ulcers
  • Cytomegalovirus: shallow ulcerations
40
Q

What type of fungi are associated with fungal esophagitis?

A
  • Most common: Candida
  • May also be mucormycosis and aspergillosis
41
Q

Bacterial esophagitis accounts for about __% of infectious esophagitis cases

A

10

42
Q

What are some morphologic changes associated with Iatrogenic Esophagitis?

A

Non-specific with ulceration and accumulation of neutrophils

43
Q

What are some causes of Iatrogenic Esophagitis?

A
  • Cytotoxic chemotherapy
  • GvH disease
  • Radiation
44
Q

What skin diseases are associated with esophagitis?

A
  • Desquamative skin disease
  • Lichen planus
  • Chron’s disease
45
Q

What characterizes Barrett’s Esophagus (BE)?

A

Normal esophageal squamous epithelium is replaced by metaplastic columnar mucosa (intestinal metaplasia)

46
Q

What types of cells define intestinal metaplasia and how are they identified?

A

Goblet cells; identified by distinct mucous vacuoles

47
Q

What percentage of GERD patients have BE? What percentage of BE patients develop epithelial dysplasia?

A

10%; 0.2-1.0%

48
Q

Which gene probably plays a role in BE? What abnormalities may lead to the development of dysplasia and later carcinogenesis?

A
  • Cdx is expressed in 100% of Barrett specimens but not normal esohagus or stomach
  • Abnormalities in P53 and cyclin D1 expression have been associated with dysplasia and later carcinogenesis
49
Q

What characterizes adenocarcinoma (intramucosal carcinoma)?

A

Characterized by invasion of neoplastic epithelial cells into the lamina propria (associated with BE)

50
Q

How does BE appear morphologically?

A
  • Tongues or patches of red, velvety mucosa extending upward from the GE junction
  • BE metaplastic mucosa alternates with residual smooth, pale squamous mucosa proximally
51
Q

What evidence is required for BE diagnosis?

A

BOTH endoscopic evidence of abnormal mucosa above the GE junction AND histologically documented metaplasia

52
Q

What is the clinical presentation of BE?

A
  • Typically white adult male (40-60yrs) with long term reflux symptoms
  • Often is completely asymptomatic (silent disease)
  • BE usually doesn’t lead to esophageal cancer
53
Q

Esophageal Adenocarcinoma has a higher incidence in…?

A
  • Developed western countries
  • White middle aged males
54
Q

What are some well known risk factors for esophageal adenocarcinoma?

A
  • Dysplasia in BE
  • Tobacco use
  • Obesity
  • Radiation therapy
55
Q

T or F: Progression of BE to adenocarcinoma occurs quickly and through a single acquisition of genetic change

A

False!

BE to adenocarcinoma occurs over time through the stepwise acquisition of genetic and epigenetic changes

56
Q

What types of genetic mutations are associated with BE to adenocarcinoma change?

A
  • P53 mutations
  • Amplifications of c-ERB-B2, cyclin D1 and cycline E genes
  • Increased expression of TNF and NF-kB dependent genes
57
Q

Esophageal adenocarcinoma usually occurs where in the esophagus?

A

The distal third of the esophagus (and may invade the adjacent gastric cardia)

58
Q

In microscopic examination of esophageal carcinoma, tumors typically produce _____ and form _____

A

mucin; glands

59
Q

Squamous cell carcinoma (SCC) typically occurs in what demographic?

A

African-American male adults older than 45 years of age

60
Q

What are some risk factors associated with SCC?

A
  • Alcohol and tobacco use (majority in developed world)
  • Poverty
  • History of caustic esophageal injury
  • Achalasia and Plummer Vinson syndrome
  • Frequent consumption of very hot beverages
  • Previous radiation therapy
61
Q

Half of SCCs occur in the ____ part of the esophagus

A

middle

62
Q

Early lesions of SCC appear as…?

A

Gray-white plaque like thickenings (can grow into tumor masses that protrude into and obstruct the lumen)

63
Q

Symptoms of esophageal SCC?

A
  • Dysphagia
  • Odynophagia
  • Obstruction
  • Patients may adjust by altering their diet (solid to liquid foods)
64
Q

What are the 5 year survival rates for patients with superficial esophageal carcionma? What is the overall 5 year survival rate?

A

75%; 9%

65
Q

What lymph nodes are associated with the different parts of the esophagus?

A
  • Upper third: cervical
  • Middle third: mediastinal, paratracheal, and tracheobronchial
  • Lower third: gastric and celiac nodes
66
Q

Esophageal carcinoma:

  • What is the 5 year survival rate for superficial adenocarcinoma?
  • Overall 5 year survival rate?
A

80%; 25%

GI/Nutrition (36 decks)

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