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121 Cards in this Set

  • Front
  • Back
What are the three areas of natural narrowing of the esophagus?
Cricoid cartilage
Tracheal bifurcation
Diaphragm
What two areas of the esophagus remain contracted at rest?
UES by the cricopharyngeal muscle
LES by the gastroesophageal junction
What cell type forms the esophageal mucosa?
non-keratinized squamous epithelium
What structure form the esophageal submucosa?
Blood vessels, lymphatics, and mucus glands
What is the structure of the esophageal muscle layer?
ICOL
Where can the esophageal myenteric plexus be found?
In between the muscle layers (IC/OL)
Why can esophageal diseases spread so easily?
Esophagus has no serosa and a rich lymphatic system
Where can skeletal muscle be found in the esophagus?
proximally
What other diseases are associated with esophageal fistulas?
Heart and GI anomalies
What are causes of esophageal stenosis?
Injury (Trauma or chemical)
GERD
Radiation
Scleroderma
What is the common clinical presentation for esophageal stenosis?
dysphagia with solids then later with anything.
What is an esophageal web?
Mucosal ring in the upper esophagus
What is Plummer-Vinson syndrome?
Upper esophageal ring
anemia
atropic glossitis (smooth tongue)
What is Schatzki's rings?
Lower esophageal ring, above the squamocolumnar junction.
What is a bougienage? What condition is treated with it?
Mechanical dilation with a leaded-tapered rubber tube
What is a mucosal ring the upper esophagus called? lower esophagus?
Upper: Web
Lower: Schatzki's ring
What supplement is used in the treatment of Plummer-Vinson?
Iron
What is a hiatal hernia?
protrusion of the stomach above the diaphragm.
What percentage of hiatal hernias are sliding?
95%
What are the two types of hiatal hernias?
sliding and rolling
What is the most common problem associated with a hiatal hernia?
GERD due to an insufficient LES
What three abnormalities form achalasia?
1. Aperistalsis
2. Partial or incomplete relaxation of LES
3. Increase resting tone of LES
What are the two forms of achalasia?
Primary and Secondary
What causes secondary achalasia?
Chagas (trypanosoma cruzi)
Amyloidosis
Sarcoidosis
Diabetes
What is a neoplastic complication of achalasia?
squamous cell carcinomas in 5%
Where does dilitation occus in achalasia?
proximal to the LES which shows increased tone.
What should you suspect if you find achalasia in south america?
Trypanosoma cruzi infection, likes to eat the myenteric plexus.
What are the key features of achalasia?
Progressive dilation of the esophagus and loss of the myenteric plexus.
What is a longitudinal tear of the GE junction called?
Mallory-Weiss Syndrome
What can cause Mallory-Weiss?
intense retching
What term describes the complete tear at the GE junction?
Boerhaave syndrome
What causes esophageal varices?
portal hypertension
What condition has the greatest propensity to cause esophageal varices?
Cirrhosis
What vein is involved with esophageal varices?
Azygos vein
What are the common causes of esophagitis (5)?
1. Reflux
2. Irritants
3. Cytotoxic agents (chemo/radiation)
4. Infection
5. Connective tissue disease, uremia
How do you treat esophagitis caused by uremia?
treat the kidney
What is the most common cause of esophagitis?
Reflux
What is Barrett's Esophagus?
replacement of the normal distal stratified squamous epithelial mucosa by metaplastic columnar cells and goblet cells.
What causes Barrett?
Long standing inflammation (reflux)
What complication is associated with Barrett?
30-40 fold increase in adenocarcinoma of the esophagus and bleeding/strictures
On biopsy of a Barrett, what should you look for?
dysplasia in the metaplastic areas.
Are benign esophageal tumors common or rare? What type are they?
Rare

Usually mesenchymal: fibromas, lipomas, hemangiomas, neurofibromas
What cell type causes most malignant tumors of the esophagus?
Squamous cells
What is the difference between the incidence of malignant squamous cell tumors in the US and in Asia?
Rare in US, and much more common in Asia, possibly due to diet and environmental conditions.

