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Core > Gastrointestinal: Luminal, Esophagus > Flashcards

Gastrointestinal: Luminal, Esophagus Flashcards

1
Q

Esophageal A ring

A

The dynamic muscular ring just above the vestibule

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2
Q

Esophageal B ring

A

The fixed mucosal ring just below the vestibule at the GE junction

Note: If this narrows and becomes symptomatic, its called a Schatzki ring.

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3
Q

At what point does the esophageal B ring become a Schatzki ring?

A

Symptomatic dysphagia

AND

Narrowing to <13 mm

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4
Q

Esophageal Z line

A

The squamocolumnar junction between the esophageal and gastric epithelium (only seen on endoscopy)

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5
Q

What is the upper esophageal sphincter made of?

A

The cricopharynxgeus muscle (at the level of C5-C6)

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6
Q

How does the larynx move while swallowing?

A

The larynx elevates and moves anteriorly while swallowing

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7
Q

Which hand should the barium cup go in while doing LPO and RPO swallows?

A

Whichever hand is closer to the detector (e.g. if RPO, put the barium in the pts right hand)

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8
Q

Esophagram demonstrates a high stricture and hiatal hernia…

A

Think Barretts esophagus in the setting of esophageal reflux

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9
Q
A

Feline esophagus (fine transverse folds in the mid and lower esophagus), suggestive of reflux esophagitis

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10
Q

Esophagram demonstrates a narrowing with irregular contour and abrupt (shouldered) edges…

A

Think cancer

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11
Q

Esophagram demonstrates irregular narrowing in the mid esophagus with shouldering in a pt with a history of smoking and alcohol use disorder…

A

Think squamous cell carcinoma

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12
Q

Esophagram demonstrates irregular narrowing in the distal esophagus with shouldering in a pt with a history of longstanding esophageal reflux…

A

Think adenocarcinoma

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13
Q

What distinguishes T3 from T4 esophageal cancer?

A

Whether there is invasion into adjacent structures on CT (which would make it stage 4)

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14
Q

What are the major types of hiatal hernia?

A
  • Type 1 sliding hiatal hernia (GE junction above the diaphragm)
  • Type 2 paraesophageal (GE junction remains at the diaphragm)
  • Type 3 mixed
  • Type 4 (additional organs herniated through)
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15
Q

Nissen fundoplication

A

When the gastric fungus is wrapped 360 degrees around the distal esophagus to reinforce the lower esophageal sphincter

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16
Q

What is the major early complication of a fundoplication

A

Esophageal obstruction due to post operative edema or a too tight fundoplication

Note: This is most common around week 2 post op.

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17
Q

What are the two main indications for a fundoplication?

A
  • Hiatal hernia
  • Reflux
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18
Q

What is the most common reason for recurrent reflux s/p fundoplication?

A

Slipped Nissen (telescoping of the GE junction through the fundoplication wrap)

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19
Q

What is the most common reason for a slipped Nissen s/p fundoplication?

A

A short esophagus (e.g. a hiatal hernia that is fixed/non-reducible and is greater than 5 cm)

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20
Q

What is the treatment for short esophagus?

A

Collis gastroplasty (esophageal lengthening and fundoplication)

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21
Q

How can you tell that a fundoplication wrap has slipped?

A

Fundoplication should cause a distal esophageal narrowing of <2 cm (anything longer than that suggests a slipped wrap)

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22
Q

Can you vomit after a fundoplication?

A

No

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23
Q

Where is the GE junction s/p fundoplication?

A

At the level of the diaphragm

Note: If the GE junction is above the diaphragm, the fundoplication has failed (recurrent hiatal hernia).

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24
Q

Risk factors for esophageal candidiasis

A
  • Immunocompromised (HIV, transplant pts)
  • Motility disorders (achalasia, scleroderma)
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25
Q

Classic imaging findings in esophageal candidiasis

A
  • Discrete plaque-like lesions
  • Mucosa with nodularity, granularity, and fold thickening
  • Shaggy esophagus with irregular luminal surface
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26
Q

Asymptomatic elderly pt

A

Think glycogenic acanthosis (epithelial collections of glycogen)

Note: This looks like candidiasis, but occurs in asymptomatic elderly people.

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27
Q

What are the major causes of esophageal ulcers?

A
  • Herpes (multiple small)
  • CMV/HIV (large flat)
  • Crohns (rare)
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28
Q

Odynophagia

A

Multiple small ulcers with surrounding edema (dots of barium surrounded by Lucent halos), suggestive of herpes esophagitis

29
Q

Odynophagia

A

Few large ulcers, suggestive of CMV or HIV esophagitis

30
Q

30 y/o with odynophagia and esophagram demonstrates aphthous ulcers (discrete ulcers surrounded by mounds of edema)…

A

Think crohns esophagitis (rare)

31
Q

Water density cyst in the posterior mediastinum…

A

Think esophageal duplication cyst

32
Q

What is the most common location for an enteric duplication cyst?

