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Pathophysiology - Gastrointestinal > Pathology of the Esophagus > Flashcards

Pathology of the Esophagus Flashcards

1
Q

What are the three layers of the mucosa in the esophagus and what type of epithelium does it have?

A
  1. Epithelium - stratified squamous non-keratinized
  2. Lamina propria - connective tissue with minimal mononuclear inflammatory infiltrate
  3. Muscularis mucosae - longitudinally oriented smooth muscle bundles becoming thicker in distal esophagus
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2
Q

What is the characteristic prengnancy finding for a tracheo-esophageal fistula and what is the most common type?

A

Characteristic finding - polyhydramnios (can’t swallow)

Most common type: Esophageal atresia with distal tracheo-esophageal fistula

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3
Q

What is a pulsion diverticulum and what are the two main types? Is it a true diverticulum?

A

Mucosal herniation (pseudodiverticulum since not the whole wall) caused by high intraluminal pressures

  1. Zenker diverticulum - most common
  2. Epiphrenic diverticulum
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4
Q

Where does Zenker diverticulum occur and what are the symptoms?

A

Occurs posteriorly between cricopharyngeus and inferior constrictor muscles
-> retention of food and secretions in pouch

Symptoms: oropharyngeal dysphagia, regurgitation of undigested food, bad breath from food, aspiration

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5
Q

What is an epiphrenic diverticulum and how does it arise typically?

A

A pulsion diverticulum of the distal esophagus just above the LES, usually associated with esophageal dismotility disorders (achalasia, hiatal hernia)

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6
Q

What is a traction diverticulum and what causes it?

A

A mid-esophageal diverticulum caused by something pulling on the esophagus

Commonly due to malignancy or TB with scarring

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7
Q

Who tends to get esophageal webs and what are they associated with?

A

Middle aged women

Associated with GERD, chronic graft-versus host disease (esophagitis will predispose), and blistering skin diseases (??)

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8
Q

What are esophageal webs? How are they different than rings?

A

Webs - Idiopathic, partially circumferential membranous thickenings in upper esophagus, cause intermittent obstruction and dysphagia

Rings - idiopathic, same as webs just slightly thicker and extend for the entire circumference

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9
Q

What characterizes Plummer Vinson syndrome?

A

Iron deficiency anemia, esophageal webs, dysphagia

Also: glossitis, cheilosis, koilonychia, and increased risk for pharyngeal and esophageal carcinoma

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10
Q

What are the two types of esophageal rings? When do they happen?

A

A ring - found proximal to GE junction, covered with squamous epithelium

B ring / Schatzki ring - occurs AT GE junction, often superiorly covered with squamous epithelium and inferiorly covered with glandular epithelium. Happens in association with hiatal hernia

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11
Q

What is an esophageal stricture and what is it most associated with?

A

Luminal narrowing due to inflammation / fibrosis of esophagus

Due to:
1. Chronic GERD

  1. Ingestion of caustic materials (i.e. lye)
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12
Q

What forms the esophageal hiatus? What components prevent gastroesophageal reflux?

A

Diaphragmatic crura

Reflux prevented by:
1. Diaphragmatic crura

  1. LES pressure, benefited by its intraabdominal location, pushing the stomach closed
  2. Angle of his - acute angle between distal esophagus and gastric cardia
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13
Q

What are the risk factors for diaphragmatic hernia?

A
  1. Decreased LES tone / elasticity - due to advanced age

2. Increased intraabdominal pressure above what’s good - obesity, pregnancy, ascites

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14
Q

What are the two types of diaphragmatic hernias and which is most common?

A
  1. Sliding hiatal hernia - GE junction slides into mediastinum, giving hourglass appearance - most common
  2. Paraesophageal / rolling hiatal hernia - fundus of stomach prolapses into thorax adjacent to GE junction
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15
Q

What are the risks associated with sliding and rolling hiatal hernias?

A

Sliding - Increased risk of GERD due to loss of angle of His and LES tone

Rolling - strangulation and perforation of involved fundic stomach (compromising blood flow)

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16
Q

What are the two esophageal syndromes associated with violent wretching and which is more serious? why?

