Gi Exam 2: Esophagitis

Front 1

name the layers of the normal digestive tract from lumen to the outside

Back 1

epithelium, lamina propria, muscularis mucosa, submucosa, muscularis propria (inner circular and outer longitudinal w/auerbach's plexus in b/w), serosa/adventitia

Front 2

what is an alternate name for auerbach's plexus?

Back 2

myenteric plexus, parasympathetic ganglia (located b/w 2 layers of muscularis propria)

Front 3

what makes up the mucosa?

Back 3

3 layers: epithelium, lamina propria (CT), muscularis mucosa

Front 4

where are blood vessels located in the normal digestive tract histology? where are inflammatory cells?

Back 4

blood vessels are in the lamina propria and the submucosa, immune cells (MALT/GALT) are in the lamina propria

Front 5

what are the common pathologic processes that occur in each layer of the digestive tract: epithelium, lamina propria, submucosa, muscularis propria

Back 5

epithelium - neoplasms; lamina propria - inflammation/infection; bleeding - submucosa; muscularis - motility d/os

Front 6

define erosion

Back 6

superficial necrotic injury to the luminal wall, involves ONLY MUCOSA, heals by REGENERATION (w/o fibrosis/scar)

Front 7

define ulcer

Back 7

deeper necrotic injury to the luminal wall, involves MUCOSA + DEEPER LAYERS, heals w/GRANULATION TISSUE (leads to fibrosis/scar)

Front 8

describe the histological appearance of an esophageal erosion

Back 8

necrosis of epithelium w/remnants of epithelial basal layer regenerating squamous epithelial cells, no necrosis in submucosa

Front 9

describe the histological appearance of a stomach ulcer

Back 9

ulcer extends into deep layers, scar tissue forms (fibrosis replaces muscularis layer, e.g.)

Front 10

what are 3 etiologies for GI stenosis?

Back 10

CONGENITAL, FIBROSIS/scar (any necrosis of the wall that causes substantial repair w/fibrosis will have a circumferential scar that contracts --> stricture), NEOPLASMS (benign or malignant)

Front 11

what is the presentation of GI stenosis?

Back 11

obstructs movement of GI lumen contents. in the esophagus, presents as dysphagia; in the rest of the GI tract presents as obstruction

Front 12

the esophagus is a ___-long ___ tube w/in the ___. it is located in the ____, behind the __, ___, and __ and it is surrounded by __ and __ nerves. it enters the abdomen through __ at the level of __.

Back 12

the esophagus is a 25-cm-long MUSCULAR tube located in the THORAX, behind the HEART, TRACHEA, and AORTIC ARCH and surrounded by VAGUS and RECURRENT LARYNGEAL nerves. it enters the abdomen through HIATUS OF THE DIAPHRAGM at the level of GE JUNCTION.

Front 13

describe 3 features of normal esophageal gross anatomy

Back 13

1. mucosa is shiny, white-tan color due to thick stratified squamous epithelium 2. abrupt transition at GE junction to red/tan epithelium (simple columnar) of stomach 3. rich lymphatic supply

Front 14

true or false: in the muscularis propria layer, the entire esophagus is lined with skeletal muscle

Back 14

false. the top 1/3 of the esophagus is skeletal muscle (for swallowing), the bottom 2/3 is smooth muscle.

Front 15

name 6 causes of esophagitis

Back 15

infection (candida, herpes, CMV), drug, chemical, eosinophilic, reflux (GERD), barrett

Front 16

what is a hiatal hernia?

Back 16

protrusion of stomach into the thorax through an enlarged diaphragmatic hiatus

Front 17

what are the 2 types of hiatal hernias? which is more common?

Back 17

sliding (portion of stomach pulled up through diaphragm) occurs in 95% of cases, pareaesophageal (rolling) occurs in 5%

Front 18

hiatal hernias are ___ (common/rare), usually ___ (acquired/congenital).

Back 18

hiatal hernias are common, and usually acquired.

Front 19

what are 3 changes that can lead to a hiatal hernia?

Back 19

weakening of hiatal opening, esophageal diseases that pull stomach cephalad, abdominal conditions that push stomach cephalad (e.g., pregnancy)

Front 20

hiatal hernias may cause ____, which can lead to ____

Back 20

may cause an INCOMPETENT LOWER ESOPHAGEAL SPHINCTER, which can lead to REFLUX of stomach contents (GERD)

Front 21

true or false: esophagitis will lead to erosion, but not ulceration of the esophagus

Back 21

false. can lead to either (recall that erosion has regenerative healing, ulceration involves fibrosis +/- stricture)

Front 22

infectious esophagitis is most common in __ patients. other predisposing conditions include __, __, __, and __.

Back 22

most common in IMMUNOCOMPROMISED patients (chemotx, transplant, AIDS). other predisposing conditions include diabetes mellitus, EtOH, old age, and systemic antibiotics

Front 23

the most common esophageal pathogen is ___. how does it cause esophagitis?

