Esophagus-path/icm Flashcards
What is Atresia?
Incomplete development
What is the most common congenital anomalies of esophagus?
Esophageal Atresia/Tracheoesophageal Fistula
What are are the clinical sx of Atresia/Tracheoesophageal Fistula?
aspiration
suffocation
pneumonia
fluid and electrolyte imbalances
When are Atresia/Tracheoesophageal Fistula diagnosed?
regurgitation during feeding
what can Atresia/Tracheoesophageal Fistula be associated with?
with heart and GU malformations
also..congential stenosis of esophagus and S.I.
What are the 3 types of Esophageal dysmotility?
- Nutcracker esophagus
- Diffuse esophageal spasm
- Hypertensive lower esophageal sphincter
What is Nutcracker esophagus?
high amplitude contractions of distal esophagus (loss of coordination btw inner circular layer and outer longitudinal layer)
What is Diffuse esophageal spams?
repetitive simultaneous contractions of distal esophageal esophagus
What is hypertensive lower esophageal sphincter?
no contraction problems
How do you diagnose esophageal dysmotility?
esophageal manometry
What is esophageal manometry?
Esophageal manometry is a test used to measure the function of the lower esophageal sphincter (the valve that prevents reflux of gastric acid into the esophagus) and the muscles of the esophagus (see diagram). This test will tell your doctor if your esophagus is able to move food to your stomach normally
what is Zenker’s Diverticulum?
it is a consequence of esophageal dysmotility -> develop diverticulae
Where is the most common area for Zenker’s Diverticulum?
- near pharynx
- immediately above upper esophageal sphincter
- Pulsion diverticulum
When do Zener’s Diverticulum usually occur?
after age 50
What are the clinical sx of Zener’s Diverticulum?
can be asymptomatic or store tons or food->mass,regurg,bad breath
where do diverticulum usually occur?
-diverticulum more common to occur right above the LES
Where does Traction diverticulum occur?
-mid-portion of esophagus
What diverticulum is associated with tuberculous lymph nodes
Traction diverticulum
What are the 2 types of pulsing diverticulum?
Zenker diverticulum
Epiphrenic diverticulum
Where does epiphrenic diverticulum occur?
immediately below lower esophageal sphincter
What is esophageal stenosis?
epithelial damage
- fibrous thickening of submucosa
- atrophy of muscular propria
what are causes of esophageal stenosis?
GERD,irradiation, or caustic injury –> inflammation and scarring
How does a patients weight fair in patients with esophageal stenosis?
- patients keep weight nml and appetite nml
- (if the strictures are malignant will see weight loss)
What are esophageal mucosal webs?
semi circumferential eccentric
thin ledge-like protrusion of mucosa
where are esophageal mucosal webs usually seen?
most common in the upper esophagus
What diseases are associated with GERD, graft-versus-host disease, blistering skin disease?
esophagus mucosal webs
What are the clinical symptoms of esophageal mucosal webs?
non-progressive dysphagia if food is not chewed well
esophageal mucosal webs is a component of _________
plummer-vinson syndrome
what are the components of plummer vinson syndrome?
- chronic iron deficiency anemia
- upper esophageal web
- atrophic glossitis
- angular cheilitis (inflame of corners of the mouth)
what does plummer-vinson syndrome increase your risk for?
esophageal squamous cell carcinoma
what is the difference between rings and webs?
- rings are similar to webs but are circumferential and thicker
- they include the mucosa,submucosa, and in some cases hypertrophied muscularis
where would a “A” ring for esophageal ring (schatzki’s Ring)
located?
above GE junction
where would a “B” ring for esophageal ring (schatzki’s Ring) located?
if at the squamocolumnar junction
What is achalasia/ what are its triad features?
-cause of esophageal obstruction
Triad Features: 1. inability to relax LES 2. Increased LES tone 3. Absence of normal peristalsis
What are the clinical sx of achalasia?
solid and liquid dysphagia
-diff belching and chest pain
What is primary achalasia?
- neurons/gangion cell degeneration (or nerves are not working properly)
- idopathic (some familial)
how can you get secondary achalasia?
chugs disease (t. cruzi) destroys of myenteric plexus
What are DD of achalasia?
