Esophagus Flashcards
What do each of the letters in ‘VITAMIN’ of the surgical sieve categories of disease discussed in lecture stand for?
- Vascular
- Infectious/Inflammatory
- Traumatic
- Anatomic
- Metabolic
- Idiopathic
- Neoplastic
Auerbach’s myenteric plexus is located in the muscularis propria or mucosal layer?
Muscularis propria
Which sphincter approximates the gastroesophageal junction (GEJ)?
Lower esophageal sphincter
The squamocolumnar junction (SCJ) is also called what?
Z line
How is the anatomic GEJ defined?
Takeoff of gastric folds
Normally the SCJ approximates the GEJ, but what happens in Barrett’s esophagus?
Proximal displacement of SCJ off GEJ
Name 3 ways to visualize the esophagus
- Gross exam (autopsy)
- Barium swallow (diagnostic)
- Endoscopy (diagnostic and therapeutic)
What is pyrosis in relation to the esophagus? What is water brash? What is globus? Eructation?
pyrosis: heartburn
water brash: hyper salivation
Globus: lump in the throat
Eructation: belching
If an infant has choking, coughing, cyanosis with onset of feeding, what should you check for?
Tracheo-esophageal fistula
Achalasia is a failure of the LES to relax with progressive destruction of the myenteric plexus. It results in dysphagia and an increased risk of what cancer?
carcinoma
Secondary achalasia is associated with what diseases (2)?
Chaga’s disease (trypanosome cruzi)
Scleroderma
Scleroderma results in fibrosis of which muscular layer of the esophagus?
INNNER CIRCULAR LAYER
If you have scleroderma, you will get unopposed reflux and have a greater propensity to develop what?
Barrett’s esophagus
T/F- a hiatal hernia (protrusion of the stomach above diaphragm) is usually symptomatic
False, most patients are asymptomatic but some have reflux symptoms, bleeding, ulceration, perforation
What type of hernia (sliding or paraesophageal (PE)) is more common?
Sliding (95%)
Paraesophageal (rolling) (5%)
What is a serious complication of paraesophageal hernias?
strangulation (infarction of incarcerated hernia)
Name the most common characteristic of diverticula in each category
- congenital or acquired
- True (all gut layers) or false
- Pulsion (peristalsis against a closed sphincter or traction (extrinsic pull secondary to inflammation)
- acquired>congential
- False>true
- Pulsion>traction
What is a zenker diverticulum?
Midesophageal?
Epiphrenic?
- zenker- usually pulsion type which forms above UES
- midesophageal- usually due to traction
- epiphrenic- pulsion, forms above LES
What symptoms would you expect in a zenker diverticulum?
Dysphagia, globus, food impaction, regurgitation, aspiration, HALITOSIS
Mallory Weiss syndrome is hematemesis from laceration of GEJ mucosa/submucosa, what causes this and who is at greatest risk?
Cause: forceful retching/coughing/vomiting
Risks: alcoholics, eating disorders
T/F- ruptured varices (dilated submucosal veins) are a frequent cause of death in alcoholics
True
What is an esophageal web and what condition is it associated with?
- web: shelf of tissue (eccentric) that can be congenital or post-inflammatory
- Plummer-vinson syndrome (sideropenic dysphagia): glossitis, dysphagia, iron deficiency
What is an esophageal ring?
- ring: circumferential (“Schatzki” if at SCJ)
- esophagitis related
Stenosis/stricture of the esophagus is commonly due to what factor?
radiation
Name common causes of esophagitis
- topical injury (alcohol, corrosive substances (acid, lye), hot liquids
- cytotoxic chemo (radiation, GVHD)
- stuck pills (doxycycline, aspirin, iron, alendronate)
- Infectious (see next flashcard)
Review Characteristics of infectious esophagitis
- Immunocompromised (DM, post-chemotherapy, transplant, HIV, older) vs. immunocompetent
- Odynophagia is a common symptom!!!!!!!!!!!!!!!!!!
- Candida – white plaques; PMN’s; parakeratosis
- Herpes – punched out ulcers; squamotropic; cytopathic effect (CPE) at edge of ulcers
- Cytomegalovirus (CMV) – single deep ulcer; endothelial/ stromal cells, columnar epithelium; CPE in depth of ulcer
Distinguish GERD vs reflux esophagitis (RE)
GERD: “condition that develops when reflux of stomach contents causes troublesome symptoms and/or complications”
RE: endoscopic or histologic evidence of reflux-associated injury
T/F- GERD is more prevalent in the west than in Asia
True (10-20% in west vs <5% in asia)
Name 3 causes of GERD
LES dysfunction, decreased acid clearance, defective barrier function
Name 3 symptoms of GERD
heartburn, regurgitation, dysphagia
Name 3 complications of GERD
stricture, Barrett’s esophagus, adenocarcinoma
Name 2 important histologic features of reflux
- Epithelial hyperplasia (basal zone and papillary elongation)
- Dilated intercellular spaces
Name the normal cutoff percentages for papillary height (PE) and basal zone height (BZH)
PE: 67%
BZH: 15%
What is the key inflammatory cell you will see histologically in reflux?
intraepithelial eosinophils
Define eosinophilic esophagitis
primary clinicopathologic disorder of the esophagus characterized by esophageal and/or upper GI tract symptoms in association with esophageal mucosal biopsy specimens containing ≥15 intraepithelial eosinophils per high-power field in 1 or more biopsy specimens and absence of pathologic GERD as evidenced by a normal pH monitoring study of the distal esophagus or lack of response to high-dose PPI medication
Name the symptoms of eosinophilic esophagitis
Symptoms include food impaction, dysphagia (adults); GERD type symptoms, feeding intolerance (children)
How would you diagnose eosinophilic esophagitis? How would you treat it?
- Diagnosis – esophageal symptoms + mucosal biopsy + exclusion of GERD (lack of response to PPI or normal pH monitoring)
- Treatment – elimination and elemental diets, acid suppression, topical corticosteroids, dilatation of strictures
Define Barrett’s esophagus
Definition (US): Endoscopically evident apparent columnar mucosa proximal to the anatomic GEJ with biopsy demonstrating intestinal metaplasia (i.e., goblet cells)
How is Barrett’s esophagus diagnosed?
Diagnosis – 2 EGD’s with bx within 1 yr (confirm dx; rule out prevalent dysplasia)
How is Barrett’s esophagus treated?
Treatment – PPI for GERD; endoscopic ablative tx or surgery for dysplasia/carcinoma
What factors is the need for “surveillance” of the barrett’s esophagus determined by?
Determined by absence or presence of dysplasia, grade of dysplasia
Name 2 advanced techniques for treating Barrett associated neoplasia?
- endoscopic mucosal resection
- radiofrequency ablation
T/F- The Incidence of Esophageal Cancer Increasing at Alarming Rate due to Adenocarcinoma
True
Compare the etiology of adenocarcinoma and squamous cell carcinoma
- adenocarcinoma: GERD, tobacco, obesity
- Squamous cell carcinoma: tobacco, alcohol, hot beverages
What determines a tumor “grade”?
-Based on microscopic features
-Refers to how well or poorly a tumor resembles the normal cells it recapitulates
-Correlates with outcome (but less so than STAGE)
(well-differentiated=low grade)
What determines tumor “stage”?
- Refers to anatomic extent of disease
- Assigned at the time of diagnosis: clinical and/or pathologic
- Most powerful predictor of outcome
T(umor)
N(ode)
M(etastasis)
