esophagus Flashcards
robbins
what is the purpose of manometry
differentiate between the different types of esophageal dysmotility by checking LES tone and peristalsis
what are the three types of esophageal dysmotility
- nutcracker syndrome= high amplitude contractions of distal esophagus with loss of normal coordination
- diffuse esophageal spasm with repetitive, simultaneous contractions of the distal sm m.
- hypertensive lower esophageal sphincter- LES high resting pressure/incomplete relaxation
because wall stress is increased, esophageal dysmotility may result in development of ______, primarily the ___ ____
small diverticulae
epiphrenic diverticulum
spasm of the ____ M after swallowing can result in increased P within the ____ ____ and thus the development of ___ ____, which is located directly above the __ ____ ____
cricopharyngeus
distal pharynx
Zenker diverticulum
upper esophageal sphincter
what population is zenker diverticulum most likely to present in
age > 50 y.o
Sx of Zenker’s Diverticulum
regurge and halitosis because food gets stuck in the diverticulum
mechanical esophageal obstruction, such as _____, starts with inability to ______ and progress to _______
strictures of CA
swallow solids
liquids
describe benign esophageal stenosis
narrowing of the lumen due to fibrous thickening of the submucosa, associated with atrophy of the muscularis propria and secondary epithelial damage
benign esophageal strictures often maintain their ___ and ___, while malignant strictures are often associated with ______
appetite, weight
weightloss
what are esophageal mucosal webs
idiopathic, ledge-like protrusions of the mucosa that may cause obstruction
in what population are you most likely going to see esophageal mucosal webs
women older than the age of 40, associated with GERD, graft-vs-host ds
upper esophagus webs may be accompanied by what other conditions
iron deficiency anemia, glossitis, cheilosis =Plummer-Vinson syndrome
in esophagus, semi-circumferential lesions that protrude less than 5 mm, made of fibrovascular CT and overlying epithelium
esophageal webs
what is the clinical presentation of esophageal webs
nonprogressive dysphagia associated with incompletely chewed food
in esophagus, circumferential, thicker than 2-4 mm, includes mucosa, submucosa, and sometimes hypertrophic muscularis propria
schatzki rings
schatzki rings: differentiate between A rings and B rings
A rings= above the gastroesophageal junction in the distal esophagus, covered by squamous mucosa
B rings= at the squamocolumnar junction of the lower esophagus, with gastric cardia-type mucosa
achalasia is characterized by this triad
incomplete LES relaxation
increased LES tone
aperistalsis of the esophagus
What are the sx of achalasia?
dysphagia for solids and liquids, difficulty in belching, and CP
what is the etiology of achalasia
distal esophageal inhibitory neuronal (ganglion cell) degeneration
x vagus N/ dorsal motor nucleus of vagus
what is the etiology of secondary achalasia
happens in Chagas Ds (trypanosoma cruzi infection–> destruction of myentric plexus, failure of peristalsis, and esophageal dilation)
association of achalasia with these three etiologies suggests that achalasia may be driven by immune-mediated destruction of esophageal neurons
HSV1 infection
sjögren syndrome
autoimmune thyroid disease
what is the treatment of achalasia
laproscopic myotomy, pneumatic balloon dilatation, botox injection
longitudinal esophageal tears near the gastroesophageal junction, most often associated with sever retching or vomiting secondary to acute alcohol intoxication
mallory-weiss tears
describe the etiology of mallory weiss teras
esophageal relaxation fails during prolonged vomiting.. gastric contents overwhelm the gastric inlet and cause the esophageal wall to stretch and tear
transmural tearing and rupture of the distal esophagus
boerhaave syndrome
describe the prognosis and treatment of boerhaave syndrome
=an emergency that results in severe mediastinitis and requires surgical intervention
what is the clinical presentation of boerhaave syndrome
CP, tachycardia, shock
common irritants of the mucosa of the esophagus
alcohol, corrosive acids or alkalis, hot fluids, heavy smoking
describe the presentation of esophageal chemical injury
in children, due to accidental ingestion of household cleaning
in adults, often after attempted suicide
esophageal infections in otherwise healthy people are uncommon and often due to ____. infections in immunosuppressed patients is more common and can be caused by ___
