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43 Cards in this Set
- Front
- Back
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What are the 2 areas at high pressure during rest?
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upper ES - at cricopharyngeus
lower ES - 2-4 cm |
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What are the layers of the normal esosphagus
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mucosal epithelium (SS)
lamina propria muscularis mucosa submucosa muscularis propria |
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What is the Z line?
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irregular serrated junction between the SS and columnar epithelium
proximmal to the gastroesophageal by 2-3 cm |
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Esophageal Atresia
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esophagus is thin, non-canalized
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T-E fistula
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associated with congenital heart disease
multiple forms - most common is upper eso ending in pouch with lower eso attached to trachea - These kids regurgitate alot - predisposition to pneumonia treat with surgery - with late complications of GERD and esophagitis |
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Ectopic Gastric Tissue
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orange-red spots, post cricoid
remebles gastric mucosa with glands and a sharp border with surrounding SS epithelium can ulcerate and become inflammed |
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Ectopic Pancreatic Tissue
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aka pancreatic heteropia
located at GE junction in 15% of people congenital and independent of Barrett's eso not significant unless becomes neoplastic |
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Esophageal Webs
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Uncommon
protrusions of mucosa into the lumen usually in upper esophagus SS epithelium with fibrous core women over 40 causing episodic dysphagia idiopathic or occuring after radiotherapy Schatzki ring - in lover esophagus |
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Esophageal Stenosis
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fibrous thickening of the esophageal wall, mainly the submucosa - atrophy of the muscularis. Epithelium may be ulcerated
caused by severe injury/inflammation with scaring, or GERD, scleroderma, or radiation rarely caused by esophageal webs progressive dysphagia - progressing to total obstruction |
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Achalasia
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failure for LES to relax
lack of progressive peristalsis increased LES resting tone due to T cell mediated destriction of mysenteric ganglion cells idiopathic or due to Chagas disease (trypanosoma cruzi) or Polio, diabetes, amyloidosis, sarcoidosis, surgery |
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Symptoms of Achalasia
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progressive dilation of esophagus above LES
slightly increased risk for esophageal SCC increased risk for Candida, diverticula, aspiration, GERD, peptic ulceration Tx with esophagomyotomy |
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Pathogenesis of Achalasia
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myenteric lymphocytic inflamation
marked depletion of ganglion cells in Auerbach plexux, replacement of nerves by fibrous tissue and muscle squamous mucosa is hyperplastic with papillomatosis and basal cell hyperplasia (similar to GERD) CD3 T cell present DDx: visceral neuropathies, normal aging, psuedoachalasia |
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Pseudoachalasia
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achalasia like syndrome
associated with neoplasms (adenocarcinoma) also caused by scleroderma and amyloidosis |
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Hiatal Hernia
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characterized by seperation of diaphragmatic crura and widening of th space between the muscular crura and the esophageal wall
sliding type is more common than the nonaxial type increasing incidence with age -heartburn or regurgitation made worse by bending forward, laying on back, and obesity can ulcerate, bleeding, perforation, and strangulation of hernias |
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Lacerations (Mallory Weiss tear)
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longitudinal tears at GE junction and in proximal gastric mucosa
due to severe retching associated with alcoholsm can be mucosal or full thickness support vasocontrictors, transfusions and balloon tamponade Boerhaave syndrome - esophageal rupture - lethal |
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Esophageal Diverticula
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epiphrenic
- immediately above the LES due to lack of coordination in peristalsis and LES relaxation - causes regurgitation of massive amounts of fluid at night/aspiration Mid-esophageal/Traction - near mid esophagus -previously thought to be due to TB, mediastinal lymphadenitis and scarring - due to motor dysfunction or congenital Zenker's diverticulum - above esophageal sphincter in posterior wall - due to cricopharyngeal motor dysfunction or weakness - food accumulates or is regurgitated and aspirated - seen in the elderly |
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Esophageal Varices
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dilated tortuous vessels develop from portal hypertension
collaterals in lower esophagus take blood diverted from portal vein through the coronary veins of the stomach into azygous veins into vena cava Alcoholics hepatic schistosomiasis can cause massive hemorrhage - 40% die on first episode of bleeding, 40% die on second bleed Tx. with sclerotherapy/ballon tamponade DDx: gastritis esophageal laceration, peptic ulcer |
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Esophagitis
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defined as epithelial damage and inflammation
Most common cause is GERD -many causes for GERD, like CNS depressants, hypothyroidism, pregnancy, alcohol, tobacco, NG intubation, sliding hiatal hernia, delayed gastic emptying |
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GERD
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pain may be mistaken for MI
long term consequences include minor bleeding, stricture, Barrett's esophagus, Barrett's ulcer. due to chronic exposure to gastic juices impairs repair bile reflux may be a factor Dx with symptoms, pH monitoring, histology examination |
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Reflux Esophagitis
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inflammatory cells in epithelial layer
basal cell hyperplasia extension of the lamina propria ballooned squamous cells vascular dilation intraepithelial eosinophils |
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What is the biopsy criteria for GERD?