Back 23

most common pathogen is candida. normal GI flora + predisposing condition (immunosuppression, e.g.) leads to overgrowth of fungus (candidiasis)

Front 24

what is the gross pathology of esophageal candidiasis?

Back 24

superficial white plaques (pseudomembranes)

Front 25

what is the histopathology of esophageal candidiasis?

Back 25

pseudomembranes composed of candida pseudohyphae, inflammatory cells (PMNs), necrotic debris. *you can use PAS stain to visualize candida

Front 26

candida histology

Back 26

budding yeast and pseudohyphae can be seen easily on PAS-stain

Front 27

describe the gross pathology of herpetic esophagitis. what is the etiology of this?

Back 27

etiology is HSV-I. gross pathology is superficial vesicles, erosions/ulcers, and/or plaques

Front 28

describe the histopathology of herpetic esophagitis.

Back 28

HSV infects EPITHELIAL CELLS (kerainocytes), replicated viral material collects in NUCLEUS (nuclear inclusions lead to ground glass appearance, pushes chromatin to the edges/margination). some cells are multinucleated w/nuclear molding.

Front 29

describe the gross pathology and pathogenesis of cytomegalovirus esophagitis

Back 29

causes erosions/ulcers (necoris of esophagus). virus is acquired through sexual contact, organ transplant, etc.

Front 30

describe the histopathology of CMV esophagitis

Back 30

infects LAMINA PROPRIA cells (including endoethelial cells and fibroblasts), replicated viral material collects in infected cells, which leads to nuclear and cytomegaly and nuclear inclusions

Front 31

describes the pathogenesis of drug esophagitis

Back 31

ingested pills get caught in mid-distal esophagus SECONDARY TO esophageal dysmotility, esophageal stricture, sticky/dry medicine, little accompanying food/H2O, or recumbent position. this causes injury of mucosa (via different mechanisms, depends on med)

Front 32

describe the gross and histopathology of pill esophagitis

Back 32

localized inflammation +/- erosion +/- ulceration

Front 33

describe the epidemiology of chemical (corrosive) esophagitis in adults and children

Back 33

adults: suicide; children: accidental ingestion

Front 34

what is the etiology of corrosive esophagitis?

Back 34

ingestion of strong alkaline agents (lye) or strong acids (sulfuric or HCl). commonly caused by ingestion of cleaning products.

Front 35

describe the pathogenesis of chemical esophagitis. which chemical causes the most damage?

Back 35

alkali --> liquefactive necrosis; acids --> coagulative necrosis (protective eschar). alkaline solutions are the worst. acids are next worse, after that is alkaline solids.

Front 36

how do you grade the severity of chemical esophagitis?

Back 36

like burns. 1st degree: injury to mucosa/submucosa (mucosa may slough); 2nd degree: injury to submucosa/muscularis propria --> ulceration, granulation tissue, fibrosis +/- stricture; 3rd degree: full thickness necrosis (through muscularis propria)

Front 37

give the epidemiology, etiology, and pathogenesis of eosinophilic esophagitis

Back 37

epidemiology: all ages, +/- association w/allergies; etiology: unknown; pathogenesis: ?--> infiltration of eosinophils in epithelium

Front 38

describe the gross pathology of eosinophilic esophagitis

Back 38

normal tissue --> erosions --> strictures

Front 39

describe the histopathology of eosinophilic esophagitis

Back 39

intraepithelial inflammation w/eosinophils (bright red cells on H&E)

Front 40

what does GERD stand for? what is it?

Back 40

gastroesophageal reflux disease. it is the movement (reflux) of gsatric contents into esophagus

Front 41

pathogenesis of GERD

Back 41

reflux of gastric contents (acid, pepsin, +/- bile) into esophagus --> chemical injury of mucosa

Front 42

describe the gross pathology of GERD

Back 42

occurs in distal esophagus, erythema +/- complications (erosions, ulcers --> fibrosis --> strictures)

Front 43

describe the histopathology of GERD

Back 43

intraepithelial inflammation containing PMNs and eosinophils

Front 44

describe the possible natural history of GERD (bad outcome, 5 steps)

Back 44

normal squamous epithelium --> esophagitis (GERD) --> Barrett metaplasia --> dysplasia --> adenocarcinoma

Front 45

define barrett esophagus

Back 45

METAPLASIA of normal esophageal stratified squamous epithelium --> intestinal columnar epithelium (contains absorptive columnar cells and mucus-secreting goblet cells)

Front 46

what is the pathogenesis of barrett esophagus?

Back 46

chronic reflux --> chronic injury --> metaplasia of epithelium

Front 47

in barrett esophagus ___ is replaced by ___

Back 47

normal esophageal stratified squamous epithelium is replaced by METAPLASTIC INTESTINAL EPITHELIUM.

Front 48

Give some basic functional anatomy of the esophagus.

Back 48

proximal 1/3 is striated (skeletal) muscle
distal 2/3 is smooth muscle
UES and LES
Normal LESP is 10-40 mmHg

Front 49

What is peristalsis?

Back 49

orderly contraction of smooth muscle to propogate food caudad

Front 50

what is primary peristalsis?

