Term
| what is dysphasia? odynophasia? |
|
Definition
| dysphasia is difficulty swallowing, odynophasia is painful swallowing |
|
|
Term
| what is nutcracker esophagus? |
|
Definition
| a lack of coordination in the muscular layers of the esophagus leading to short lived obstruction |
|
|
Term
| what can a diffuse esophageal spasm lead to? |
|
Definition
| a diffuse esophageal spasm can lead to functional obstruction and pseudodiverticula |
|
|
Term
| what is a zenker diverticulum? what is usually the cause? |
|
Definition
| a diverticulum above the upper esophageal sphincter that may grow large and trap food. zenker's diverticuli are usually due to points of weakness in the wall |
|
|
Term
| what is a tracker diverticulum? what is usually the cause? |
|
Definition
| a diverticulum near the midpoint of the esophagus. tracker diverticuli are usually due to inflammation and traction |
|
|
Term
| what is a epiphrenic diverticulum? what is usually the cause? |
|
Definition
| a diverticulum above the lower esophageal sphincter. epiphrenic diveriticuli are usually due to complications including pneumonia, perforation, mediastinitis and carcinoma |
|
|
Term
| what characterizes esophageal stenosis? can it be congential? what is is usually due to? |
|
Definition
| a narrowing of the lumen due to fibrous thickening of the submucosa and atrophy of the muscularis propria and epithelial damage. it can be congenital but is usually due to reflux, caustic material or irradiation. it results in a gradual narrowing, causing change in dietary habits from ingesting solids to liquids |
|
|
Term
| what is an esophageal web? who commonly gets them? what is associated with their incidence? |
|
Definition
| an uncommon ledge-like protrusion of mucosa, usually seen in women >40 and may be associated with GE reflux, graft v host disease, or blistering skin diseases |
|
|
Term
| what is *plummer-vinson syndrome*? |
|
Definition
| plummer-vinson syndrome includes upper esophageal webs, iron deficiency anemia, glossitis, and cheilosis |
|
|
Term
| where are esophageal webs most common? how do they appear? what are they composed of? what can they cause? |
|
Definition
| esophageal webs are most common in the upper esophagus and are semicircular lesions protruding < 5 mm into the lumen. they are composed of fibrovascular connective tissue and overlying epithelium. esophageal webs can cause dysphagia |
|
|
Term
|
Definition
| esophageal rings that are similar to webs, but circumferential and thicker |
|
|
Term
| what are the 2 types of schatzki rings? |
|
Definition
| A rings: in distal esophagus, above the GE junction and covered by squamous mucosa and B rings: may have gastric cardia-type mucosa on their undersurface |
|
|
Term
|
Definition
| achalasia is increased tone of the lower esophageal sphincter (LES), which leads to decreased relaxation of the LES and aperistalsis of the esophagus |
|
|
Term
| what is primary achalasia? |
|
Definition
| primary achalasia is the failure of the distal esophageal inhibitor neurons, possibly due to degenerative changes in neural innervation |
|
|
Term
| what specific kind of infection can lead to achalasia? |
|
Definition
| chagas disease, or infection by trypanosoma cruzi can lead to destruction of the myenteric plexus, which then leads to failure of peristalsis and esophageal dilatation |
|
|
Term
| what are some chronic diseases that can lead to achalasia-like symptoms? |
|
Definition
| DM, malignancy, and amyloidosis |
|
|
Term
| what are symptoms of achalasia? |
|
Definition
| dysphagia, vomiting, some chest pain |
|
|
Term
| what is a common esophageal laceration? |
|
Definition
| the mallory-weiss tear, which is a *longitudinal (vertical)* tear at the gastroesophageal junction - often due to retching associated w/alcohol intoxication (an alcoholic w/cirrhosis can die of bleeding out this way). this may cross into the GE junction, and can be lethal - though healing is usually the outcome |
|
|
Term
| what is boerhaave syndrome? |
|
Definition
| a distal esophageal rupture, usually the lower 1/3 in the L posterolateral region, accounting for 15% of esophageal ruptures |
|
|
Term
| what is boerhaave syndrome associated with? what causes it? |
|
Definition
| boerhaave syndrome is associated with mediastinitis (due to esophageal contents leaking out) and a high mortality rate. usually boerhaave syndrome occurs from a sudden increase in intraluminal pressure - often from violent vomiting following heavy food or alcohol intake |
|
|
Term
| why is the esophagus more vulnerable to rupture? |
|
Definition
| the esophagus lacks a serosal layer |
|
|
Term
| do both the mallory weiss and boerhaave tears go all the way through the esophageal wall? |
