Pathology of Esophagus Flashcards
dysphagia definition
difficulty swallowing due to mechanical and functional disorders
odynophasia definition
painful swallowing
heartburn definition
retrosternal burning pain , usually due to regurgitation of gastric contents into lower esophagus
hematemesis definition
vomiting of blood due to inflammation, or ulceration or rupture of blood vessels
Problem swallowing both solids and liquids then the issue is usually?
nerve related - peristalsis
Problem swallowing solids then the issue is usually?
an obstruction
Achalasia: symptoms:
progressive dysphagia, nocturnal regurgitation, young adults, functional obstruction
Achalasia - abnormalities:
- aperistalsis
- incomplete relaxation of LES (NO and VIP chemical issue)
- increased resting tone of LES
–> lower esophagus is constricted and above LES is dilation due to crap getting stuck == muscle hypertrophy and thinned wall (distention)
birds beak appearance with CT contrast or MRI whatever
Achalasia - causes:
1) usually primary (idiopathic) uncertain etiology
2) Secondary causes:
- failure of distal inhibitory neurons containing NO and VIP
- degenerative changes in innervation
- decreased myenteric ganglia
Danger of achalasia?
Other complications?
-SCC*
- candida esophagitis
- diverticula
- aspiration pneumonia
Secondary achalasia occurs with?
1) Chagas disease (Trypanosoma cruzi destroys ganglion cells)
* 2) Disorders of the vagal dorsal motor nuclei (polio surgical ablation)
* 3) Diabetic autonomic neuropathy
* 4) Infiltrative disorders (malignancy, amyloidosis, sarcoidosis)
Hiatal hernia - how does it happen? What 2 types?
1) cause unknown but there is a separation of diaphragmati crura with widening
2) types:
a) sliding hernia - MOST COMMON - proximal part of the stomach slides up through hole in diaphragm
b) paraesophageal - some portion of cardia goes through like a finger projection = possible acute strangulation!
True diverticula definition:
all of the layers of the whatever part of GI tract pouch out
false diverticula definition
only mucosa or submucosa pouch out
Zenker diverticula:
where is it?
what kind is it?
PROXIMAL
- right above UES/cricopharyngeus muscle
- FALSE DIVERTICULUM
Traction diverticula
where is it?
what kind is it?
midportion of esophagus
- TRUE DIVERTICULUM
- probably congenital or due to scarring from surgery or something
Epiphrenic diverticula
where is it?
what kind is it?
- distal esophagus right above LES
- TRUE DIVERTICULUM
- probably due to peristaltic dyscoordination and LES relaxation
Patient presentation of diverticula?
usually bad breath
Mallory Weiss Tears
- where do these happens?
- who gets these often?
- longitudinal lacerations/tears at GE junction
- severe vomiting ex) ALCOHOLICS or pregnancy
- hiatal hernia predisposes
- people with Ulcers!
Mallory Weiss Tears
-what happens?
-Failure of reflex relaxation of LES
Mallory Weis Tears - patient symptoms:
- coughing up blood
- if not coughing up look for blood stools - melena
- usually no symptoms prior to massive rupture = fatal
Main cause of Esophageal varices?
Liver disease - alcohol cirrhosis!
2nd most common cause=schistosomiasis
Esophageal varicies-
-what happens?
- collateral bypass channels bc of portal hypertension (liver damage - blood cant get through liver so finds another way back to heart)
- dilated submucosal and subepithelial veins
- rupture == massive bleed, frequently fatal
Esophagitis - definition:
inflammation of esophageal mucosa
esophagitis - prevelance:
northern iran and some of china - might be diet related
esophagitis - symptoms
dysphagia, heartburn, regurgitation, hematemiesis, melena
esophagitis - etiology:
-most common cause?
- can be physical, chemical, or biologic
- USUALLY A COMBO OF THINGS - decreased efficacy of antireflux mechanisms (LES tone)
- REFLUX ESOPHAGITIS MOST COMMON!
- barretts
- infectious & chemical
- eosinopilic
Some causes of esophagitis:
- sliding hiatal hernia
- slow clearance of refluxed material & acid exposure - inflammation
- delayed gastric emptying = inc gastric volume
What causes the damage in reflux esophagitis?
acid peptic juices!
Early marker of reflux esophagitis?
Eosinophils!
Tissue changes of reflux esophagitis:
- eosinophils, lymphocytes, and PMNs
- basal zone hyperplasia 9-thickens!
- elongation of lamina propria papillae
- superficial necrosis
- ulceration
Prolonged Reflux esophagitis = tendency to develop:
Barrett esophagus = metaplasia = risk for esopageal carcinoma!!
Key feature to see for Barrett esophagus?
-metaplasia from squamous to columnar WITH GOBLET CELLS!*
Salmon red epithelium in esophagus think:
Barrett esophagus - metaplasia has happened!
Radiation esophagitis usually heals how and which layer?
Severe fibrosis of submucosa
Major cause of esophagus strictures?
inflammation*
- peptic
- caustic
- ischemic
- post op
- radiation
- congenital
- infectious
- trauma
- scleroderma*
Scleroderma predisposes/causes what issue? How? What issues do these patients have?
- esophageal stricture
- vascular obliteration and fibrosis in smooth muscle = weak LES, poor esophageal contraction, delayed gastric emptying
- swallowing liquids and solids in addition to a whole bunch of other stuff
Prevalence of benign esophageal tumors? Which is most common
- RARE
- most common is leiomyoma
- usually mesenchmal within wall of esophagus
Malignant tumors of esophagus:
- discovery?
- origin of tumor?
- most common?
- discovered LATE
- epithelial origin
- Squamous cell carcinoma and **adenocarcinomas **
most common cancer of esophagitis worldwide??
SCC
most common regions for SCC/esophagitis?
Highest in Iran
N China
S Africa
S Brazil
Population stats regarding SCC/esophagitis?
M to F varies but blacks more likely than whites
Causes of SCC/esphagitis:
- dietary enivornmental factors a promoters/potentiators of carcinogens
- nitroso compounds knock out p53 via mutations - stepwise accumulation
- Chronic esophagitis and associated chronic inflammation = dysplasia
First place esophageal SCC metastasizes?
LN!
then they like the liver and lungs
Patient presentation of esophageal SCC?
- Extreme weight loss
- progressive gradual dysphagia - not noticed until lumen 30-50% blocked (low survival)
- substernal or back pain
- hoarseness and cough
3 types of esophageal SCC?
Which is most common
- protruded- polypoid, fungating
- flat - diffuse, infiltrative
- excavated - necrotic, ulcerates deeply
Adenocarcioma of esophagus:
- think what tissue type affected?
- most common area to get?
- associated with what disease?
- some risk factors?
- think GLANDS
- distal 1/3
- most from Barrett
- tobacco , obesity, H pylori? ETOH
Cause of adenocarcina?
population stats?
- cause = mutlistep process - overexpression of p53
WHITE MORE COMMON THAN BLACK
MORE MALES
Which esophageal is more common in whites and which in blacks?
– Whites = adenocarcinoma
–Blacks = SCC
Adenocarcinoma micro - what is associated with more aggressive cancer?
lots of mucin-producing cells
-signet ring
prognosis for SCC and adenocarcinoma?
both really poor
if superficial adenocarcinoma 5yr is 80%
Lymphatics and esophagus
Lymphatics all over the place and run from top to bottom = easy spread for the tumor if it wants to metastasize