- diabetic neuropathy
- cancer
- amyloidosis
- sarcoidosis
- down syndrome
- remote herpes infection
- sjogrens
- Allgrove syndrome
what is allgrove syndrome?
- achalasia
- alacrima
- adrenal insufficiency
how do you treat lap myomectomy?
- lap myomectomy
- ballon dilation
- botox injection into LES
what is mallory-weiss tears?
-longitudinal laceration at GE junction
what is mallory-weiss tears caused by?
- severe vomiting
- associated with severe alcoholism or bulimia
how does severe vomiting cause mallory-weiss tears?
-gastic contents cause wall to stretch and tear (bc no relaxation or contraction)
what is the prognosis of mallory-weiss tears?
usually heal rapidly and completely
what are the clinical symptoms of mallory-weiss?
hematemesis
what does malory-weiss increase the risk of?
Boerhaave syndrome
what is Boerhaave syndrome?
-transmural tearing and rupture of the distal esophagus
what can boerhaave syndrome lead to?
mediastinitis
what are the clinical syndromes of Boerhave syndrome?
severe chest pain
- tachycardia
- shock
what is the DD of Boerhave syndrome?
MI
how do you treat Boerhave syndrome?
surgery
which side is the tear on in mallory-weiss syndrome?
on the gastric side of the gastroesophageal junction
which may extend to the distal esophagus
what layers does mallory-weiss syndrome affect?
the mucosa and the submucosa
what layers des boerhaave’s syndrome effect?
complete rupture at the lower thoracic esophagus
In which syndrome do you see hammans sign?
boerhaaves syndrome
what is hammans sign?
crushing sound upon auscultation of the heart but due to pneumomediatstinum
which of the two syndromes boerhaave’s syndrome vs mallory-weiss syndrome gives you subcutaneous emphysema?
boerhaaves syndrome
what can cause esophageal varicies?
portal hypertension #1-alcohol #2-(world) schistosomiasis
what is the pathology of esophageal varies?
- inflammatory erosion
- venous pressure
- increased hydrostatic pressure (associated with vomiting)
what population do you usually see esophageal varicose?
patients with cirrhosis?
what is the prognosis of esophageal varicose?
emergency
up to half die from first bleed
50% will bleed again w/in year
what do patients with esophageal varcies?
hypovolemic shock
hepatic coma
what is the clinical presentation of esophageal varies ?
- clinically silent
- rupture with iller hematemesis
how do you treat esophageal varices?
- sclerotherapy (inject thrombotic agents)
- ballon tamponade
- band ligation
- PROPHYLACTICS: beta blockers and endoscopic vatical ligation
what is chemical esophagitis caused by?
- alcohol
- heavy smoking
- corrosive acids and alkalis-kids
- pills
what are the clinical sx of chemical esophagitis?
- odynophagia (pain when swallowing)
- bleeding
- stricture
- perforation
what are the desquamative disorders associated with esophagitis?
- pemphigus
- epidermolysis bullosa
Where do you see infectious esophagitis?
-seen in immunosuppressed indiv
-Herpes
-cytomegalovirus
-candida
-Aspergillus
_mucormycosis
how does herpes esophagitis px?
punched out ulcers
what is the micro of herpes simplex esophagitis ?
-multinucleated squamous cells with herpes virus nuclear inclusions
how does canidada Esophagitis px?
adherent gray-white pseduomemebranes composed of mated pseudohyphae
How does eosinophilic esophagitis px micro?
large numbers more then 15 of intraepithelial eosinophils
how does eosinophilic esophagitis px clinically?
adults-dysphagia
kids-GERD symptoms
how does eosinophilic esophagitis occur?
may be allergic reaction against ingested food
how do you treat eosinophilic esophagitis ?
avoid food allergens and steroids
what is a major cause of esophagitis?
-reflux esophagitis aka GERD
what gives you GERD/reflux esophagitis?
conditions that decrease LES tone or increases abdominal pressure
what are the conditions that decrease LES tone or increases abdominal pressure leading to GERD
alcohol tobacco obesity pregnancy HIATAL HERNIA CNS deppressants delayed gastric emptying increased gastric volume
what are the clinical symptoms of GERD?
