esophagus Flashcards
what disorder is seen with “birds beak” on CXR
achalasia
define reflux esophagitis
- inflammation of esophagus caused by GERD (LES relaxation) or hiatal hernia
sx: chest pain, dysphagia, odynophagia
-can lead to hemorrhagic esophagitis
infectious esophagitis RF and key features
- neutrophils are present
- RF: immunocompromised, diabetes, systemic steroids, radiation, abx
- pathogens:
1. candida: yellow white plaque on mucosa
2. HSV: multiple small DEEP ulcers
3. CMV: 1+ large SHALLOW ulcers
diffuse vs limited scleroderma antibodies
diffuse: Scl-70 Ab, and anti- topiosomerase Ab
limited (CREST syndrome): anti-centromere Ab
what is Killians triangle
area of muscular weakness around the level of the upper esophageal sphincter in which Zenkers Diverticulum protrude
(cricopharyngeus M. and inferior constrictor M.s)
define hemorrhagic esophagitis
- inflammation of the esophagus that presents with hematemesis
- RF: GERD (dyspepsia, water brush), reflux esophagitis
- sx: dysphagia, odynophagia, sharp chest pain, at night and early morning
risk factors of esophageal variceal bleed
- size of varices (>5mm)
- red wale marks on EGD
- liver disease severity (raises hepatic venous pressure)
- active alcohol abuse
(others: hepatic venous pressure or previous bleed)
prevention by nonselective beta blockers
risk factors of esophageal adenocarcinoma
- hiatal hernia (causes GERD)
- GERD
- BARRETTS ESOPHAGUS
- obesity
(all factors related to development of chronic GERD and subsequent BARRETTS)
most common type of esophagitis
reflux esophagitis
most common diaphragmatic hernia and associated complications
sliding hiatal hernia (displacement of GEJ superiorly)
-leads to GERD–> Barretts esophagus –> increased risk of adenocarcinoma
(also but less commonly associated with reflux esophagitis–> hemorrhagic esophagitis)
esophagitis
leads to stricture sites
- it is ulcers with superficial necrosis that leads to fibrosis
- major sx: odynophagia , dysphagia (second), Chestpain (third)
what can cause acquired esophageal webs
eosinophilic esophagitis and plummer vinson syndrome
histological characteristics of Barretts esophagus
Histo: distinct mucous vacuoles that stain pale blue by H&E (hematoxylin and eosin)
-dx: EGD and biopsy
treatment risk associated with eosinophilic esophagitis
dilitation can cause PERFORATION –>hematemesis, pnuemomediastinum, subcutaneous emphysema, Hammans sign
what is Romana sign
painless peri-orbital swelling
seen in achalasia associated with Chagas Dz
pill esophagitis RF and key features
RF: NSAIDs, Potassium chloride pills, ronate, abx, injured esophagus
- EGD shows 1+ ulcers
- complications: stricture, hemorrhage, rupture
- tx: stop meds or take with 4oz water and stand for 30 minutes
characteristics of nutcracker esophagus
- esophageal dysmotility disorder caused by hypertensive peristalsis (tight contraction) of the DISTAL portion of the esophagus
- Unique features:
1. NL coordinated contractions (except at distal part there is incoordination),
2. NL relaxation of the LES,
3. high amplitude pressure on manometry, (high baseline pressure of LES)
(SX same as DES)
sx: intermittent (nonprogressive) esophageal dysphagia (solids and liquids), atypical Chest pain
characteristics of Boerhaves syndrome
- spontaneous TRANSMURAL tear at the GEJ leading to esophageal perforation
- associated with hx of retching, vommiting, alcohol
- sx: VERY SICK, PAINFUL hematemesis, shock, subcutaneous emphysema, Hammans sign
- dx: CXR (seen pneumomediastinum)
tx: NPO, Abx, stent, surgery
diagnostic triad of achalasia by esophageal manometry
- incomplete LES relaxation
- increased LES tone
- aperistalsis of the esophagus
characteristics of Schatzki Ring
- DISTAL structural obstruction that causes intermittent (Non progressive) esophageal dysphagia
- aka “steakhouse syndrome”
- associated with hiatal hernia
- dx: barium swallow
- tx: dilitation
LN spread of esophageal cancer
upper 1/3- cervical LN
middle 1/3 - mediastinal, tracheobronchial LN
lower 1/3 - Celiac, gastric LN
causes of esophageal obstruction (motility and mechanical causes)
- esophageal dysmotility (nutcracker esophagus, diffuses esophageal spasm, hypertensive LES, scleroderma CREST)
- esophageal stenosis / stricture
- esophageal webs (plummer vinson syndrome)
- Schatszki ring
- esophagitis
- cancer
- achalasia
- hiatal hernia
*causes sx: of esophageal dysphagia
characteristics of esophageal stricture
- structural esophageal obstruction caused by GERD or eosinophilic esophagitis at the GEJ
- progressive
- **GERD pain RELIEVES as stricture worsens !!!
