Path 3 Esophagus And Int

Front 1

ESOPHAGUS AND INTESTINE - LEE - WEDNESDAY FEB 21

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ESOPHAGITIS

Front 5

what is the most common type of esophagitis?

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reflux esophagitis

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what infections can cause esophagitis (2)?

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1) candida; 2) HSV

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in what systemic illnesses can esophagitis arise (3)?

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1) pemphigoid; 2) GVHD; 3) Crohn's

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what else can cause esophagitis (2)?

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1) prolonged intubation; 2) ingestion of irritants (alkali, acid, hot tea in Iran)

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REFLUX ESOPHAGITIS

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what is gastroesophageal reflux disease?

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abnormal degree of gastroesophageal reflux (regurgitation of acid-peptic gastric content into esophagus) with sympotoms or tissue damage

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what is reflux esophagitis?

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inflammation and other objective evidence of injury to the esophageal mucosa from GERD

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what are four causative factors of reflux esophagitis/GERD?

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1) decreased efficacy of esophageal anti-reflux mechanisms (LES tone); 2) sliding hiatal hernia; 3) ninadequate or slow esophageal clearance of refluxed material; 4) action of gastric juices

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in severe cases, what can be refluxed?

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bile from duodenum

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what are the two most important clinical features of reflux esophagitis?

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1) heartburn (substernal burning pain); 2) regurgitation (reflux of sour/bitter material into mouth)

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what type of extraesophageal manifestations occur?

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pulmonary symptoms

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what are other symptoms in clinical presentation (3)?

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1) dysphagia; 2) odynophagia; 3) hemorrhage

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what inflammatory cells are involved (2)?

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1) eosinophils; 2) neutrophils

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what hyperplastic changes occur in the epithelium (2)?

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1) basal cell hyperplasia; 2) elongated papillae

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what complications must we know for reflux esophagitis (3)?

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1) ulcer; 2) stricture; 3) Barrett esophagus

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BARRETT ESOPHAGUS

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what is Barrett Esophagus a complication of?

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long standing gastroesophageal reflux

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what % of symptomatic GERD patients get it?

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10%

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what happens in response to injury?

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the distal squamous mucosa is replaced by metaplastic columnar epithelium

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what criteria are used to diagnose?

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columnar mucosa with intestinal metaplasia (goblet cells)

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what is there an increased risk for, and how much is risk increased?

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adenocarcinoma of the esophagus (30 to 40 fold increase rate over general population)

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what should be done to these patients?

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periodic surveillance every 1 or 2 years with endoscopic biopsy to detect dysplasia and early cancer

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what is 5 years survival rate for esophageal adenocarcinoma after surgery, and how does this differ for early cancer?

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less than 20% survival after surgery, but 80% for early cancer

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CARCINOMAS OF THE ESOPHAGUS

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what is the most common esophageal carcionma?

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squamous cell carcinoma (90% worldwide, 50% in USA)

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what causes most adenocarcinoma?

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Barrett esophagus

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what is the highest incidence area in the world for squamous cell carcinoma?

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Central China, followed by Iran and South Africa

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what race and sex is most likely to get squamous cell carcinoma of the esophagus?

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blacks > whites, male > female

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what are major etiological factors in the USA and Europe (2)?

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1) heavy smoking; 2) chronic drinking

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what are factors in China and South Africa (3)?

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1) fungus-contaminated food; 2) nitrosamine containing food; 3) deficiencies in vitamins/metals

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what else can be etiological factors (2)?

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1) genetic alterations; 2) chronic injury to esophageal mucosa (lye stricture, achalasia, diverticuli, Plummer-Vinson)

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what are clinical manifestations of squamous cell carcinoma of the esophagus (3)?

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1) dysphagia; 2) gradual obstruction; 3) aspiration pneumonia

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why may there be aspiration pneumonia?

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tracheoesophageal fistula

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where in the esophagus is the most common location, and what % occur there?

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middle third - 50%; lower third - 30%; upper third - 20%

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what is the most common morphological form, and what are two other forms?

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fungating - 60%; ulcerated - 25%; flat - 15%

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what is the five year survival rate for all patients with squamous cell carcinoma of the esophagus?

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9%

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what groups have higher survival rates (2), and what is the 5 year survival rate for each?

