Esophagus Flashcards by Alex Grushky

At what point are esophageal folds abnormal? (size)

Differentiate reflux esophagitis from varices.

2-3 mm in diameter

Varices will be more serpentine and change shape during fluoro

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What do transverse folds represent? How do they differ from those in a feline esophagus?

Develop as a result of prior linear ulceration with scar formation with the longitudinal muscle layer

Transverse folds are fixed, coarser, and shorter. They also do NOT cross the entire esophageal lumen

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Describe the imaging/pathology of intramural pseudodiverticulosis.

Who gets it and what is the association?

Multiple tiny outpouchings diffuely/segmentally in the esophagus with an apparent LACK OF COMMUNICATION with the esophageal lumen. Represent dilated submucosal glands (like GB adenomyomatosis).

Elderly patients with chronic reflux, complain of progressive dysphagia. 90% have association with upper/mid esophageal stricture.

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Where is a barretts stricture seen? what is the pathology?

What are the other types of stricture and where are they seen?

Focal esophageal stricture above the GE junction in the mid esophagus with associated reticulation. Metaplasia of normal squamous epithelium to adenomatous mucosa. Occur at mid esophagus because adenomatous mucosa is resistant.

Medication induced - points of anatomical narrowing (thoracic inlet, aortic arch, left mainstem bronchus)

Caustic - long segment of narrowing.

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What percentage of reflux patients develop barrets? What is the risk for cancer transformation?

5-20%

1%/year

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Give 3 diagnoses for multiple nodular filling defects of varying size

Reflux esophagitis

Candida - symptomatic

Glycogen acanthosis - asymptomatic elderly patient. Due to increased cytoplasmic glycogen in squamous epithelial cells. Margins are hazy.

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How does crohns present in the esophagus?

Aphthous ulceration - discrete ulcers with mounds of edema

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Describe the appearance of candidal esophagitis.

Differentiate between reflux, glycogen acanthosis, and herpes

Discrete plaquelike lesions are most common. Can have nodular and granular appearance with fold thickening. Severe disease will have SHAGGY IRREGULAR luminal surface.

Reflux - usually distal esophagus
GA - asymptomatic elderly patient
Herpes - more commonly ulceration

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Describe the appearance of herpes esophagitis

Differentiate between CMV

discrete ulcerations in an otherwise normal esophageal mucosa

CMV is usually a large, solitary, discrete ulcer

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Large solitary ulcer in AIDS patient suggest what. What is seen on biopsy.

CMV esophagitis. Will see intranuclear inclusions

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What is the pathology behind achalasia? What is the gold standard for diagnosis? What is the main differential?

Failure of the lower esophageal sphincter to relax.

Manometry

Pseudoachalasia (due to carcinoma) - achalasia will show periodic relaxation

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What is vigorous achalasia?

What are the complications of achalasia?

Less severe form with non-propulsive contractions on top of LES tightening

Squamous cell carcinoma (surveillance begins 10-15yrs after dx)

Candidiasis results from stasis

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What is pseudoachalasia?

Fixed, rigid stricture at the GEJ due to carcinoma

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When does caustic stricture develop? What is the risk of carcinoma?

Usually 1-3 months after injury

1-4% risk of esophageal cancer after 20 years

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What is cicatricial pemphigoid strictures of the esophagus? Who gets it? Associated findings?

Differentiate between caustic strictures

Multifocal strictures throughout the esophagus in a patient with bullous disease. Will have blistering of all mucous membranes (mouth, eyes, nose, esophagus, larynx, urethra, anus). Usually between 60-80 yrs with transient skin lesions on back of head and neck.

Caustic usually isn’t multifocal.

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Distinguishing feature of radiation induced esophageal stricture? How high of a dose usually?

time frame for acute radiation injury? stricture development?

Spares the GE junction. >50 Gy

Acute= 1-4 weeks
Strictures= 4-8 months

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Diffusely small caliber esophagus with ringlike indentations and granular mucosa +/- stricture?

Tx?

Eosinophilic esophagitis.

Topical steroids

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How does lymphoma affect the esophagus?

Usually by mass effect from a mediastinal LN causing a focal stricture. Can also spread via stomach

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With regard to strictures, give the main differential dx for the following findings:

smooth margins, immediately above GEJ
mid esophagus
Abrupt, shouldered margins
GEJ stricture with transient relaxation
GEJ fixed stricture
Long and narrow stricture
Skin lesions
Stricture with multiple rings

Peptic 
Barretts
Carcinoma
Achalasia
Pseudoachalasia
Caustic/NG tube
Cicatricial/bullous
Eosinophilic esophagitis

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Differential for a smooth surfaced mass with an obtuse angle between mass and esophageal lumen

with enhancement?

SUBMUCOSAL

GIST (+CE)
Leiomyoma (+CE)
Duplication cyst - water attenuation

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Most common submucosal neoplasm of the esophagus? Where does it present

Leiomyoma

mid to distal, high presence of smooth muscle cells

Differential for a lobulated filling defect in the distal esophagus? Which are malignant?

Adenoma - usually seen with barretts. Malignant potential, higher risk if larger lesion

Papilloma - no malignant potential

Inflammatory esophagogastric polyp - extend from the stomach

What are inflammatory esophagogastric polyps?

Enlarged polypoid fold arising from the fundus of the stomach into the lower esophagus. No malignant potential, but has similar appearance to adenoma so endoscopy is advised.

Differential for a smooth intraluminal esophageal mass arising from a stalk in the cervical esophagus

Fibrovascular polyp > Spindle cell carcinoma (usually more distal) > Adenomatous polyp (usually smaller)

What is a fibrovascular polyp in the esophagus?