- MUST do an EGD to rule our cancer
- tx: dilitation, ppi
sx of esophageal SCC
progressive dysphagia (obstruction), weight loss, anoxeria, bleeding (hematemesis), hoarseness, cough
characteristics diffuse esophageal spasm
- esophageal dysmotility disorder caused by DIFFUSE multiple spastic circular M. contractions via excitatory/inhibitory imbalance
- Unique features:
1. COMPLETELY uncoordinated contractions
2. NL LES function
3. no high pressure on manometry
4. corkscrew esophagus
5. associated with GERD, diabetes, and stress
(SX same as NS)
sx: intermittent (nonprogressive) esophageal dysphagia (solids and liquids), atypical Chest pain
characteristics of limited scleroderma
CREST syndrome (calcinosis, Raynaulds Phenomenon, esophageal dysmotility, sclerodactyly, telangiectasia)
- structural, progressive, esophageal dysphagia
- *May have chronic heartburn
- Key features: esophageal smooth muscle atrophy, fibrosis–>aperistalsis, microangiopathy
- tx: sx control
characteristics mallory weiss tear
longitudinal MUCOSAL/SUBMUCOSAL tears of the GEJ due to severe retching, vommitting, vigorous coughing
- associated with alcohol intoxication
- sx: PAINFUL hematemesis
- dx/tx: EGD
*can lead to Boerhaves Syndrome
geographic distrubtution of esophageal adenocarcinoma vs esophageal squamous cell carcinoma
adenocarcinoma: US, UK, Cananda, AUS (westernized)
(*more common in men and distal location)
SCC: Iran, China, Hong Kong, (Asia)
(*more common in black men, and middle location)
sx of esophageal varices
asymptomatic until it ruptures then PAINLESS hematemesis
*esophageal variceal bleed is the most common cause of death in cirrhosis patients
characteristics if esophageal web
- structural esophageal obstruction caused by protrusion of esophageal MUCOSA
- usually in upper (mid/proximal) esophagus and causes oropharngyeal dysphagia, but can arise in distal esophagus and causes esophageal dysphagia
- *(Structural (solids), intermittent, non progressive dysphagia )**
- can be congenital or acquired via plummer vinson syndrome or eosinophilic esophagitis
- *INCREASES RISK OF esophageal SCC
dx: barium swallow
tx: dilatation
signs, sx, and Risk factors of food obstruction/impaction
sx: severe chest pain, dysphagia, odynophagia, choking,
- signs: vommiting, hypersalivation (drooling, foaming)
- RF: schatzi ring, webs, esophagitis, achalasia, cancer stricture (obstructions)
eosinophilic esophagitis RF and key features
aka feline esophagus, tracheal esophagus
- RF: GERD, PPI use, Celiac, Crohns,
- ASSOCIATED with hx of ATOPIC ALLERGIES and food impaction
- males> females
- EGD= corrugated multiple circular rings
- biopsy= eosinophils
- tx: dilatation (RISK OF PERFORATION)
_____ distinguishes between types of esophageal dysmotility
esophageal manometry
what causes symptoms of orophargnygeal dysphagia
- proximal esophageal web (plummer vinson)
- zenker diverticulum
- Sjorgrens Syndrome
caustic esophagitis RF and key features
- usually due to acid/drain cleaner bc of accidents in children or suicide attempts in adults
- sx: severe burning, gagging, dysphagia, drooling, stridor/wheezing
dx: laryngoscopy, CXR (check for perforation, or pneumonitis) - **INCREASES RISK OF ESOPHAGEAL SCC
- *DO NOT NASOGASTRIC LAVAGE or ORAL ABX
- admit to ICU
achalasia primary and secondary causes
- primary cause: ganglion degeneration of the DISTAL myenteric plexus controlling esophageal inhibitory neuronal stimulation (loss of NO neurons)
- secondary: Chagas Dz by trypano cruzi
characteristics of Sjogrens syndrome (rheumatic dz)
sx:
- dry eyes –> keratoconjuncitivitis sicca
- dry mouth–> oropharyngeal dysphagia
- parotid gland enlargement
- population: postmenopausal females
- association: Non Hodgkin B cell Lymphoma
dx: lip biopsy
tx: supportive
characteristics of zenker diverticulum (ZD)
-structural esophageal anomaly caused by out pouching of pharyngeal mucosa at/above UES through ACQUIRED muscular wall defect of cricopharynxgeus M. and inferior pharyngeal constrictor M.s (false diverticula)
(*area of muscle weakness is called KILLIANS TRIANGLE)
(structural (solids) , progressive oropharyngeal dysphagia)
-sx: halitosis, spontaneous regurgitation, nocturnal choking, throat gurgling, neck protrusion, voice changes, weight loss, LUNG ABSCESS
-dx: video barium esophagraphy
-tx: upper mytomy /diverticulotomy
risk factors of esophageal SCC
- alcohol/ tabacco
- hot beverages (reason why worse in places that drink hot tea)
- achalasia
- esophageal web
- esophageal injury (CAUSTIC ESOPHAGITIS)
- tylosis (Howel Evans Syndrome)
- HIV/AIDS
sx and complications of achalasia
sx: undigested regurgitation, nocturnal choking, substernal discomfort, adaptive food maneuvers, halitosis
(if chagas = romana sign)
-complications: increased risk of SCC (get EGD to rule out), if untreated it becomes SIGMOID ESOPHAGUS
define “pseudoachalasia”
caused by cancer invading GEJ
define GVHD esophagitis
- basal epithelial cell apoptosis, mucosal atrophy, submucosal fibrosis WITHOUT acute inflammatory infiltrates
sx: rash, vommiting, odynophagia
what is Howel Evans Syndrome
tylosis
- RHBDF2 mutation caused hyperkeratinosis
- risk factor for esophageal SCC
esophageal varices two most common causes
cirrhosis of the liver due to
1. alcoholism
2. hepatic schistosomiasis (shistosoma endemic in
Egypt)
define plummer vinson syndrome
- occurs mainly in middle aged women
- iron deficiency anemia (kolionychia) , atrophic glossitis, esophageal webs, angular chelitis
(Plummer Vinson is A GEeK who hits on middle aged women )
sensation of lump in throat without anything there or any dysphagia present
globus pharyngeus
