Esophagus

Question 1

What type of muscle is esophagus made up of?

Answer 1

Upper 1/3: striated only. Middle 1/3: striated/smooth. Inferior 1/3: smooth only.

Question 2

Causes of mechanical dysphagia (solids > liquids)

Answer 2

Foreign body, inflammation (infectious esophagitis, caustic exposure), strictures, neoplasms, extrinsic compression (aortic aneurysm, retropharyngeal abscess, thyromegaly)

Question 3

Causes of neuromuscular dysphagia (solids = liquids)

Answer 3

Tongue paralysis, lesions of CN 9 and/or 10, MG, poly or dermatomyositis, esophageal smooth muscle d/o (scleroderma, achalasia, diffuse esophageal spasm)

Question 4

Achalasia

Answer 4

Result of derangement of the myenteric plexus -> nonpersistalsis, incomplete LES relaxation after swallowing, increased LES tone at rest

Question 5

Tx of achalasia

Answer 5

Meds: CCBs or nitrates. Surgery: endoscopic dilation (less successful, higher risk of perf) or esophagomyotomy with fundoplication

Question 6

Complications of achalasia

Answer 6

Increased risk of SCC. Pulmonary complications from aspiration

Question 7

Diffuse esophageal spasm (DES)

Answer 7

Primary or secondary to reflux esophagitis, esophageal obstruction, CTD, diabetic neuropathy. Spasm is in distal 2/3. Dysfunction of myenteric plexus -> large uncoordinated contractions of smooth muscle

Question 8

DES presentation

Answer 8

Unlike achalasia, no regurg. Can present with chest pain that is mistaken for ACS. Barium swallow may show corkscrew or be normal if not in spasm

Question 9

DES tx

Answer 9

Meds: nitrates, CCB decrease LES pressure. Esophagomyotomy not as successful as for achalasia so only use if totally debilitating

Question 10

Mortality of esophageal rupture

Answer 10

50%

Question 11

Boerhaave syndrome

Answer 11

Full thickness esophageal tear. Due to forceful vomiting, cough, labor, lifting, trauma. Most common site of rupture is L lateral wall just above esophageal hiatus. Needs surgical repair.

Question 12

Mallory-Weiss syndrome

Answer 12

Partial thickness esophageal tear. Due to forceful vomiting. Bleeding gen resolves spontaneously. 90% can be medically managed with NG tube and gastric lavage.

Question 13

What are the three anatomic narrowings of the esophagus?

Answer 13

Above the UES. Near the aortic arch. Above the LES (which is not an anatomic sphincter btw)

Question 14

Hammon’s crunch

Answer 14

Mediastinal emphysema heard as “crunching” sound with heartbreat, finding in esophageal perf

Question 15

Plummer-Vinson syndrome

Answer 15

Esophageal webs from chronic iron deficiency

Question 16

Risk factors for esophageal carcinoma

Answer 16

Alcohol, tobcco, diet high in nitrates, achalasia, chronic esophagitis, Plummer-Vinson

Question 17

Prognosis of esophageal carcinoma

Answer 17

Poor; dysphagia doesn’t develop until esophagus is more than half occluded, so by the time of presentation most patients have mets. Tx is mostly palliative and has many complications. 5 yrs survival 5%. Radiation can shrink and provide some palliation.

Question 18

True vs. false esophageal diverticulum

Answer 18

True = all three layers of esophagus. False = only mucosa and submucosa

Question 19

Three types of esophageal diverticula

Answer 19

Pharyngoesophageal (Zenker’s), midesophageal, epiphrenic

Question 20

Pharyngoesophageal and epiphrenic diverticular are caused by what?

Answer 20

Pulsion diverticula, meaning caused by increased pressure. These are false diverticula

Question 21

Midesophageal diverticular are caused by what?

Answer 21

Traction. They are true diverticula

Question 22

Dx of esophageal diverticula

Answer 22

Barium swallow

Question 23

Why is quitting smoking good for GERD?

Answer 23

Nicotine decreases LES tone