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(J2) GI II Test 1 > Esophagus > Flashcards

Esophagus Flashcards

1
Q

What is the blood supply of the upper, middle, and lower thirds of the esophagus?

A

Upper - inferior thyroid

Middle - branches of thoracic aorta

Lower - left gastric artery

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2
Q

What causes of dysphagia are progressive?

A
  • SCC/adenocarcinoma
  • systemic sclerosis/CREST
  • esophageal strictures
  • achalasia
  • Zenker diverticulum
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3
Q

What are examples of functional esophageal dysphagias?

A
  • nutcracker esophagus
  • diffuse esophageal spasm
  • systemic sclerosis/CREST syndrome
  • GERD
  • achalasia
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4
Q

What is nutcracker esophagus?

(symptoms and diagnosis)

A

Functional esophageal obstruction

-nomral coordination of contractions, but with increased LES pressure

Symptoms:

  • dysphagia (intermittent)
  • chest pain

Diagnostic:

-manometry wil show elevated LES pressure (>180 mmHg)

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5
Q

What is diffuse esophageal spasm?

(symptoms and diagnosis)

A

Functional esophageal obstruction

-uncoordinated contractions, normal LES tone

Symptoms:

  • dysphagia (intermittent)
  • chest pain

Diagnostic:

-barium swallow study show “corkscrew” or “rosary bead” esophagus

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6
Q

What are examples of structural esophageal dysphagias?

A
  • esophageal webs
  • Schatzki rings
  • strictures
  • Zenker diverticulum
  • cancer
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7
Q

What are esophageal webs and Schzatzki rings?

(epi and compare)

A

diaphragm-like protrusion of mucosa in the esophagus

both more common in females

can be associated with GERD

Webs:

  • proximal and not fully circumferential
  • associated with Plummer-Vinson syndrome

Schatzki rings:

-distal and fully circumferential

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8
Q

How are esophageal webs and Schatzki rings diagnosed and treated?

A

Diagnosed:

-barium swallow

Treatment:

  • dilation
  • if persistent, PPI for GERD
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9
Q

What is Plummer-Vinson syndrome?

What condition is it associated with and increased risk of?

A

Triad:

  • iron deficiency anemia
  • beefy red tongue (glossitis w/ angular chelitis)
  • esophageal webs (dysphagia)

increased risk of esophageal SCC

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10
Q

What are esophageal strictures?

What odd feature is present in its course?

A

complication of esophagitis (most commonly GERD) resulting in fibrosis and narrowing of esophagus

-most frequently occurs at the gastroesophageal junction

As stricture worsens -> GERD improves (stricture prevents reflux)

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11
Q

What is Zenker’s diverticulum?

(symptoms and diagnosis)

A

herniation of the esophageal mucosa and submucosa (false diverticula) posteriorly through cricopharyngeus muscle in Killian’s triangle, just above the UES

Symptoms:

  • coughing or discomfort
  • dysphagia (progressive)
  • entrapment of food
  • halitosis (bad breath)
  • aspiration

Diagnosis:

  • video esophagography
  • barium swallow
  • no EGD -> risk of perforation
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12
Q

What is achalasia?

(etiology)

A

loss of NO producing inhibitory neurons -> increased LES tone and loss of peristalsis in lower 2/3 of esophagus

Primary/idopathic:

-loss of ganglion cells in myenteric plexus of esophagus

Secondary:

-most commonly from Chagas disease leading to destrucion of ganglion

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13
Q

How is achalasia diagnosed and treated?

A

Diagnosis:

  • “bird beak” esophagus on barium swallow; constriction of LES with proximal dilation
  • manometry confirms; absence of peristalsis w/ incompelete LES relaxation during swallowing
  • peripheral smear to detect T. cruzi

Treatment:

  • nitrates and calcium channel blockers
  • dilation
  • myotomy (risk of GERD development)
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14
Q

What is pseudoachalasia?

A

tumor at the gastroesophageal junction causing obstructive “bird beak” pattern similar to achalasia

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15
Q

What are the common types of esophageal bleeding?

A
  • Mallory-Weiss syndrome
  • Boerhaave syndrome
  • ruptured varices
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16
Q

What is Mallory-Weiss syndrome?

