Esophagus

Question 1

Scleroderma/Progressive Systemic Sclerosis (PSS)

Answer 1

• multisystem disorder characterized by obliterative small vessel vasculitis, fibrosis of multiple organs
• smooth muscle atrophy and gut wall fibrosis
• myopathic process
• smooth muscle atrophy-> weak perstalsis-> dysphagia
• smooth muscle atrophy-> weak LES-> GERD
• dx with esophageal manometry

Question 2

Lower Esophageal Sphincter

Answer 2

• gatekeeper between esophagus and stomach
• failure to relax due to loss of enteric nerves is called achalasia
• inappropriate LES relaxation can cause acid reflux

Question 3

Achalasia

Answer 3

• failure of LES to relax due to loss of enteric nerves
• makes swallowing difficult
• abnormal peristalsis
• idiopathic
• both genders, all races, adults (25-60)

Question 4

Oropharyngeal Dysphasia

Answer 4

• inability to initiate a swallow or transfer food bolus into esophagus
• may occur with obstruction of neuromuscular disease

Question 5

Zenker’s Diverticulum

Answer 5

-outpouching of esophagus leading to food regurgitation or bacterial colonization

Question 6

Squamous Cell Carcinoma

Answer 6

-most common in upper 2/3 of esophagus

Question 7

Dx of Oropharyngeal Disease

Answer 7

• history and physical most helpful
• barium swollow
• neuro consult

Question 8

Percutaneous Endoscopic Gastrostomy Tube

Answer 8

• may be needed for feeding and to prevent aspiration

- directly to stomach

Question 9

Types of Manometry Findings

Answer 9

• 1: swallowing with no significant change in esophageal pressurization
• 2: swallowing with simultaneous pressurization spanning entire esophagus length (botox, pneumonic dilation, surgical myotomy work best)
• 3: swallowing is abnormal, lumen obliterating contractions/spasms (botox, dilation, surgery may have poor outcomes)

Question 10

Secondary Achalasia

Answer 10

• pseudoachalasia
• direct mechanical obstruction of LES
• infiltrative submucosal invasion
• paraneoplastic
• chagas disease

Question 11

Achalasia Treatment

Answer 11

• medical therapy: nitrates (stimulates intracellular Ca bloackers)
• endoscopic therapy: GE junction botox injections, balloon dilation, POEM

Question 12

Esophageal Strictures

Answer 12

• benign (GERD, radiations, congenital) or malignant (squamous cell carcinoma, adenocarcinoma)
• cardical sx id dysphagia to solids
• weight loss is ominous

Question 13

Schatski’s Ring

Answer 13

• tx same as stricture

- 3 cell layers thick

Question 14

Eosinophilic Esophagitis

Answer 14

• chronic immune/antigen mediated esophageal disease
• features: dysphagia, food avoidance, maybe heartburn, vomiting, pain, dyspepsia, stenosis
• most common

Question 15

GERD

Answer 15

• pathologic reflux of gastric acid juice
• common
• inc. cancer risk
• relieved by antacids or anti-decretory meds
• causes: inappropriate LES relaxation, hiatal hernia, zollinger-ellison, sjogrens, scleroderma
• risk factors: obesity, tobacco, meds, pregnancy,
• complications: erosive esophagus, barrett’s
• Dx: pH testing, wireless capsule, transnasal catheter

Question 16

Barrett’s Esophagus

Answer 16

• metaplasia to intestinal glandular type tissue (salmon colored)
• consequence of GERD
• risks: male, white, central adiposity, inc. age, chronic GERD
• risk of developing esophageal adenocarcinoma (1-5% with BE will develop)
• tx: ablation of Barrett’s tissue, endoscopic resection of lesions

Question 17

Squamous Cell Carcinoma

Answer 17

• risks: inc age, tobacco use, caustic injuries, EtOH, dietary factors, low SES
• most common in top 2/3 of esophagus but can occur anywhere
• more common in developing countries (Asia and Africa)
• more common in men (4M : 1F) and African Americans
• squamous cell epithelial malignancy- infiltrative nests of squamous cells

Question 18

Adenocarcinoma

Answer 18

• risks: old age, smoking, obesity, radiation, GERD, Barrett’s esophagus (most common)
• bottom 1/3 of esophagus
• more common in men (7M : 1F)
• glandular epithelial malignancy
• more common than squamous cell carcinoma in the US

Question 19

Esophagitis

Answer 19

• inflammation and injury of esophageal mucosa
• results from a variety of etiologies: reflux/chemical injury, infection (herpes, candids), immune related, trauma
• extremely common (5% US adults)
• heartburn and regurgitation are typical sxs

Question 20

Types of Esophageal Obstruction

Answer 20

• functional: nutcracker esophagus, diffuse esophageal spasm, hypertensive lower esophageal sphincter, achalasia
• structural: diverticula, esophageal mucosal webs/rings, congenital abnormalities, benign esophageal stenosis, tumors

Question 21

Esophageal Obstruction: Structural

Answer 21

• acquired
• diverticula
• -zenkers: upper esophagus, associated with reduced UES compliance
• -mid esophagus: mediastinal inflammations (ie TB)
• -epiphrenic: secondary to coexistence with hiatal hernia

Question 22

Esophageal Webs/Rings

Answer 22

• structural esophageal obstruction
• acquired
• more common in females >40yo
• mostly asymptomatic, dysphagia, odynophagia
• 2 cell layers thick

Question 23

Esophageal Atresia and Tracheoesophageal Fistula

Answer 23

• congenital anomalies resulting from failure of the foregut to divide into trachea and esophagus during 4th week of embryonic development
• features: food regurg, drooling, aspiration

Question 24

Congenital Esophageal Stenosis

Answer 24

-significant narrowing of mid esophagus

Question 25

Esophageal Lacerations

Answer 25

- mallory-weiss tears - boerhaave syndrome - severe vomiting, often associated with EtOH intoxication

Question 26

Varices

Answer 26

- cirrhosis-> portal hypertension-> inc. blood in esophageal vasculature - compounded by liver dec. ability to make clotting factors

Question 27

Nitric Oxide

Answer 27

- inc. smooth muscle relaxation, including LES | - loss of NO secretion is implicated in inc. LES tone in achalasia

Question 28

Odynophagia

Answer 28

-painful swallowing