Esophageal Disorders B&B

Question 1

GERD is due to a failure of…

Answer 1

lower esophageal sphincter (decrease in tone)

Question 2

what would histology show in a patient with reflux esophagitis? (3)

Answer 2

1. basal zone hyperplasia (epithelium)
2. elongation of lamina propria papilla
3. eosinophils and neutrophils

Question 3

what are teh symptoms of GERD beyond heartburn? (3)

Answer 3

1. dysphagia (pain with swallowing)
2. asthma (adult-onset) due to reflux into respiratory tract
3. damage to teeth enamel

Question 4

which 2 medical therapies are used to treat GERD?

Answer 4

1. H2 blockers - famotidine, ranitidine, nizatidine, cimetidine —> block receptors on parietal cells
2. proton pump inhibitors - omeprazole, pantoprazole, lansoprazole, esomeprazole —> block H+/K+ pump in parietal cells

Question 5

what is the danger of accidental lye ingestion?

Answer 5

lye: alkali substance found in household cleaners, may be accidentally ingested by children

cause liquefactive necrosis of mucosa in esophagus —> may result in strictures (fibrous blockages) later in life

Question 6

of what is Barrett’s esophagus a compilation?

Answer 6

Barrett’s esophagus = metaplasia of esophagus (squamous —> intestinal columnar)

result of long-standing GERD

regular surveillance/endoscopy is done to monitor for esophageal adenocarcinoma

Question 7

what are the 2 types of esophageal cancer, and how do they present?

Answer 7

squamous or adenocarcinoma

smoking is a risk factor for both, present late with advanced metastasis

presents with progressive dysphagia

Question 8

where anatomically does squamous vs adenocarcinoma esophageal cancer occur?

Answer 8

squamous: results from damage to upper/middle esophagus - can involve recurrent laryngeal nerve or trachea (cough)

adenocarcinoma: involves lower 1/3 - epithelium transforms to intestinal columnar

Question 9

to which lymph nodes does the upper, middle, and lower portion of the esophagus drain?

Answer 9

upper (neck) —> cervical nodes

middle (chest) —> mediastinal and tracheobronchial nodes

lower (abdomen) —> celiac and gastric nodes

Question 10

what are 3 infectious causes of esophagitis?

Answer 10

1. candida - white membranes + pseudohyphae on biopsy
2. HSV-1 - oral herpes, “punched out” ulcers
3. CMV - AIDs patients (CD4<50), linear ulcers

Question 11

Patient presents with dysphagia and is treated with H2 blockers and PPI for GERD. They are unresponsive to therapy, so a biopsy is taken which shows eosinophils. What is the dx?

Answer 11

eosinophilic esophagitis - note this is dx of exclusion because eosinophils are seen in GERD, as well!!!

Question 12

what causes achalasia? with what infection is it associated?

Answer 12

achalasia: inability to relax lower esophageal sphincter due to loss of ganglion cells in Auerbach’s plexus (found in muscular layer)

often idiopathic, but associated with chronic Chagas disease (Trypanosoma cruzi)

Question 13

which layer of the esophagus is involved in Malloy-Weiss Syndrome?

Answer 13

damage to esophageal mucosa at GE junction

causes painful hematemesis (epigastric pain/ back pain + bloody vomit)

caused by severe, chronic vomiting (alcoholism, bulimia)

Question 14

what are 2 causes of Malloy-Weiss Syndrome?

Answer 14

damage to esophageal mucosa at GE junction

causes painful hematemesis (epigastric pain/ back pain + bloody vomit)

caused by severe, chronic vomiting (alcoholism, bulimia)

Question 15

BoerHaave Syndrome

Answer 15

transmural esophageal rupture as a result of severe, chronic vomiting/retching

air exits esophagus - can see air in mediastinum on CXR or under skin of neck (“subcutaneous emphysema”)

Question 16

Pt presents with severe pain in their chest. They have been violently ill for many days with frequent vomiting and retching. CXR shows air in the mediastinum. When the neck is palpated, there is bubbling and crackling felt beneath the skin. What occurred?

Answer 16

BoerHaave Syndrome: transmural esophageal rupture as a result of severe, chronic vomiting/retching

air exits esophagus - can see air in mediastinum on CXR or under skin of neck (“subcutaneous emphysema”)

Question 17

Schatzki Ring

Answer 17

esophageal ring (extension/protrusion of mucosa) occurring specially at the squamocolumnar junction

common cause of dysphagia to solids

Question 18

what is the triad of Plummer-Vinson Syndrome?

Answer 18

1. iron deficiency anemia
2. beefy red tongue (damage to mucosal layer)
3. esophageal web (protrusion of mucosa)

most common in middle-age white women

Question 19

iron deficiency anemia + beefy red tongue + esophageal web =

Answer 19

Plummer-Vinson syndrome - most common in middle-age white women, cause unknown

Question 20

what is the cause of Zenker’s Diverticulum? where does is classically occur?

Answer 20

mucosa + submucosa protrude through muscular wall at junction of esophagus and pharynx (classically at Killian’s Triangle, just proximal to upper esophageal sphincter)

usually result of chronic swallowing problem in which cricopharyngeal muscle fails to relax, so there is chronic high pressure in pharynx to force the food down