- dyphagia
- heart burn
- sour gastric contents in mouth
- rare: severe chest pain that mimics MI
how do you treat GERD?
proton pump inhibitors (PPI)
H2blockers
what is the micro of GERD?
- basal cell hyperplasia
- elongation of lamina propria papillae
- eosinophils (scattered) and neutrophils in epithelial layer
what is a hiatal hernia
protrusion of stomach into thorax
what is a complication of hiatal hernia?
can cause LES incompetence
what is barrett’s esophagus a complication of?
chronic GERD
how does barrett’s esophagus look macro?
-red velvety mucosa extending up from GE junction
describe the micro pathology of barrett’s esophagus
-squamous esophageal mucosa->intestinal metaplasia (columnar epithelium with goblet cells)
what does barrett’s esophagus increase your risk of?
-increased risk of esophageal adenocarcinoma
what is the most common benign tumor of the esophagus?
Leoimyoma
what are the benign tumors of the esophagus
- leiomyoma
- fibroma
- lipoma
- hemangioma
- neurofibroma
- lymphangioma
what are the most common malignant tumors of the esophagus?
-adeno carcinoma and squamous cell carcinoma are the most common
what are the risk factors for adenocarcinoma of the esophagus?
- # 1obesity related GERD and barrett’s esophagus
- tobacco use and radation
what is protective against adenocarcinoma of the esophagus?
- diets rich in fruits and veggies
- some types of H. pylori (gastric atrophy)
is adenocarcinoma more common in men or women?
men!!
what race is adenocarcinoma most common in?
whites
what is the strongest indicator of progression to adenocarcinoma?
degree of dysplasia
what are the chromosomal abnormalities associated with adenocarcinoma
TP53 mutations
- downreg of CDKN2A
- downreg of p16/INK4 (early stage)
- EGF,ERBWMET,cynclinD1 and E mutations (Late)
what are the clinical sx of adenocarcinoma?
dysphagia
- weight loss
- hematemesis
- chest pain
- vomiting
what is the prognosis of adenocarcinoma of the esophagus?
many have spread to the submucosal lymphatics at Dx
what improves the prognosis of adenocarcinoma of the stomach?
if it is only in the mucosa and submucosa 80%
what is the gross pathology of adenocarcinoma of the esophagus?
- usually distal 1/3
- can invade cardia of stomach
- initially flat or raised patch
- nodular mass or diffusely infiltrative or ulcerated
what is the micro of adenocarcinoma of the esophagus?
- usually mucin producing glandular tumors with intestinal features
- rare: signet ring
- rare: poor differentiation
what age group do you see squamous cell carcinoma of the esophagus?
45+
which gender do you see a higher prevalence of squamous cell carcinoma of the esophagus?
males
what are the risk factors for squamous cell carcinoma of the esophagus?
- alcohol
- tobacco
- synergistic
- caustic injury
- achalasia
- plummer-vinson syndrome
- diet
- papillomavirus
- prior radiation (5-10 years before)
- HPV
plummer-vinson syndrome is a risk factor for?
squamous cell carcinoma of the esophagus
what is the molecular basis for squamous cell carcinoma of the esophagus?
- amplification for SOX2 gene (stem cell renewal)
- over-expression of Cyclin D2
- Loss of function mutations in TP53, e-cadherin and NOTCH1
what are the sx of squamous cell carcinoma of the esophagus?
- dysphagia
- weight loss
- hemorrhage
- sepsis secondary to ulceration
- tracheobronchial fistula with aspiration
what race is squamous cell carcinoma of the esophagus most prevalent
african american
iron deficiency anemia is associated with
squamous cell carcinoma of the esophagus
what determines a poor prognosis for squamous cell carcinoma of the esophagus?
LR+
what is a common way of death due to squamous cell carcinoma of the esophagus?
aspiration due to fistula
where are squamous cell carcinoma of the esophagus usually seen?
mostly in mid 1/3 of esophagus
how does the macro of squamous cell carcinoma of the esophagus look?
