Esophagus Flashcards
Achalasia triad
Form of
incomplete LES relaxation
inc LES tone
esophageal aperistalsis
Functional esophageal obstruction
Most frequent site of ectopic gastric mucosa
upper third of esophagus:
inlet patch
Small patches of ectopic gastric mucosa in si and colon
Gastric heterotopia
Dilated coronary veins in lower esophagus due to portal hypertension
(cirrhosis, schistosomiasis)
Develop in 90% of cirrhotic px esp alcoholic liver disease
Second most common cause is hepatic schistosomiasis
Detected by angiography tortuous dilated coronary veins lying within submucosa of distal esophagus
Most common complication: hematemesis and rupture
Commonly collapse postmortem
Esophageal varices
Most common esophageal laceration assoc with severe retching and vomiting
Acute alcoholic intoxication
Failure of relaxation of esophagus preceding antiperistalsis leading to stretch and tear
Longitudinal lacerations across GEJ
superficial
Chronic vomiting with severe counter peristalsis
Mallory weiss tear
Transmural esophageal tear and mediastinitis
Severe
Boerhaave syndrome
Most common fungal pathogen in esophagitis
Candida
Mucormycosis
Aspergillosis
Punched out ulcers
nuclear viral inclusion within a rim of degenerating epithelial cell at ulcer edge
Herpes virus
Shallow ulcer with nuclear and cytoplasmic inclusion within capillary endothelium and stromal cell
CMV
Most frequent reason for esophagitis
Central to mucosal injury
Most common outpatient GI diagnosis
Causative mechanism:
Dec LES and inc abdominal pressure
reflux of gastric content
Reflux esophagitis
Hyperemia
Eosinophil in squamous mucosa followed by neutrophil
Basal zone hyperplasia exceeding 20%
GERD
Complications of GERD
Melena Hematemesis Ulceration Stricture Barret’s
Separation of diaphragmatic crura and protrusion of stomach into the thorax through gap
Asymp in 90%
Hiatal hernia
Food impaction Dysphagia Feeding intolerance Epithelial infiltration of eosinophil superficially at sites far from GEJ Atopic associated
Tx: avoidance of allergen
Eosinophilic esophagitis
Complication of GERD charac by intestinal metaplasia within the esophageal squamous mucosa
40-60 years
Confers greatest risk of esophageal adenocarcinoma
Premalignant
Preinvasive lesion:
Barrett’s esophagus
Dysplasia 0.2-1%
Complication of chronic GERD
Intestinal metaplasia within the esophageal squamous mucosa
Confers an increased risk of esophageal carcinoma
Tongues or patches of red velvety mucosa extending upward from GEJ
Metaplastic mucosa alternates with residual smooth pale squamous (esophageal) mucosa proximally and interfaces with light brown columnar gastric mucosa distally
Esophageal mucosa becoming metaplastic mucosa with goblet cell (squamocolumnar metaplasia)
Barrett esophagus
Invasion of neoplastic epithelial cell into lamina propria
Tx:
Intramucosal carcinoma
Surgical resection esophagectomy
Barrett’s dx
Endoscopy
Biopsy
Most common esophageal tumor worldwide
SCC
adeno in US
Arises from background of Barrett’s and GERD
Occurs in the distal third
inc by tobacco use, obesity, radiation and documented dysplasia
Dec in diet rich in fruit and vegetable
M, 7x
Esophageal adenocarcinoma
Associated with progression from dysplasia to invasive ca in esophageal adenocarcinoma
TP53 mutation
Most common location of adenocarcinoma
distal third of esophagus invading adjacent gastric cardia
Adults >45, M 4x
Alcohol, tobacco, poverty, caustic, achalasia, Plummer-Vinson, hot beverage, mediastinum radiation, polycyclic hydrocarbon, nitrosamine, HPV,tylosis
Occurs in middle third or the esophagus
6x in Africans
SCC of esophagus
SCC of esophagus occurs
Middle third
SCC begins as small gray plaquelike thickening
Invades respiratory tree, aorta, exsanguination
in situ squamous dysplasia
SCC metastasizes frequently bec of invasion of
submucosal lymphatic network promoting circumferential and longitudinal spread
Cancers on upper third metastasize to
cervical LN
Cancer in middle third metastasize to
mediastinal
paratracheal
tracheobronchial
Cancers in lower third metastasize to
gastric and celiac nodes
Thin, noncanalized cord replaces a segment of esophagus, causing a mechanical obstruction
Most common at or near the tracheal bifurcation
Usually associated with a tracheoesophageal fistula
Esophageal atresia
Occurs when incomplete formation of the diaphragm allows the abdominal viscera to herniate into the thoracic cavity
Displaced viscera can cause pulmonary hypoplasia that is incompatible with life
Diaphragmatic hernia
Left posterolateral hernia
Bochdalek’s hernia
Anterior, right diaphragmatic hernia
Morgagni
Most common type of esophageal atresia and TEF
Type C then
A
Gives rise to central tendon of diaphragm
Septum transversum
Gives rise to muscular part of diaphragm
Pleuroperitoneal membrane
More common type of esophageal diverticula Esophago-pharyngeal junction Above cardia Unknown etiology Killian’s triangle
Pulsion type (Zenker’s)
Less common
Lower 1/3, near hilum
Rarely collect food
Tuberculous lymphadenitis
Esophageal diverticula
Achalasia Idiopathic muscular hypertrophy Progressive systemic sclerosis Plummer-Vinson Syndrome Leiyomatosis
Esophageal dysmotility
Primary esophageal motility disorder
Failure of LES smooth muscle relaxation leading to high pressure
Absence of peristalsis
Dysphagia
Vomiting
Regurgitation
Heartburn
Achalasia
Megaesophagus
Achalasia/Megaesophagus
Primary: idiopathic
Secondary: T cruzi (amastigotes damage the ganglion cells)
Vasculitis with muscle wall degeneration
Part of CREST syndrome
Progressive Systemic Sclerosis
Esophageal web Atrophic glossitis, dysphagia Hypochromic, microcytic anemia Esophagitis in upper 1/3 Most common in middle-aged females Increased risk of CA in upper 1/3 esophagus, oropharynx and tongue
Plummer-Vinson Syndrome
Adenoma of esophagus arises from
Barett’s esophagus
Associated with leiomyomas
GIST
Portal vein is formed by union of
SMV
Splenic vein
Presinusoidal block of portal vein
Schistosomiasis
Benign tumors of esophagus
Adenoma
GIST
Granular cell tumor
Localized amyloidosis
80-85% of all esophageal carcinomas 10% of all GIT cancers More common in blacks and males 12% upper 56% middle 32% lower portion
Squamous Cell Carcinoma of Esophagus
Tributaries of portal vein
Left gastric
Periumbilical
Superior Rectal Vein
The rectal veins that drain into inferior vena cava
Inferior rectal
Middle rectal
Secondary causes of Esophageal Motility Disorder
GERD
Scleroderma
Chagas disease
Post-operative
Hypermotility disorder of esophagus
Achalasia
Hypermotility disorders of esophagus
Diffuse Esophageal Spasm
Nutcracker esophagus
Hypertensive LES
Antibody in CREST
anti centromere
Antibody in tropical sprue
Gluten enteropatht
Anti-gliadin