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increased thickness of the basal layer, increased height of the papillae, and inflammation with intraepithelial eosinophils
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Carditis
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biopsies distal to the Z line in patients with GERD shows carditis
caused by H pylori gastritis and GERD increases incidence of gastric cardia cancer dysplasia rarely diagnosed |
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Barrett's esophagus
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squamous epitlelium is replaced with columnar epithelium (and goblet cells) - more resistant to acid, pepsin and bile
major risk factor for adenocarcinoma more common in med, CF patients, and after chemo has a red velvety appearance Dx by endoscopy and biopsy Tx with antacid therapy and frequent endoschopy |
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Pathogenesis of Barrett's Esophagus
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squamous epithelium is replaced by columnar cells and goblet cells
-goblet cells are definitive ID for Barretts Eso lamina propria is fibrotic and it has mild chronic inflamation muscularis mucosa is thickened erosions/ulceration may mimic carcinoma |
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Barrett's related dysplasia
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Barrett's is a precursor to esophageal adenocarcinoma
NOT linked to SCC step-wise process of dysplasia usually patchy and irregular, thickend, velvety mucosa |
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Barrett's low grade dysplasia
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anti-reflux therapy and intensive surveilance
the bigger it is the higher chance of transforming to adenocarcinoma |
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Barrett's High Grade dysplasia
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50% risk for invasive adenocarcinoma
on diagnosis rebiopsy to exclude missed carcinoma - consider esophagectomy biopsy should be reviewed by a second experienced consultant |
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DDx of Esophageal Dysplasia
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intramucosal adenocarcinoma
reactive inflammation (PMN's) |
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Eosinophilic Esophagitis
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disease of childhood mostly
young caucasian males increased frequency of diagnosis |
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Allergic Esophagitis in Children
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resembles RE but pH tests show no acid in esophagus
does not respond to antacids associated with dysphagia, failure to thrive, peripheral eosinophilia High numbers of eosinophils in esophagus -DDx - rule out relfux disease |
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Chemical Esophagitis
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caused by ingestion of strong alkalis, acids, detergents, or chemotherapy
can turn into Barrett's esophagus - rarely SCC mucosal or transmural injury with hemorrhage, necrosis, possible bacteral infectio |
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Infections
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restricted to immunocompromised patients, diabetics, HIV, chemo, or transplant recipients
Mostly Candada, HSV, or CMV |
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Acute Esophagitis
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manifested by increased neutrophils in the submucosa as well as in the squamous mucosa
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Candida
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most common cause of infectious esophagitis
immunocomprimised, and associated with antibiotic therapy grey-white pseudomembrane or plaques in mid esophagus mucosa is red and swollen, may be ulcerated -- Thrush" -- densely atte pseudohyphae and budding spores, exudate, necrosis positive for PAS and GMS |
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CMV
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immunocompromised
numerous inclusions atypical in HIv patients look like unched out mucosal ulcers (similar to HSV) virus present in endothelium and enlarged cells at ulcer base Intranuclear inclusions surrounded by clear halo macrophage aggregations inclusions are NOT seen in SCC |
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HSV
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opportunistic infection in IC patients
usually also have secondary bacterial and fungal infections shallow vesicles and ulcers coalsce into extensive areas of erosion ulcers have necrotic debris and exudates with neutrophils inclusions IN multinucleates squamous cells at margins (different than CMV) inclusions usually Cowdry type A, and ground glass inclusions |
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Esophageal Carcinoma
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low incidence by numbers are increaseing
shifting from SCC to AC (equal occurrance) usually presents as advanced/metastatic disease |
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Eitiology/Epidemiology of Squamous cell carcinoma
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most common - adults over 50, and men
geographically high in Iran and Asia, south Africa, Eastern europe, and Puerto Rico caused by Vit. A, C, thiamine, B6, riboflavin, zinc, molybdenum, nitrates, Betel nuts, tobacco associated with achalasia, other SCC;s, chronic esophagitis, Plummer-Vinson syndrome, celiac disease, epidermolysis bullosa, radiation, HPV begins in dysplasia |
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Symptpms/appearance of SCC
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dysphagia, anorexia, weight loss
invasion of muscularis propria, adjacent structures, lymph node metastasis protruded (usually), can also be flat or excavated moderately to well differentiated tumor clusters surround a main mass focal glandular or small cell differentiation |
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Adenocarcinoma
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progression from Barrett's esophagus
increasing in incidence more common in men and whites -- common in people with hiatal hernia, smokers, and alcohol users -- |
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Symptoms/Appearance of Adenocarcinoma
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GERD
invasion through wall often with lymph node involvement distal esophagus with invasion of cardia flat patches or nodular masses moderate to well differentiated next to Barretts with high grade dysplasia |
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Granular Cell Tumor
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rare
solitary in lower esophagus treat with excision look like sheets of uniform cells and abundant eosinophillic cytoplasm |
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Leiomyoma
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most common benign tumor
small tumors near gastroesophageal junction circumsised solitary mass bulges into lumen, grey-white, and whorled rarel ulcerated |