Causes 20% of cancer deaths in Asia
What disorders can cause esophageal malignancies?
Long standing esophagitis
Achalasia
Plummer-Vinson
What dietary factors can contribute to esophageal malignancy? (4)
1. Vitamin A, C, riboflavin, thiamine, pyridoxine deficiency
2. Zn or Mb deficiency
3. Fungal infection of food (mycotoxins)
4. Nitrite/nitrosamine consumption
What is the only known precursor to adenocarcinoma of the esophagus?
Barrett's
Where do esophageal tumors metastasize?
Upper 1/3 to the cervical nodes
Mid 1/3 to the mediastinum, paratracheal, and tracheobronchial nodes
Lower 1/3 to the gastric and celiac nodes
Adenocarcinoma of the esophagus is more common in ________. Squamous cell carcinoma is more common in _________.
Adenocarcinoma in White males
Squamous cell in Black males
What is the primary malignancy of the esophagus?
Squamous cell tumors
What are the parts of the stomach (cranial to caudal)?
LES, cardia, fundus, body, antrum, pylorus.

Also note: greater and lesser curvature, and angularis
What heterotopias are common at the stomach?
Pancreatic tissue in the wall of the stomash
Gastric cells in the doudenum or more distal in a meckel's
What is the fetal complication of a diaphragmatic hernia?
Respiratory insult causing death due to incomplete formation of the diaphragm
What causes pyloric stenosis?
Thickening of the wall of the pylorus (muscularis propria)
How will a pyloric stenosis present?
Knot in the abdomen
Projectile vomiting at 2-3 weeks
How is a pyloric stenosis treated?
Cut the pylorus longitudinally
Why is gastritis often missed?
Chronic gastritis is often asymptomatic
What is more common, chronic or acute gastritis?
Chronic
What are five common factors associated with gastritis?
NSAID use
Corticosteroid use
EtOH and tobacco
Uremia
Severe stress
How does uremia cause gastritis?
Uremia causes phosphate retention. Hyperphosphatemia causes hypocalcemia which trigger PTH. Reflex hypercalcemia triggers acid in the stomach.
What is the presentation of gastritis?
From asymptomatic to gross hematemesis, melena, and fatal blood loss.
What inflammatory cells are associated with chronic gastritis?
Lymphocytes: plasma cells
What ultimately happens to the mucosal layer with chronic gastritis?
develop atrophic gastritis with loss of the mucosal layer. This causes loss of acid and intrinsic factor.
What type of gastritis most commonly will result in atrophic gastritis?
autoimmune
What is the cancer risk with autoimmune gastritis?
2-4%
Intestinal metaplasia in the stomach is a sign of ______.
Chronic gastritis
Does chronic gastritis have erosion?
No.
What is the most common etiology of chronic gastritis?
infection (H. Pylori)
Where does autoimmune gastritis occur?
in the body and fundus
In autoimmune gastritis, what are the antibodies against?
Parietal cells
What is the result if the patient has antibodies to intrinsic factor?
Pernicious anemia (B12 deficiency)
Antibodies to parietal cells directly effect what structure?
H/K/ATPase and IF
What percent of people over 50 are infected by H.Pylori?
50%
What is the association of lymphoma and H. Pylori?
Lymphoid tissue expansion in the gastric mucosa caused by the infection is associated with increased risk of lymphoma.
What carcinomas can be caused by H. Pylori?
Epithelial and lymphoid.
What are the presenting symptoms of an autoimmune gastritis?
Hypo or achlorhydria with hypergastrinemia
What is the difference between autoimmune and non-autoimmune chronic gastritis?
With NAI you will not get achlorhydria and gastrin levels will remain normal or only slightly elevated.
Where are peptic ulcers typically found?
98% in the proximal duodenum.
What is the lifetime likelihood of developing a gastric ulcer?
10% of men
4% of women
Which four conditions increase the risk of gastric ulceration?
1. alcoholic cirrhosis
2. COPD
3. Chronic renal failure
4. Hyperparathyroidism
Why do renal failure and hyperparathyroidism cause gastric ulceration?
Reflex hypercalcemia stimulates gastrin and acid production.
What two key facts mediate the pathogenesis of peptic ulceration?
1. mucosal exposure to acid and pepsin
2. H. Pylori
What toxins are produced by H. Pylori? (4)
urease
protease
phospholipases
PAF
What is the role of NSAID use and ulceration of the gastric mucosa? Stress?
NSAIDs block protective prostaglandin production.

Stress can also increase the risk for ulceration
What is Zollinger-Ellison syndrome?
Tumor of the pancreas.