(etiology, presentation, and treatment)

A

superficial tear of the esophagus at gastroesophageal junction

-caused by increased stress on esophagus, such as forceful vomiting; frequently associated with alcohol use and bulemia

Presentation

  • painful hematemesis
  • common cause of upper GI bleed

Treatment:

-normally self-limited

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17
Q

What is Boerhaave syndrome?

(etiology, presentation, and treatment)

A

transmural tear of the esophagus at gastroesophageal junction -> esophageal rupture

-caused by increased stress on esophagus, such as forceful vomiting; frequently associated with alcohol use

Presentation:

  • pneumomediastinum -> Hamman’s sign (crunching sound on ascultation of heart)
  • subcutaneous emphysema
  • hematemesis
  • chest pain
  • acute distress

Treatment:

  • LIFE THREATENING
  • surgery to repair
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18
Q

What are esophageal varices?

A

dilation of veins in the esophagus due to portal hypertension (cirrhosis)

-asymptomatic themselves but can rupture

19
Q

What complication is associated with esophageal varices?

(epidemiology and risk factors)

A

Variceal hemorrhage (rupture of varices)

  • occurs in 1/3 of patients with varices
  • 1/3 die and 50% recur within 1 year

Risk factors:

  • large varices (>5mm)
  • red wale marking on endoscopy
  • severe liver disease
  • alcohol abuse
20
Q

What is the presentation of variceal hemorrage?

How is it treated?

A

Presentation:

  • actue onset typically preceeded by retching/vomiting
  • upper GI bleed -> melena, hematochezia, and hematemesis
  • hypovolemia/shock

Treatment:

  • MEDICAL EMERGENCY
  • blood, FFP, and vitamin K transfusion
  • emergent EGD w/ variceal banding
  • beta-blockers and banding help prevent recurrence
21
Q

What symptom differentiates cause of esophageal bleeding?

A

painful hematemesis:

-Mallory-Weiss/Boerhaave syndrome

painless hematemesis:

-variceal hemorrhage

22
Q

What are causes of pneumomediastinum and subcutaneous emphysema?

A
  • Boerhaave syndrome
  • iatrogenic esophageal perforation
  • pulmonary causes (ie. COPD with bleb rupture)
  • trauma
23
Q

What is Hamman’s sign?

A

crunching sound that is synchronized w/ heartbeat in the setting of pneumomediastinum

24
Q

What is esophagitis?

(associated symptoms)

What are the main causes?

A

Inflammation of the esophagus

  • can cause pain with swallowing (odynophagia)
  • can cause obstruction

Causes:

  • radiation
  • chemical irritation (pills/caustic substances)
  • infections
  • eosinophilic
  • reflux
25
Q

What are the main causes of infectious esophagitis?

A
  • CMV
  • HPV
  • candida
26
Q

What are the endoscopic findings for CMV, HSV, and candida based infectious esophagitis?

A

CMV:

-shallow, linear ulcers

HSV:

-punched-out lesions

Candida:

-white pseudomembrane

27
Q

What is eosinophilic esophagitis?

(presentation)

A

eosinophil infiltration of esophagus

-associated with allergic/atopic conditions

Presentation:

-dysphagia

-**food impaction**

  • regurgitation
  • possible asthma or atopic rash

GERD-like presentation though slightly more severe; also more likely to present in children than GERD

28
Q

How is eosinophilic esophagitis diagnosed and treated?

A

Diagnosis:

  • “tracheal/feline” esophagus on EGD; multiple esophageal rings
  • eosinophil infiltrate on biopsy (15-20 eosinophils per field); eosinophil also seen with GERD but less numerous

Treatment:

  • swallowing, instead of inhaling, inhaled glucocorticoids
  • allergist referral/elimination of food allergens
  • esophageal dilation
29
Q

What is GERD?

(presentation)

A

reflux of stomach acid into esophagus due to relaxation of LES or increased intra-abdominal pressure

Presentation:

  • “heart burn“/chest pain
  • dysphagia
  • regurgitation of gastric contents (sour taste)
30
Q

What are extrapharyngeal symptoms that are rather indicative of GERD?

A
  • nocturnal cough
  • nocturnal asthma
31
Q

What are causes of GERD?