herpes simplex virus
herpes simplex virus, CMV, fungal organisms, candidiasis
what is the most common fungal infection of the esophagus
candida
pill induced esophagitis frequently occurs at the site of ____. ulceration, when present, is accompanied by ________ and eventually _____
strictures
superficial necrosis with granulation
fibrosis
nonpathogenic oral bacteria are frequently found in _________, which pathogenic organisms may invade the ___ ____ and cause _____ or overlying mucosa
ulcer beds
lamina propria, necrosis
_____ virus usually causes punched-out ulcers (in esophagus)
herpes
_______ causes shallower ulcerations and characteristic nuclear and cytoplasmic inclusions within capillary endothelium (in esophagus)
CMV
submucosal glands in the ___ and ____ esophagus secrete ____ and _____
proximal and distal
mucin and bicarb
what is the most frequent cause of esophagitis
reflux of gastric contents into the lower esophagus, most commonly caused by transient LES relaxation
what is the most common outpatient GI complaint in the US
esophagitis
what factors and conditions can cause LES relaxation and gastric reflux
normally mediated by vagus N
can be triggered by gastric distension, gas or food, mild pharyngeal stimulation, stress,
swallow-induced relaxation of LES
abrupt increase in intra-abdominal P
alc and tobacco use, obesity, CNS depressants, pregnancy, hiatal hernia, delayed gastric emptying, increased gastric volume
(esophagus) basal zone hyperplasia exceeding 20% of total epithelial thickness and elongation of lamina propria papillae extending into the upper third
extensive GERD
in what population is GERD most common
older than 40, infants and children
describe the clinical presentation of GERD
heartburn, dysphagia, regurge of sour-tasting gastric contents
in chronic GERD–> attacks of severe CP
what is the treatment for GERD and what are some complications of reflux esophagitis
PPIs for symptomatic relief
complications–> ulceration, hematemesis, melena, stricture development, Barrett esophagus
“separation of diaphragmatic crura and protrusion of the stomach into the thorax through the resulting gap”
hiatal hernia
what is the clinical presentation of hiatal hernia
heartburn and regurge
in what population will you see hiatal hernia
can have congenital in infants and children
mostly acquired later in life
what are the sx of eosinophilic esophagitis
food impaction and dysphagia in adults and feeding intolerance in children
majority of patients are atopic- atopic dermatitis, allergic rhinitis, asthma, modest peripheral eosinophils
(esophagus) large number of intraepithelial eosinophils, particularly superficially
eosinophilic esophagitis
differentiate the sx and trx of GERD vs eosinophilic esophagitis
unlike GERD, acid reflux is not prominent in eosinophilic esophagitis and high doses of PPIs usually do not provide relief
in e.e., give dietary restrictions (no milk or soy), and topical or systemic corticosteroids for atopic sx
“tortuous dilated veins lying primary within the submucosa of the distal esophagus and proximal stomach”
esophageal varices
what are the two most common causes of esophageal varices (the portal HTN that precedes them)
first- alcoholic cirrhosis
second- hepatic schistosomiasiss
what is the risk of untreated varices
rupture–> hemorrhage into the lumen of the esophageal wall–> overlying mucosa appears ulcerated and necrotc
(esophagus) squamous cells with nuclear inclusions = __
- seen in the setting of ___
HSV, immunocompromised (infectious esophagitis)
what two viral infectious should come to mind with infectious esophagitis
HSV-1 and CMV
vascular ectasia- what is he?
in the antrum of the stomach
=watermelon stomach-
= ectatic mucosal vessels producing stripes of edematous erythematous mucosa alternating with less severely injured paler mucosa
associated with cirrhosis and systemic sclerosis
what does H. Pylori infection look on endoscopy
nodular lesions in the antrum
what population is associated with adenocarcinoma
white men
what is the treatment for esophageal variceal hemorrhage
an emergency
can be treated by inducing splanchnic vasoconstriction endoscopically by sclerotherapy balloon tamponade variceal ligation (banding is semi-permanent)
patient’s with high risk for hemorrhage are treated prophylactically with B blockers to reduce portal blood flow and with endoscopic variceal ligation
what is the prognosis of esophageal varices hemorrhage
30% die from hypovolemic shock, hepatic coma, etc.