It is a gastrinoma which secretes massive amounts of gastrin, triggering acid production and ultimate ulceration of the gastric mucosa.
Where do most duodenal ulcers occur?
Within two cm of the pylorus on the anterior and posterior surfaces.
Where do most gastric ulcers occur (non-duodenal)?
In the antrum
Why do most non-duodenal gastric ulcerations occur in on the lesser curvature?
40% of the lesser curve is covered by antral mucosa, and only 10% of the greater curve is covered by antral mucosa.
What is the significance of the punch-out appearance of the peptic ulcer?
Punch-out appearance with straight walls is benign.
What is the presentation of a peptic ulcer?
gnawing, aching, burning which is worse at night and occurs 1-3 hours post-prandial. Relieved by food or alkalis.
Why do anterior perforations of the stomach refer to the shoulder?
Free air under the diaphragm causes phrenic irritation.
What diagnostic tool is used to reveal a peptic ulcer?
Barium radiography
If a patient with suspected peptic ulcer has an elevated diaphragm, what has happened?
perforation with free gas moving into the peritoneal cavity
What is the difference between a gastric perforation and penetration?
Perforation = anterior
Penetration = posterior
n badger
pester; annoy continually with demands; persuade by asking again and again; Ex. The children badgered me into taking them into the cinema; N: a kind of mountain animal
1) травить, изводить
2) дразнить
What is the difference between an erosion and an ulceration?
Erosion is limited to the destruction of the mucosa, where ulceration extends through the muscularis mucosa into the submucosa and beyond.
What is difference between Cushing and Curling ulcers?
Cushing: ulcer associated with intracranial pressure

Curling: ulcer associated with burns and other severe trauma.
What is Menetrier's disease?
Mucosal hyperplasia with glandular atrophy.
How does Menetrier's disease present?
Diarrhea
Weight loss
Bleeding
PLE
abdominal discomfort
Describe how Menetrier's disease is associated with gastric carcinoma.
Hyperplasia may become metaplastic then later dysplastic, increasing the risk of carcinoma.
What is a GI polyp?
Mass lesion from the mucosa
How common are Gastric polyps?
Uncommon. 0.4%.
What are the three types of gastric polyps?
Hyperplastic
Fundic gland polyps
Adenomatous polyps
Which gastric polyps are thought to be hamartomas? Which are neoplastic?
Fundic gland polyps are thought to be hamartomas.

40% of adenomatous polyps are malignant at the time of discovery.
What are the majority of gastric carcinomas? What about the rest?
95% are adenocarcinomas
4% are lymphomas
1% are others
Where is the highest incidence of gastric adenocarcinoma?
Japan
What percent of cancer deaths are due to gastric cancers? What is the 5 year survival?
3%, with 5 yr survival less than 10%
What are the two types of gastric carcinomas?
Intestinal
Diffuse
Signet ring cells are characteristic of what type of gastric carcinoma?
Diffuse
Where does intestinal gastric carcinoma arise from?
Metaplasia from chronic gastritis
Where does diffuse gastric carcinoma arise from?
de novo from gastric epithelial cells
Which type of gastric carcinoma has a male predominance?
Intestinal
What does a malignant ulceration look like?
Rounded edge due to metaplasia. No punch-out appearance. Need biopsy to confirm.
An ulcer on what part of the stomach is presumed to be malignant until proven otherwise?
Ulcer on the lesser curvature.
Which gastric carcinoma type will receive a complete gastrectomy?
Diffuse with signet ring cells
Which gastric carcinoma type is thought to be independent of H. Pylori and gastritis risk factors?
Diffuse
What is the usual antecedent to Krukenberg tumors of the ovaries?
Diffuse gastric carcinoma
Which gastric carcinoma has a stronger A blood group association?
Diffuse
What is the rate of involvement of the greater and lesser curvature in gastric carcinoma?
Lesser: 40%
Greater: 12%
What is linitis plastica?
Gross presentation of gastric carcinoma.

"Leather bottle stomach" with infiltration of the entire gastric wall.
What are the main factors that cause intestinal gastric carcinomas?
Mostly environmental causes.

Nitrites
Smoked/pickled foods
Salt intake
Decreased antioxidants
H. Pylori
Pernicious anemia
Subtotal distal gastrectomy