Esophagus

Question 1

Tracheoesophageal fistula

Answer 1

Congenital defect resulting in a connection between the esophagus and trachea
- most common variant consists of proximal esophageal atresia with the distal esophagus arising from the trachea

Presents with

• vomiting
• polyhydramnios
• abdominal distension
• aspiration

Question 2

Esophageal web

Answer 2

Thin protrusion of esophageal mucosa, most often in theupper esophagus

• presents with dysphagia for poorly chewed food
• increased risk for esophageal squamous cell carcinoma

Plummer vinson syndrome –> characterized by severe iron deficiency anemia, esophageal web, and beefy-red tongue due to atrophic glossitis

Question 3

Zenker diverticulum

Answer 3

Outpouching of pharyngeal mucosa through an acquired defect in the muscular wall (false diverticulum)
- arises above the upper esophageal sphincter at the junction of the esophagus and pharynx

Presents with

• dysphagia
• obstruction
• halitosis

Question 4

Mallory weiss syndrome

Answer 4

Longitudinal laceration of mucosa at the gastroesophageal junction

• caused by severe comiting, usually due to alcoholism or bulimia
• presents with painful hematemesis
• risk of Boerhaave syndrome = rupture of esophagus leading to air in the mediastinum and subcutaneous emphysema

Question 5

Esophageal varices

Answer 5

Dilated submucosal veins in the lower esophagus –> arise secondary to portal hypertension

• distal esophageal vein normally drains into the portal vein via the left gastric vein
• in portal hypertension, the left gastric vein backs up into the esophageal vein, resulting in dilation = varices

Asymptomatic, but risk of rupture exists

• presents with painless hematemesis
• most common cause of death in cirrhosis

Question 6

Achalasia

Answer 6

Disordered esophageal motility with inability to relax the lower esophageal sphincter –> due to damaged ganglion cells in the myenteric plexus

• ganglion cells of the myenteric plexus are located between the inner circular and outer longitudinal layers of the muscularis propria and are important for regulating bowel motility and relaxing the lower esophageal sphincter
• damage to ganglion cells can be idiopathic or secondary to a known insult –> e.g. trypanosoma cruzi infection in Chagas disease

Clinical features

• dysphagia for solids and liquids
• putrid breath
• high LES pressure on esophageal manometry
• bird beak sign on barium swallow study
• increased risk for esophageal squamous cell carcinoma

Question 7

Gastroesophageal reflux disease (GERD)

Answer 7

Reflux of acid from the stomach due to reduced LES tone

Risk factors = alcohol, tobacco, obesity, fat rich diet, caffeine, hiatal hernia

Clinical features

• heartburn –> mimics cardiac chest pain
• adult onset asthma and cough
• damage to enamel of teeth
• ulceration with stricture and Barrett esophagus are late complications

Question 8

Barrett esophagus

Answer 8

Metaplasia of the lower esophageal mucosa from stratified squamous epithelium to nonciliated colmnar epithelium with goblet cells –> seen in 10% of patients with GERD

• response of lower esophageal stem cells to acidic stress
• may progress to dysplasia and adenocarcinoma

Question 9

Esophageal carcinoma

Answer 9

Subclassified as adenocarcinoma or sqamous cell carcinoma

Adenocarcinoma = malignant proliferation of glands –> most common type of esophageal carcinoma in the west
- arises from preexisting barett esophagus -> usually involves the lower 1/3 of the esophagus

Swaumous cell carcinoma = malignant proliferation of swamous cells –> most common esophageal cancer worldwide

• usually arises in upper or middle 1/3 of the esophagus
• major risk factors:
• –> alcohol
• –> very hot tea
• –> achalasia
• –> esophageal web (plummer vinson)
• –> esophageal injury (e.g. lye ingestion)

Question 10

Esophageal carcinoma - clinical symptoms

Answer 10

Presents late –> poor prognosis

Symptoms

• progressive dysphagia (solids to liquids)
• weight loss
• pain
• hematemesis
• squamous cell carcinoma may also present with hoarse voice (recurrent laryngeal nerve involvement) and cough (tracheal involvement)

Location of lymph node spread depends on the level of the esophagus that is involved

• upper 1/3 –> cervical nodes
• middle 1/3 –> mediastinal or tracheobronchial nodes
• lower 1/3 –> celiac and gastric nodes