50% of those who survive will have a recurrent hemorrhage within 1 year
complication of GERD that is characterized by intestinal metaplasia within the squamous mucosa of the esophagus
barrett esophagus
in what population is Barrett esophagus most common
white males between 40-60
the greatest concern in Barrett esophagus is that it confers an increased risk of ___ ______
esophageal adenocarcinoma
“one or several tongues or patches of red, velvety mucosa extending upward from the gastroesophageal junction” “metaplasic mucosa alternates with residual smooth, pale squamous mucosa”
barrett esophagus
Barrett esophagus can only be identified through ___ and ___, which are usually prompted by _______
endoscopy and biopsy,
GERD sx
what is the trx for Barrett esophagus
surgical resection, esophagectomy, photodynamic therapy, laser ablation, and endoscopic mucosectomy
the most common esophageal CA
squamous cell carcinoma
most esophageal adenocarcinomas arise from ___ ____
Barrett esophagus
risk factors for adenocarcinoma
obesity-related GERD barrett esophagus tobacco radiation H.
protective factors against adenocarcinoma of the esophagus
a diet full of fruit and vegetables
H. pylori (decreased acid secretion secondary to gastric atropy)
in what population is adenocarcinoma most common
Caucasian, men in the US/UK/Australia/Netherlands
describe the genetic and epigenetic changes that cause the progression from Barrett’s to adenocarcinoma
first mutation of TP53 and downregulation of CDKN2A, aka p16/NK4a
later progression= amplification of EGFR, ERGBB2, MET, cyclin D1, and cyclin E
esophageal adenocarcinoma usually occurs in the ___ ____ of the esophagus and may invade the ___ ___ ____
distal third
adjacent gastric cardia
esophageal adenocarcinomas most commonly produce ___ and form ___, with intestinal-type morphology
mucin
glands
describe the prognosis of adenocarcinomas
by the time they present, its usually already spread to the submucosal lymphatic vessels
5 year survival less than 25%
in the few patients where it is limited to the mucosa or submucosa, the 5 year survival is about 80%
in what population are you most likely to see squamous cell carcinoma
adults older than 45, males, AAs
also in patients in western kenya under 30 who consume traditional fermented milk
what are risk factors for squamous cell carcinoma
alcohol and tobacco use, poverty, caustic esophageal injury, achalasia, tylosis, plummer-vinson syndrome, diets without fruits or vegetables, previous radiation to the mediastinum
describe alcohol as a risk factor for squamous cell carcinoma
not a risk factor on its own, but is synergistically risky with tobacco use
what genetic abnormalities are associated with squamous cell carcinoma of the esophagys
amplification of SOX2, over-expression of cyclin D1 (cell cycle regulator), loss of function of TP53, E-cadherin, and NOTCH1
where in the esophagus are squamous cell carcinoma commonly found
middle third of the esophagus
describe the morphology of squamous cell carcinoma in the esophagus
begins as an in situ lesion called squamous dysplasia
early lesions appear as small, gray-white, plaque-like thickenings
metastasis from the upper third of the esophagus will go to ____, from the middle third will go to ________,and from the lower third will go to the _________
- cervical lymph nodes
- mediastinal, paratracheal, and tracheobronchial nodes
- gastric and celiac nodes
what is the clinical presentation associated with squamous cell carcinoma
dysphagia, odynophagia, obstruction causing to switch to liquid foods
prominent weight loss, debilitation
hemorrage and sepsis with tumor ulceration, iron deficiency
sometimes the first sx are aspiration of food via a tracheoesophageal fistula
what is the prognosis of squamous cell carcinoma
5 year survival= 75% if superficial
overall= 20%, and varies by stage, age, race and gender