-grey-white lesions/plaques (early)->exophytic mass or cancerous ulceration or diffusely infiltrative neoplasm
what can be a complication of squamous cell carcinoma of the esophagus if it invades the respiratory tree?
pneumonia
what can be a complication of squamous cell carcinoma of the esophagus if it invades the aorta?
bleed out
what type of muscle is seen in the upper 1/3 of the esophagus?
striated
what type of muscle is seen in the lower 2/3 of the esophagus?
smooth muscle
Is the esophagus relaxed or tonic during a swallow?
relaxed
is the esophagus relaxed or tonic at rest?
tonic
what is the junction between the esophagus and the stomach?
squamo-columnar junction
what foods increased LESp?
protein
what foods decrease LESp?
fats
chocolate
ethanol
peppermint
what drugs decrease LESp?
Theophylline ca-ch blockers morphines diazepam serotonin
what drugs increase LESp
histamine
antacids
pro-kinetics (memtoclopramid;doperidone)
what is the intial test in diagnostic approach to dysphagia?
barium esophagram
what type of disorders does barium esophagram evaluate?
- structual lesions (stricture, web, haital hernia)
- at times GE reflux
what esophageal diagnostic test directly visualized esophageal mucosa ad enables tissue diagnosis?
-endoscopy with biopsy
useful for hemostasis/dialation of strictures/stenosis
what diagnostic test is useful for imaging lesions that are int he esophageal wall or immediately adjacent and good for staging esophageal malignancy?
endoscopic ultra sound
what diagnostic test demonstrates reflex proper/amount and duration of reflux?
24 hour pH probe
what esophageal manometry demonstrates tendency for GE reflux?
esophageal manometry
what does esophageal manometry do?
measures pressures contractile activity and sphincter function
esophageal manometry is useful for what type of disorders?
motility
what are the 2 different pathologies for GERD?
Aggressive(acid) vs defensive
describe the defensive pathologies for GERD?
-anti-reflux barrier***most impt (LES-reduced resting pressure, TLESRs; increased abdominal pressures)
-esophageal acid clearance
(saliva, esophageal peristalsis, gastric emptying, intact esophageal mucosa, hiatal hernia)
what is barrett’s metaplasia?
squamous epithelium changes to columnar epithelium
what is the etiology of odynophagia
infectious
Candida
HSV
CMV
if one has dysphagia with solid food only what type of disorder is this?
structural disorder
if one has dysphagia with solid food only and it is progressive and rapid what is it?
structural disorder
carcinoma
if one has dysphagia with solid food only and it is progressive and gradual with hx of GERD what is it?
structural disorder
peptic stricture
if one has dysphagia with solid food only and it is intermittent what is it?
web
ring
if one has dysphagia with solids and liquids what type of disorder is it?
motility disorders
if one has dysphagia with solids and liquids and is progressive with heartburn what is it?
scleroderma
if one has dysphagia with solids and liquids and is progressive without heartburn what is it?
achalasia
if one has dysphagia with solids and liquids and is intermittent with chest pain what is it?
spasm
what are the sx of zener’s diverticulum?
halitosis, dysphagia
regurgitation of undigested material
what is the treatment of zenker’s diverticulum?
- cervical myotome
- diverticulectomy
what decade does achalasia px?
-presentation in 3rd to 5th decade
how do you treat achalasia?
botox
pneumatic dilation
heller myotomy
what causes pseudo-achalasia?
- chagas’ disease (from T. cruzii)
- cancer for GE junction (more rapid onset, more weight loss)
what is scleroderma?
- connective tissue disorder
- replacement of smooth muscle with fibrosis (loss of LES function, poor esophageal peristalsis, result GE reflux)
describe the manometry of scleroderma?
- poor esophageal motility
- Low LESp
what are the symptoms of diffuse esophageal spasm?
-chest pain or odynophagia or both
what does the X-ray of diffuse esophageal spasm look like?
corkscrew esophagus
what does the manometry of diffuse esophageal spasm look like?
- simultaneous contractions
- repetitive contractions
- LES usually normal
how do you treat diffuse esophageal spasm?
- muscle relaxants
- ca-ch blockers
- nitrates
- surgery
what is the difference between the benign and malignant strictures?
benign-smooth
malignant-irregular
what is caused by iron deficient anemia?
cervical webs
what does the biopsy of esophageal mucosa show in eosinophilic esophagitis?
eosinophils>20HPF