Benign, pedunculated intraluminal lesion of various mesenchymal elements, covered by normal squamous epithelium. Considerable fatty component on CT Usually longer than 7cm (bigger than adenoma) Can propel into cervical esophagus and cause respiratory issues

What are findings of a malignant esophageal mass

Irregular contour of lumen Abrupt/shouldered edges Ulcer that DOESNT extend beyond normal esophageal mucosa

Differential for bulky polypoid filling defect in the esophagus

Adenocarcinoma - usually distal Spindle cell, lymphoma SqCC is usually an annular constricting mass

What is the normal thickness of the esophageal wall?

Where is a spindle cell carcinoma usually located

Bulky, polypoid intraluminal mass in MID or DISTAL esophagus with pedunculation

DDx for multiple serpentine filling defects in distal esophagus?

Varicoid esophageal carcinoma - fixed Varices - change in shape and size

Describe the physiology of "uphill" varices

Hepatic cirrhosis causes portal HTN Increased portal venous pressure reverses normal venous bloodflow upwards from the portal vein to the left gastric vein, to the periesophageal venous plexus, to the azygos and hemiazygous collateral dumping into the SVC

Describe the physiology of "downhill: varices

Obstruction of the SVC due to mass or fibrosing mediastinitis causes enlargement of collaterals (supreme intercostal, bronchial, inferior thyroidal). Blood flows DOWN to the left gastric and portal veins and dump into the lower SVC

What are the 3 foregut cysts? Differnetiation?

Esophageal duplication - squamous epithelium Bronchogenic - respiratory epithelium Neurenteric - associated vertebral body anomolies

What is the difference between foreign body impaction by a fishbone and meat?

Meat is distal, fishbone is proximal

What is the treatment plan for impacted foreign body? What is the risk?

Glucagon (1mg) decreases pressure of the LES Endoscopic retrival with basket Follow because if impacted >24hours, there is a risk of transmural ischemia

Small outpouchings from the lateral hypopharynx? Who gets them?

Lateral pharyngeal pouches Arises through an unsupported weak area in the thyrohyoid membrane. Best seen if patient blows against pressure Seen in glassblowers, trumpeters

Diverticulum from the posterior wall of cervical esophagus? Where does it go through?

Zenker diverticulum Killian dehiscense/triangle - between oblique and horizontal fibers of esophageal wall just above cricopharyngeus. Arise from abnormally increased pressure in the hypopharynx due to failure of the cricopharyngeus muscle to relax "Z is in the back (posterior) of the alphabet"

Diverticulum off the lateral wall of the cervical esophagus

Killian jamieson Protrudes through area of weakness below cricopharyngeus on cricoid cartilage and lateral to suspensory ligaments "Killian Jamieson" Space on ANTEROLATERAL wall

Triangular shaped/wide based outpouching in midesophagus, associated with TB adenitis/fibrosing disorders

Traction diverticula Pulsion (more common) are round

Distal esophageal diverticulum associated with achalasia, doesnt empty with peristalsis

Epiphrenic pulsion diverticulum.

Define primary/secondary/tertiary contractions.

Primary - intiiated by swallow. Smooth, continuous contraction the length of esophagus. Secondar - initiated by bolus/esophageal distenstion Tertiary - nonpropulsive, irregular, do not move bolus, increased in the elderly

Dysphagia and chest pain with vigorous nonpropulsive contraction? Main differential?

Diffuse esophageal spasm (nutcracker esophagus) - normal peristalsis will eventually show. Corkscrew appearance. "Nutcracker esophagus" is a precursor related to high manometry findings. Vigorous achalasia will not have a normal stripping wave in response to swallowing

What is the muscular ring (A ring)?

Broad, smooth indentation in lower esophagus superior to vestibule. Changes shape and disappears at fluoroscopy (vs hiatal hernia).

What is the musocal ring (B ring)?

thin, fixed ring that doesnt change in appearance and marks location of esophagogastric junction.

Thin weblike ring at the level of the GEJ with symptoms. What is the usual diameter?

Schatzki ring - must be symptomatic, otherwise its a B ring usually 10-15mm is when symptoms occur

Thin, smooth, shelflike filling defect along ANTERIOR wall of esophagus. Association? main differential?

Esophageal web - RARELY circumferential Plummer vinson - esophageal web, anemia Anterior venous plexus - will change and vary from swallow to swallow

Small shallow indentations along the lateral wall of the cervical esophagus,

Ectopic gastric mucosa - last place in the esophagus to undergo replacement with stratified squamous epithelium in embryogenesis.

How often does scleroderma affect the esophagus? How does it affect the esophagus? What are the complications?

80% of scleroderma patients Degeneration and atrophy of smooth muscle and fibrosis within distal 2/3 of esophagus. Radiographically, there is absent peristalsis in the distal 2/3 of the esophagus with and incompetent LES. results in reflux Complications - candidiasis due to stasis and aspiration

How high above the diaphragm is a hiatal hernia? How is it radiographically seen?

>2cm for confident diagnosis Gastric folds will be seen above diaphragm

What are the two types of hiatal hernia? Which is more prone to complication?

Sliding - abnormal location of the GEJ Paraesophageal - normal location of the GEJ with the stomach herniating through the diaphragm. Paraesophageal are more prone to gastritis and bleeding, ulceration, and strangulation.

Differentiate iatrogenic and spontaneous esophageal perforations.

Iatrogenic are usually at the cervical esophagus Spontaneous are usually just above the GEJ