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1) patients who undergo "curative" for advanced disease - 25%; 2) patients with superficial disease - 75%

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HIATAL HERNIA

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what is hiatal hernia?

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herniation of the stomach through an enlarged esophageal hiatus in the diaphragm

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what are the two basic types (2) and which is most common?

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1) sliding hernia (95%); 2) paraesophageal hernia

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what is a sliding hernia (location, part of stomach)

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supradiaphragmatic herniation of portion of the cardia

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how common is it (what % of otherwise normal individuals)?

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4-7% of otherwise normal individuals

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what are symptoms referable to?

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GE reflux

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what is a paraesophageal hernia (location, part of stomach)?

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herniation of portion of gastric fundus alongside the esophagus through a defect in the diaphragm

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what is the clinical course usually like in paraesophageal hernia?

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asymptomatic

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what symptoms may occur (2)?

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1) strangulation; 2) infarction

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LACERATIONS (MALLORY-WEISS SYNDROME)

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what is Mallory-Weiss syndrome (lesion, location)?

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longitudinal tears at esophageal junction

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who is this syndrome most common in and why?

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alcoholics - attributed to episodes of excessive vomiting

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ISCHEMIC BOWEL DISEASE

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where in the bowel does this disease affect, and what does the area affected depend on?

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may be restricted to small or large intestine, or may affect both, depending on particular vessels affected

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what are three types of ischemic bowel disease?

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1) transmural; 2) mural; 3) mucosal

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what causes transmural IBD?

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mechanical compromise of major mesenteric blood vessels

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what causes mural IBD?

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hypoperfusion (acute or chronic)

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what causes mucosal IBD?

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hypoperfusion (acute or chronic)

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what are four categories of predisposing factors for IBD (other miscellaneous causes exist)?

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1) arterial thrombosis; 2) arterial embolism; 3) venous thrombosis; 4) nonocclusive ischemia

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what are some causes of arterial thrombosis (list)?

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severe atherosclerosis, systemic vasculitis, dissecting aneurysm, angiography, oral contraceptives

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what are some causes of arterial embolism (list)?

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cardiac vegetations, aortic atheroembolism

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what are some causes of venous thrombosis (list)?

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hypercoagulable states, oral contraceptives, postoperative state, intraperitoneal sepsis, invasive neoplasms, cirrhosis, abdominal trauma

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what are some causes of nonocclusive ischemia (list)?

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cardiac failure, shock, dehydration, vasoconstrictive drugs

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what are some miscellaneous causes of IBD (4)?

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1) radiation; 2) volvulus; 3) stricture; 4) herniation

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if the small bowel is involved, what part is normally affected?

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substantial portion of total length

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if the colon is involved, what part is normally affected?

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the splenic area (the watershed between the distribution of superior and inferior mesenteric arteries)

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what is seen microscopically if there is infarction or acute ischemia (2)?

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1) coagulative necrosis; 2) hemorrhage (minimal inflammatory reaction)

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what is seen microscopically if there is chronic ischemia (3)?

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1) chronic inflammation; 2) fibrosis; 3) stricture

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what is the most serious form of IBD, and what is the mortality?

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transmural infarction - uncommon but grave disorder (mortality 50-75%)

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what will the patient present with, in transmural IBD?

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severe pain and tenderness

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what will stool be like (2)?

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1) bloody diarrhea; 2) grossly melanotic

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what will patients complain of in mucosal and mural infarction (2)?

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1) nonspecific abdominal complaints; 2) intermittent bloody diarrhea

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PSEUDOMEMBRANOUS COLITIS

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what is the normal cause?

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C. difficile overgrowth secondary to broad-spectrum antibiotics

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what is this acute colitis characterized by?

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formation of an adherent layer of inflammatory cells and debris (pseudomembrane) overlying sites of mucosal injury

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what is the pathogenesis (2 things caused by C. difficile, and 2 results)?

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C. difficile produces toxin A and toxin B which: 1) induce cytokine production; 2) cause host cell apoptosis

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what does C. difficile enterocolitis look like grossly?

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raised yellowish plaques (1-2 mm)

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what is the appearance microscopically?

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"volcano or mushroom like" pseudomembrane

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what are the clinical symptoms (4)?

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1) fever; 2) pain; 3) leukocytosis; 4) diarrhea

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what tools are used to diagnose (3)?

