Esophagus

Question 1

Conditions of the esophagus

Answer 1

1. Congenital anomalies
   - Atresia
   - Tracheo-esophageal fistula
2. Motor dysfunction
   - Achalasia
   - Hiatus hernia
3. Esophageal varices
4. Esophagitis
5. Neoplasms
   - SCC
   - Adenocarcinoma
   - Leiomyoma

Question 2

Causes & types of esophagitis (4)

Answer 2

1. Lacerations & ruptures
   - Mallory-Weiss Tears - assoc w severe retching/vomiting + acute alcohol intoxication
   - Boerhaave Syndrome - distal esophageal rupture due to vomiting
2. Chemical
   - mucosal damage by irritants eg alcohol, acids/alkalis, excessively hot liquids, smoking, cytotoxic chemo, radiation, uremia, drugs, toxins
3. Infectious
   - mucosal damage by infectious agents eg HSV, CMV, candida
   - typically in immunocompromised
4. Reflux Esophagitis (GERD)
   - most common cause of esophagitis

Question 3

Effects & complications of chemical & infectious esophagitis (4)

Answer 3

1. Dysphagia
2. Hemorrhage
3. Stricture
4. Perforation

Question 4

Definition of GERD

Answer 4

• gastroesophageal reflux disease
• reflux of acidic gastric contents into lower esophagus resulting in acid-induced mucosal damage
• due to decreased LES tone/increased abdominal pressure

Question 5

Causes of GERD (3)

Answer 5

1. Hiatal hernia
2. Alcohol & tobacco use, pregnancy, antidepressants, obesity (decrease in LES tone)
3. Delayed gastric emptying (increased abdo pressure)

Question 6

Effects of GERD (3)

Answer 6

1. Heartburn (retrosternal pain), acid regurgitation, sore throat, cough
2. Dysphagia (sclerosis & stricture)
3. Peptic ulceration of esophageal mucosa - hematemesis

Question 7

Pathogenesis of GERD

Answer 7

• transient LES relaxation
• reflux of gastric/duodenal fluids into esophagus
• not direct injurious effect of gastric acid, pepsin, bile, duodenal fluids
• but acids & bile salts triggering inflammatory response (lymphocytes, polymorphs)

Question 8

Histology of GERD

Answer 8

• basal zone hyperplasia
• elongated lamina propria papillae
• polymorphs, lymphocytes, eosinophils

Question 9

Features of Barrett Esophagus

Answer 9

• complication of chronic GERD (10%)
• distal squamous mucosa replaced by columnar metaplasia - more proximal squamo-columnar junction
• red velvety looking mucosa amidst pearly grey-white squamous epithelium

Question 10

Diagnosis of Barrett Esophagus (2)

Answer 10

1. Endoscopy - columnar epithelium above gastroesophageal junction
2. Histology - intestinal metaplasia (goblet cells)

Question 11

Effects & complications of Barrett Esophagus

Answer 11

1. Ulceration, bleeding
2. Scarring, stricture
3. Dysplasia
4. Adenocarcinoma

Question 12

Squamous cell carcinoma of the esophagus

Answer 12

• older age group, more males
• alcohol, tobacco, nitrites etc
• 50% in middle 1/3 of esophagus
• squamous dysplasia - CIS - invasive carcinoma
• circumferential, ulcerated, polypoid/exophytic

Question 13

Spread of esophageal SCC

Answer 13

• submucosal lymphatics in esophageal wall allows tumour cell infiltration
• local extension into mediastinum (direct invasion)
• lymph node mets: upper 1/3 to cervical nodes, middle 1/3 to mediastinal nodes, lower 1/3 to gastric & celiac nodes

Question 14

Features of adenocarcinoma of the esophagus

Answer 14

• typically in lower 1/3 of esophagus

- associated with Barrett esophagus