Esophageal Pathologies

Question 1

Boerhaave syndrome

Answer 1

• Transmural
• Usually distal esophageal rupture + pneumomediastinum due to violent retching
• Surgical emergency

Question 2

Eosinophilic esophagitis

Answer 2

• Infiltration of eosinophils in esophagus often in atopic pts
• Food allergens –> dysphagia (difficulty swallowing), food impaction
• Schatzki ring (narrowing of lower portion of esophagus) + linear furrows

Question 3

Esophageal strictures

Answer 3

• Associated with caustic ingestion and acid reflux
• Chronic gastric exposure –> scarring –> narrowing of lumen
• Dysphagia

Question 4

Esophageal varices

Answer 4

• Dilated submucosal veins in lower 1/3 esophagus 2ndary to portal HTN (L gastric vein backs up into esophageal vein which normally drains into portal vein)
• Common in cirrhotics
• Asymptomatic but if rupture occurs, may be source of life-threatening hematemesis

Question 5

Esophagitis

Answer 5

• Associated with reflux
• Infection in immunocompromised
  
  • Candida: white pseudomembrane (thrush)
  • HSV-1: punched-out ulcers (organ transplant)
  • CMV: linear ulcers

Question 6

GERD

Tx

Answer 6

• Weight Loss, Heartburn, Odynophagia, regurgitation, Dysphagia
• Associated with asthma
• Transient decreases in LES tone

Tx: diet modifications, H2 blockers, PPI, Nissen fundoplication (wrap fundus around LES to inc. pressure)

Question 7

Mallory-Weiss syndrome

Answer 7

• Mucosal lacerations at GEJ due to severe vomiting
• Hematemesis (differentiating factor from Boerhaave**)
• Alcoholics/bulimics

Question 8

Plummer-Vinson syndrome

“Plumbers” DIE

Answer 8

• Dysphagia, Iron deficiency anemia, Esophageal webs
• May be associated w glossitis
• Increased risk of esophageal SCC

Question 9

Sclerodermal esophageal dysmotility

Answer 9

Esophageal smooth muscle atrophy –> dec. LES pressure and dysmotility –> acid reflux + dysphagia –> stricture, Barrett esophagus, aspiration

Part of CREST syndrome (calcinosis, Raynaud phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia) - sclerodermal syndrome

Question 10

Barrett Esophagus

Answer 10

Specialized intestinal metaplasia

nonkeratinized SS epithelium –> nonciliated columnar + goblet cells in distal esophagus

Due to chronic GERD

Associated with inc risk of esophageal adenocarcinoma

Question 11

Esophageal cancer

Two types

Lymph node spread

Answer 11

• Progressive dysphagia (first solids, then liquids) + weight loss; poor prognosis
• SCC (upper 2/3 esophagus) - common worldwide
  
  • Alcohol
  • Hot liquids
  • Caustic strictures
  • Smoking
  • Achalasia
  • Esophageal web (e.g., PV syndrome)
  • Esophageal injury (e.g., lye ingestion)
• Adenocarcinoma (lower 1/3 esophagus) - America
  
  • Chronic GERD
  • Barrett esophagus
  • Obesity
  • (Smoking, achalasia)

Lymph node spread depends on level of esophagus that is involved:

1. Upper 1/3 - cervical
2. Middle 1/3 - mediastinal or trachobronchial
3. Lower 1/3 - celiac and gastric

Question 12

Achalasia

Answer 12

• Failure of relaxation of LES due to loss of myenteric (Auerbach) plexus
• Uncoordinated/absent peristalsis + high LES resting pressure –> progressive dysphagia to solids and liquids (vs. obstruction - solids only)
• Halitosis
• “Bird’s beak” on barium swallow
• 2ndary achalasia from Chagas disease (T cruzi infection)
• Inc. risk of esophageal cancer, esp. SCC