A

Ileum (followed by esophagus)

33
Q

Clinical presentation of esophageal duplication cyst

A
  • Incidental finding
  • Dysphagia/breathing problems in an infant (if large enough)
34
Q
A

Zenker diverticulum

Note: Z in the back of the alphabet.

35
Q

Where is the weakness in the esophagus that leads to a Zenker diverticulum?

A

Killian dehiscence (posterior esophagus in the hypopharynx)

Note: Zenker diverticula arise in the hypopharynx (not the cervical esophagus like Killian-Jamieson diverticula).

36
Q
A

Killian-Jamieson pulsion diverticulum

37
Q

Where is the weakness in the esophagus that leads to a Killian-Jamieson diverticulum?

A

In the anterolateral cervical esophagus, just below the attachment of the cricopharynxgeus muscle

Note: Killian-Jamieson diverticula arise in the cervical esophagus (not the hypo pharynx like Zenker diverticula).

38
Q
A

Traction diverticulum

Note: These are usually mid esophageal and more triangular than round.

39
Q

What causes traction diverticula?

A

Esophageal scarring (e.g. granulomatous disease/tuberculosis) leading to traction

40
Q

How can you differentiate traction from pulsion esophageal diverticula?

A

Traction diverticula tend to be more triangular and will empty on esophagrams

Pulsion diverticula tend to be more round and will not empty on esophagrams (the walls do not contain muscle to contract)

41
Q
A

Epiphrenic diverticulum

42
Q

Where do epiphanic diverticula tend to occur?

A

On the right, just above the diaphragm

Note: Para-esophageal hernias tend to occur on the left.

43
Q

What type of diverticulum is an epiphanic diverticulum?

A

Pulsion

44
Q
A

Esophageal pseudodiverticulosis (usually due to chronic reflux esophagitis)

Note: The outpouchings of contrast are due to dilated submucosal glands.

45
Q

What is the most common benign mucosal lesion of the esophagus?

A

Papilloma (basically just hyperplastic squamous epithelium)

46
Q
A

Esophageal web

Note: These are usually in the cervical esophagus near the cricopharyngeus.

47
Q

Esophageal webs are risk factors for…

A

Esophageal/hypopharyngeal carcinoma

48
Q

Iron deficiency anemia, dysphagia, and an esophageal web…

A

Plummer-Vinson syndrome

49
Q

Treatment for dysphagia in Plummer-Vinson syndrome

A

Iron repletion (may resolve dysphagia)

Dilatation of esophageal web (if needed)

50
Q

30 y/o M with history of dysphagia despite long standing treatment with PPIs

A

Eosinophilic esophagitis

Note: “Ringed esophagus” on esophagram.

51
Q
A

Diffuse esophageal spasm

52
Q

Treatment of eosinophilic esophagitis

A

Steroids

53
Q

Nutcracker esophagus

A

A finding on manometry (pressures >180 mmHg)

54
Q

Dysphagia lusoria

A

Dysphagia secondary to esophageal compression from an aberrant right subclavian artery

55
Q

Differential for large, dilated esophagus with air-fluid level on esophagram

A
  • Achalasia
  • Chagas disease
  • Pseudoachalasia
  • Scleroderma
56
Q

Pathophysiology of achalasia

A

Absent primary peristalsis in the distal esophagus with failure of the lower esophageal sphincter relaxation

57
Q
A

Think achalasia

Note: Bird’s beak sign.

58
Q

Pts with achalasia are at an increased risk for…

A

Esophageal candidiasis

59
Q

Esophagram demonstrates achalasia appearance, but the narrowed GE junction never relaxes…

A

Think pseudoachalasia (cancer at the GE junction)

60
Q

Classic findings of Chagas disease on esophagram

A

Achalasia

Note: Chagas disease of the esophagus can be thought of as achalasia caused by parasitic infection.

61
Q

Massively dilated esophagus with air-fluid level and pulmonary fibrosis with subpleural sparing…

A

Scleroderma

Note: Scleroderma is highly associated with NSIP.

62
Q

How does scleroderma affect the esophagus

A

Distal esophageal dysmotility with an incompetent lower esophageal sphincter, leading to chronic reflux causing scarring, Barrets, and/or cancer

Note: The esophagus will be dilated with an air-fluid level.

63
Q
A

Esophageal varices or varicoid carcinoma

Note: You need to show that these disappear with the esophagus fully distended on single-contrast esophagram to show that they are varices and not varicoid carcinoma.

64
Q

Uphill vs downhill varices

A

Uphill varices are caused by portal hypertension and are confined to the lower half of the esophagus

Downhill varices are caused by SVC obstruction and are confined to the upper half of the esophagus

65
Q

Esophageal mucosal fold thickening…

A

Think esophagitis (many causes)

66
Q

Reticulated mucosal pattern of the distal esophagus…

A

Think Barretts esophagus

67
Q

Esophageal ulcers at the level of the aortic arch…

A

Think medication induced esophagitis (pills getting stuck at the level of the aortic arch)

68
Q

Common causes of a long esophageal stricture

A
  • NG tube placement for too long
  • Radiation changes
  • Caustic ingestion

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