Back 50

peristalsis assoc. w/ a swallow

Front 51

What innervates the LES?

Back 51

vagal pre-ganglionic and sympathetic post-ganglionic neurons

Front 52

True or False: The LES contracts at the onset of swallowing?

Back 52

False! It relaxes.

Front 53

What is tLESR?

Back 53

Transient LES relaxation. It serves to vent the stomach

Front 54

What are some natural mucosal barrier defenses?

Back 54

1. Tight junctions
2. Enhanced mucosal bicarb production
3. increased blood flow to aid cell repair and provide bicarb
4. transmembrane pumps: Na/H and Cl/Bicarb
5. salivary bicab aids in neutralizing pH

Front 55

Define GERD

Back 55

Cephalad displacement of gastric contents into the esophagus causing EITHER tissue damage of symptoms

Front 56

What is the common presentation of a pt w/ GERD?

Back 56

1. Most commonly "heartburn" (substernal chest burning), often w/ regurgitation and belching
2. NOT manifest as epigastric pain (dyspepsia)
3. Often silent
4. Extra-esophagel sx: hoarseness, asthma, chronic cough, sinusitis, bronchitis, bronchiectasis, erosion of dental enamel

Front 57

What are some risk factors of GERD?

Back 57

Age, male, obesity, pregnancy, smoking, CVD, EtOH use, Hiatal hernia

Front 58

What are some potential contributors to the pathophys of GERD?

Back 58

Loose LES
too many/prolonged tLESRs
poor/incomplete peristalsis
decreased gastric emptying
weakened epithelial resistance (EtOH & smoking)

Front 59

True or False: Too much acid production is commonly a cause of GERD

Back 59

FALSE

Front 60

How can you see a Hiatal Hernia?

Back 60

Barium swallow or EGD

Front 61

True or False: It is easy to exclude things from your DDx and jump right to GERD?

Back 61

False! Your DDx should be broad and include CAD, Esophageal CA, Lung CA, panic d/o, etc.

Front 62

What is erosive esophagitis?

Back 62

A major complication of GERD (occurs in 10-40% of pts) which occurs secondary to high amounts of acid, pepsin and bile refluxing

Front 63

Is erosive esophagitis an acute or chronic condition?

Back 63

chronic and relapsing

Front 64

Which GERD pts are most likely to get erosive esophagitis?

Back 64

Those w/ Hiatal Hernia

Front 65

How does erosive esophagitis present?

Back 65

chest pain, dysphagia, odynophagia

Front 66

True or False: Erosive esophagitis increases the chance of developing strictures or Barrett's?

Back 66

TRUE

Front 67

How do esophageal strictures form?

Back 67

secondary to circumferential mucosal damage from GERD. The are composed of circular bands of scar tissue underlying mucosa.

Front 68

How does a pt w/ strictures present?

Back 68

dysphagia

Front 69

What is Barrett's esophagus?

Back 69

Metaplastic change of mucosa from squamous to specialized (intestinal) columnar epithelium w/ goblet cells

Front 70

True or False: Barrett's is a premalignant condition for squamousCA of the esophagus.

Back 70

False! it's premalignant for adenoCA.

Front 71

Barrett's occurs in ___% of pts w/ GERD.

Back 71

10

Front 72

Why might Barrett's be less symptomatic than normal mucosa?

Back 72

Because it is composed of specialized epithelium that is designed to handle the the refluxing contents

Front 73

How do you test pts for GERD?

Back 73

Empiric therapy. Good response obviates need for further testing.

Front 74

What are some alarm symptoms that trigger early investigation of GERD w/ a Barium swallow or EGD?

Back 74

Weight loss, dysphagia, anemia, early satiety, bleeding

Front 75

True or False: EGD is excellent for detecting GERD

Back 75

False! It misses non-erosive reflux disease (NERD). It is good for looking for complications of GERD.

Front 76

What is the best test for dx'ing GERD?

Back 76

24hr pH probe

Front 77

True or False: Barium swallow is sensitive, but not specific for GERD

Back 77

False! It is neither sensitive nor specific

Front 78

If you have a pt you think may have GERD, what's the first thing you're gonna do?

Back 78

Try conservative Tx:
1. elevate the head of the bed
2. stop smoking, drinking
3. lose weight...

Front 79

For occasional, mild, or non-erosive disease, what is the best therapy?

Back 79

baking soda, OTC antacids, and H2 blockers

Front 80

What therapy is used to heal erosive esophagitis and for severe GERD?

Back 80

PPIs

Front 81

True of False: It usually takes decades for pts to develop complications from GERD

Back 81

False! They usually occur early.

Front 82

Besides GERD, name some sources of esophagitis

Back 82

Eosinophilic esophagitis
Candida
Herpes
CMV
Radiation
HIV
Pill-induced

Front 83

What is the characteristic endoscopic picture of Eosinophilic Esophagitis?

Back 83

"Ringed esophagus"

Front 84

What is the characteristic endoscopic picture of CMV esophagitis?

Back 84

Shallow, wide ulcers w/ geographic edges