A
  • decreased LES tone
  • increased intra-abdominal pressure

Causes:

  • vagus nerve dysfunction
  • alcohol and tobacco
  • obesity
  • pregnancy
  • stress
  • hiatal hernia
  • gastroparesis
32
Q

What are concerning features in GERD?

What complications can occur?

A

Concerning symptoms:

  • s/x of UGIB -> ulceration
  • constant severe pain -> ulceration
  • odynophagia -> ulceration
  • dysphagia -> stricture
  • persistent vomiting -> dehydration
  • palpable mass/weight loss ->adenocarcinoma

Complications:

  • ulceration
  • stricture
  • Barrett esophagus -> adenocarcinoma
33
Q

How is GERD treated?

A

No alarming features:

-emperical

  • possible acid suppressing medications
  • treatment of H. pylori if present

-lifestyle changes

Alarming features:

  • endoscopy
  • imaging
  • surgical evaluation
34
Q

What is a common symptom that occurs with esophageal impaction/foriegn body obstruction?

A

hypersalivation

35
Q

What is Barrett esophagus?

(presentaiton, diagnosis, and management)

A

distal esophageal metaplasia

  • squamous -> intestinal columnar w/ goblet cells
  • highly associated with GERD

Presentation:

  • asymptomatic itself
  • underlying GERD symptoms

Diagnosis:

  • endoscopy (“pink tongues” extending from gastroesophageal juction)
  • metaplasia on biopsy; columnar epithelium w/ goblet cells

Management:

  • can progress to adenocarcinoma -> survelience endoscopy
  • PPI (reduces progression risk)
  • ablation of high-grade dysplasia
36
Q

What are the most common tumors of the esophagus?

(epi)

A

Benign:

-leiomyoma (smooth muscle/mesenchymal)

Malignant:

  • adenocarcinoma
  • SCC
37
Q

How do benign and malignant esophageal tumors appear different on a barium swallow?

A

Benign/leiomyoma appear as a smooth, rounded obstruction of the esophageal lumen

Malignant appear as asymmetrical, ulcerated or infiltrative masses that obstruct lumen

38
Q

What is the epidemiology of esophageal adenocarcinoma and SCC?

A

Adenocarcinoma:

  • men
  • western countries/caucasians (rapidly increasing prevalence)

SCC:

  • men
  • Asia and African Americans
  • more commonly globally
39
Q

What are risk factors associated with esophageal adenocarcinoma?

A
  • GERD/Barrett esophagus
  • H. pylori
  • tobacco
  • achalasia
  • radiation
40
Q

What is the clinical presentation of esophageal adenocarcinoma?

A

Frequently goes undiscovered until too late unless incidentally detected early duing evaluation of GERD

Early presentation:
-asymptomatic

-underlying GERD s/x possible

Late presentation:

  • dysphagia (progressive)
  • weight loss
  • chest pain
  • hematemesis
41
Q

How is esophageal adenocarcinoma diagnosed and where is it typically found?

(appearance)

A

EGD with biopsy:

  • glandular/mucinous appearing high-grade dysplasia
  • adjacent Barrett mucosa is common (columnar epithelium with goblet cells)

Typically in lower 1/3 of esophagus (due to high association with Barrett esophagus)

42
Q

What are risk factors associated with esophageal SCC?

A
  • alcohol/tobacco
  • low fruit/vegetable intake​
  • chemical/thermal injuries (hot beverages)
  • achalasia
  • radiation
  • tylosis
  • HPV
  • Plummer-Vinson syndrome
  • poverty
43
Q

What is the clinical presentation and prognosis of esophageal SCC?

A

Insidious onset with aggressive course:

  • dysphagia
  • odynophagia
  • obstruction -> shift of diet from solids to liquids

-weight loss

Frequently caught late, after LN metastasis -> poor survival

If caught early (typically through screening, not symptoms) significant increase in surival

44
Q

How is esophageal SCC diagnosed and where is it typically found?

(appearance)

A

EGD with biopsy:

  • early grey/white plaque-like thickening -> late polypoid/exophytic growth
  • squamous dysplasia with keratinization/keratin pearls

Typically in middle 1/3 of esophagus

(J2) GI II Test 1 (14 decks)

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