|
Definition
| only the boerhaave tear typically goes through the entire wall |
|
|
Term
| what can cause esophagitis? |
|
Definition
| alcohol, acid/alkali, medications, hot fluids, heavy smoking, radiation, chemo, and infections |
|
|
Term
| what characterizes esophagitis? |
|
Definition
| infiltration of neutrophils, wall necrosis, ulceration, granulation tissue, and possible fibrosis |
|
|
Term
| what is the *most common cause* of infectious esophagitis? |
|
Definition
| candidiasis, due to its adherent soft white pseudomembranes |
|
|
Term
| can herpes cause esophagitis? |
|
Definition
| yes, herpes can cause *round punched out ulcers and nuclear viral inclusions |
|
|
Term
| can CMV cause esophagitis? |
|
Definition
| yes, CMV can cause shallower, linear ulcerations w/nuclear *and cytoplasmic inclusions in capillary endothelium and stromal cells (cells are larger - 'mega') |
|
|
Term
| what is reflux esophagitis? what are contributing factors? |
|
Definition
| reflux of acid injuring the mucosa of stratified squamous epithelium (which is sensitive to acid) - giving rise to GERD. contributing factors include decreased LES tone, smoking, alcohol, obesity, pregnancy, and increased gastric volume (things that increase the intraluminal stomach pressure). reflux esophagitis is kind of the opposite of achalasia |
|
|
Term
| what are morphologic changes associated with reflux esophagitis? |
|
Definition
| hyperemia, infiltration by eosinophils and neutrophils and basal zone hyperplasia w/elongation of the lamina propria papillae |
|
|
Term
| who is GERD most commonly seen in? |
|
Definition
| adults over 40 - but it can be seen in children/infants |
|
|
Term
| what are the most common symptoms of GERD? |
|
Definition
| dysphagia and heartburn, sometimes severe chest pain (mimics an MI) |
|
|
Term
| what are common complications of GERD? |
|
Definition
| ulceration, barrett esophagus and stricture development |
|
|
Term
| what is eosinophilic esophagitis? are there other common co-presentations? |
|
Definition
| a marked increase in intraepithelial eosinophils in larger numbers than would be seen in reflux esophagitis. other common co-presentations are atopic dermatitis, allergic rhinitis, asthma, or peripheral eosinophilia (overall allergic asthmatic kinds of people). pts w/this may have significant dietary restrictions |
|
|
Term
| what is *barrett esophagus*? who does it most commonly affect? |
|
Definition
| a complication of GERD, where intestinal metaplasia occurs in the esophageal squamous epithelium (becomes adenomatous and columnar w/goblet cells). barrett esophagus most commonly affects white males between 40-60 and is associated with an approx 30x greater risk of developing adenocarcinoma. incidence is rising. |
|
|
Term
| what is the major risk with barrett esophagus? |
|
Definition
| the metaplasic component can give rise to a dysplastic component and then to well differentiated and finally poorly differentiated adenocarcinoma |
|
|
Term
| how is barrett esophagus diagnosed? |
|
Definition
|
|
Term
| how does barrett esophagus present? |
|
Definition
| barrett esophagus presents as patches of red velvety mucosa that alternate with smooth pale squamous mucosa and light brown columnar gastric mucosa |
|
|
Term
| what is considered a long segment of barrett esophagus? short? |
|
Definition
long segment: 3 cm or more
short segment: less than 3 cm |
|
|
Term
| what needs to be established above the gastroesophageal junction to dx barrett esophagus? |
|
Definition
|
|
Term
| what do metaplastic columnar cells contain? |
|
Definition
| goblet cells, non-goblet mucinous columnar cells, enterocytes, paneth cells and multilayered epithelium (Me) |
|
|
Term
| what is a sensitive and specific marker for GERD? |
|
Definition
| Me (multilayered epithelium) |
|
|
Term
| does multilayered epithelium (Me) have squamous or columnar differentiation? |
|
Definition
|
|
Term
| how is dysplasia defined? |
|
Definition
| increased levels of epithelial proliferation, either low/high grade |
|
|
Term
| is dysplasia detectable under endoscopy? |
|
Definition
|
|
Term
| how do dysplastic esophageal cells appear? |
|
Definition
| crowded glands w/abnormal glandular architecture, atypical mitosis and a high N-C ratio |
|
|
Term
| what is the most life threatening esophageal pathology associated with alcoholics? |
|
Definition
|
|
Term
| what are esophageal varices composed of? |
|
Definition
| porto-systemic shunts w/congestion of collateral blood vessels - some of which are present in the esophageal submucosa. |
|
|
Term
| what diseases lead to the porto-systemic shunts seen in esophageal varices? does the primary causative disease depend on location in the world? |