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1) C. difficile toxin in stool; 2) endoscopy/biopsy; 3) clinical history of antibioti use

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what is the treatment (2)?

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1) metronidazole; 2) vancomycin

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CELIAC DISEASE

Front 100

what type of lesion occurs, and where?

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mucosal lesion, small intestine

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what cells increase in number?

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intraepithelail lymphocytes

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what antibodies can be found in serology (3)?

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1) anti-gliadin; 2) andi-endomysial; 3) TTG (tissue transglutaminase)

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what is there a small long-term increased risk for (3)?

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malignant diseases including: 1) intestinal lymphoma; 2) small intestinal adenocarcinoma; 3) esophageal squamous cell carcinoma

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COLLAGENOUS COLITIS

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who does collagenous colitis predominantly affect (age, sex)?

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middle-aged and elderly women

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what is seen on colonoscopic examination?

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normal

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what is the clinical symptom?

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chronic watery diarrhea

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what alteration is the cause?

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markedly thickened subepithelial collagen layer

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ACUTE APPENDICITIS

Front 114

who usually gets acute apendicitis?

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adolescents and young adults (but can occur in any age group)

Front 115

what is pain like, in location and progression?

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at first periumbilical, but then localizing to right lower quadrant

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what are other pesentations (4)?

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1) nausea/vomiting; 2) abdominal tenderness (appendix region); 3) mild fever; 4) leukocytosis

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what is regrettable about classic presentation?

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more often absent than present

Front 118

what is acute appendicitis associated with in 50-80% of cases?

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obstruction (fecalith, tumor, worm)

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what is diagnostic for acute appendicitis?

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neutrophilic infiltration of the muscularis

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what are complications of acute appendicitis (3)?

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1) perforation; 2) liver abscess; 3) bacteremia

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what error commonly occurs among highly competent surgeons?

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false positive diagnosis (20-25%)

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ANGIODYSPLASIA

Front 125

what is angiodysplasia?

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tortuous dilatations of submucosal and mucosal blood vessels

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where is this most often seen (2)?

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1) cecum; 2) right colon

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at what age is angiodysplasia seen?

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usually only after sixth decade of life

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what is the main symptom?

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lsignificant ower intestinal bleeding

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what % of significant lower intestinal bleeding is angiodysplasia responsible for?

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20%

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what may be involved in pathogenesis (2 - remains speculative)?

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1) mechanical factors/congenital malformation; 2) vascular degenerative changes related to aging

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INTESTINAL OBSTRUCTION

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what are the two main categories of obstruction?

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1) mecahnical; 2) pseudo-obstruction

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what is the most common cause of mechanical obstruction?

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adhesions

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what are other causes of mechanical obstruction (list)?

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hernias, intussusception, tumors, inflammatory strictures, volvulus, obstructive gallstones, fecaliths, foreign bodies, congenital strictures, atresia, congenital bands, meconium in mucoviscidosis (cystic fibrosis), imperforate anus

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what are causes of pseud-obstruction (4)?

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1) paralytic ileus (e.g. post-operative); 2) vascular (bowel infarction; 3) myopathies; 4) neuropathies

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what are hernias?

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weakness or defect in wall of peritoneal cavity

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what are four types of hernias?

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1) incisional; 2) inguinal; 3) femoral; 4) umbilical

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what are two problems caused by hernias?

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1) incarceration (trapping); 2) strangulation

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who does intussusception most often occur in?

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infants, children

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what happens in intussusception?

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telescoping of one part of the intestine into the immediately distal segment of bowel

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what region of the intestine does this most commonly occur in?

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iliocecal region

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what problem can this cause besides obstruction?

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infarction

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what is the underlying pathology in childhood?

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lymphoid hyperplasia related to rotavirus infection

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what is the underlying pathology in adulthood?

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usually associated with intraluminal mass

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what is the treatment for early/uncomplicated cases, and what is the treatment for late cases?

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1) barium enema (early); 2) surgery with manual reduction ore resection (late)

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what is volvulus?

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torsion or twisting of intestine (causing obstruction)

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where does volvulus occur (3)?

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1) sigmoid colon; 2) cecum; 3) small intestine

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what problem can this cause besides obstruction?

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infarction

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what are predisposing conditions (3)?

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1) redundant loop; 2) peritoneal adhesions; 3) congenital long mesentery