A
  1. Mallory-Weiss syndrome - partial-thickness longitudinal mucosal lacerations at GE junction
  2. Boerhaave syndrome - transmural, distal rupture due to violent wretching -> can cause mediastinitis and subcutaneous emphysema (due to air in mediastinum) and is a surgical emergency
17
Q

What causes esophageal varices and why do they ultimately rupture?

A

Portal hypertension -> overtime the epithelium overlying them breaks down due to trauma -> erosion causes rupture

Massive hematemesis has high morbidity / mortality

18
Q

What are some causes of esophagitis due to ingested chemicals? What is the pathogenesis of this?

A

Various irritants -> mucosal ulceration and necrosis -> acute inflammation and fibrosis

i.e. pills causing irritation, caustic ingestion, or acid ingestion

19
Q

What is iatrogenic esophagitis?

A

Most often due to radiation or graft-versus-host disease -> something the doctors did predisposes to esophagitis

20
Q

What are the three causes of infectious esophagitis and who generally gets it? Give the morphology for each.

A

Generally immunocompromised individuals

  1. Candida - white pseudomembranes
  2. HSV-1 - punched out ulcers
  3. CMV - linear ulcers from base of esophagus
21
Q

What are the risk factors for GERD / Reflux Esophagitis?

A

Same as sliding hiatal hernias
-> things that decrease sphincter tone or increase intraabdominal pressure

i.e. hiatal hernia, obesity/pregnancy, delayed gastric emptying (increased pressure and acidic stomach pH)

only thing not explained: alcohol and tobacco use -> they are irritants

22
Q

What does reflux esophagitis look like grossly and microscopically?

A

Grossly - Mild hyperemia, can’t tell much

Microscopically - Intraepithelial eosinophils (first infiltrate seen in GI inflammation), later neutrophils, and bazal zone hyperplasia with elongation of lamina propria papillae

23
Q

What are the symptoms of GERD?

A

Dysphagia, heartburn, waterbrash (tasting acid in your mouth), chest pain in adults

24
Q

What are the complications of GERD?

A
  1. Stricture formation
  2. Barrett esophagus
  3. Erosion / ulceration of esophagus with possible bleed (Rare)
25
Q

What is Barrett esophagus? How does it appear grossly?How is it told apart from glandular stomach epithelium?

A

Glandular intestinal metaplasia of distal esophagus due to longstanding GERD

Appears as patchy red spots wherever the glandular epithelial metaplasia is

-> told apart from stomach epithelium by presence of Goblet cells

26
Q

What are the complications of Barrett esophagus? How do you track this?

A

Track this by periodic endoscopy and biopsy

  1. Epithelial dysplasia - low or high grade
  2. Adenocarcinoma - intramucosal and invasive
27
Q

What type of esophageal carcinoma is most common in the US and what is its presentation?

A

Adenocarcinoma - progression from Barrett esophagus

Progressive dysphagia for solids then liquids, progressive weight loss

28
Q

What type of esophageal carcinoma is most common in the rest of the world and what are its risk factors? Where does it arise?

A

Squamous cell carcinoma, arises usually mid-esophagus but can be anywhere

RF: alcohol and tobacco smoking**, hot liquids and achalasia (irritation), caustic strictures with repeated injuries, Plummer-Vinson, etc

29
Q

Where does squamous cell carcinoma spread?

A

Locally extends to other mediastinal organs, even aorta causing a massive bleed

Can also infiltrate lymphatics and spread hematogenously

30
Q

How does squamous cell carcinoma of the esophagus appear grossly and microscopically?

A

Grossly: Mucosal plaque becomes exophytic, ulcerative, or diffusely infiltrative and gray-white. May form a stricture

Microscopically - Nests of large, polygonal, eosinophilic cells +/- keratinization depending on degree of differentiation

31
Q

How does adenocarcinoma of the esophagus appear grossly and microscopically?

A

Grossly - Irregular mucosal plaque which can become nodular, ulcerative, or diffusely infiltrative

Microscopically - adenocarcinoma arising amongst Barrett esophagus

Pathophysiology - Gastrointestinal (24 decks)

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