|
Definition
| in western countries these shunts are usually due to cirrhosis, however worldwide, hepatic schistosomiasis is the second most common cause of varices |
|
|
Term
| what about esophageal varices makes them so life-threatening? how? |
|
Definition
| the potential for hemorrhage. vomiting can lead to erosion of the mucosa and with pressure from increasingly dilated veins, bleeding can be massive. |
|
|
Term
| are esophageal varices symptomatic in their early phase? |
|
Definition
|
|
Term
| how do esophageal varices appear? |
|
Definition
| as tortuous dilated veins in the submucosa of the distal esophagus and proximal stomach |
|
|
Term
| can esophageal varices be detected? |
|
Definition
|
|
Term
| why are esophageal varices difficult to detect in a surgical or postmortem specimen? |
|
Definition
| esophageal varices may be difficult to detect due to a lack of blood pressure - in a living state, the blood pressure forces the submucosal vessel closer to the surface, making them more prone to injury and bleeding |
|
|
Term
| what are the most common esophageal tumors? |
|
Definition
| squamous cell carcinoma and adenocarcinoma |
|
|
Term
| who are esophageal squamous cell carcinomas more common in? what are risk factors? |
|
Definition
| males over 45 in rural/underdeveloped countries (high incidence in iran, central china, hong kong, brazil, south africa). risk factors include *alcohol, *tobacco, plummer-vinson syndrome, achalasia, caustic esophageal injury, previous radiation therapy to the mediastium, nutritional deficiency, nitrosamines, *polycyclic hydrocarbons (seen in *fungus in contaminated food), and HPV |
|
|
Term
| are there genetic risk factors for esophageal SCC? |
|
Definition
| yes, loss of tumor suppressor genes such as p53 and p16/INK4a can play a role |
|
|
Term
| where in the esophagus is SCC more common? |
|
Definition
| SCC is seen more commonly in the *upper/middle esophagus |
|
|
Term
| how does SCC usually start in the esophagus? |
|
Definition
| SCC usually starts as squamous dysplasia which appears as white patches. this can eventually grow into exophytic and polypoid masses that an encroach on the lumen of the esophagus, leading to increasing dysphagia (however, often progression is so slow making detection difficult) |
|
|
Term
| what local structures are often the first points of spread if esophageal SCC metastasizes? what potentiates this spread? |
|
Definition
| the respiratory tree, aorta, mediastinum and pericardium. b/c of insidious onset, most cases present w/advanced lesions which have invaded the esophageal wall. the esophagus itself has a rich lymphatic network which promotes the spread both longitudinally and circumferentially w/satellite lesions |
|
|
Term
| how differentiated are most cases of esophageal SCC? |
|
Definition
| moderately to well differentiated |
|
|
Term
| which lymph nodes are often infiltrated by upper esophageal SCC lesions? |
|
Definition
|
|
Term
| which lymph nodes are often infiltrated by middle esophageal SCC lesions? |
|
Definition
| mediastinal, paratracheal, and tracheobronchial nodes |
|
|
Term
| what is a possible marker for esophageal cancer in terms of a pt's diet? |
|
Definition
| a slow change from solid to semisolid to liquid |
|
|
Term
| what are complications of esophageal SCC? |
|
Definition
| malnutrition, hemorrhage/sepsis, or aspiration via a tracheoesophageal fistula |
|
|
Term
| what is key but difficult to preventing death due to esophageal SCC? |
|
Definition
|
|
Term
| what is the overall 5 yr survival rate for pts with esophageal SCC? |
|
Definition
|
|
Term
| where are esophageal adenocarcinomas usually found? how do they interact with the surrounding tissue? do they form glands? |
|
Definition
| the lower 1/3 of the esophagus and esophageal adenocarcinomas may invade the gastric cardia, infiltrate diffusely/invade deeply and usually will form glands/produce mucin |
|
|
Term
| what demographic are esophageal adenocarcinomas usually seen in? |
|
Definition
| white males in developed countries (*incidence is increasing) |
|
|
Term
| what is the relationship between barrett esophagus/GERD and esophageal adenocarcinomas? |
|
Definition
| there is a close association, barrett esophagus can progress to an esophageal adenocarcinoma via a series of genetic changes |
|
|
Term
| what are the genetic risk factors for an esophageal adenocarcinoma? |
|
Definition
| mutations of p53, amplification of c-ERB-B2, cyclin D1, cyclin E, mutation of retinoblastoma tumor suppressor gene, allelic loss of cyclin dependent kinase inhibitor p16/INK4a, and since TNF and NF kappa B dependent geners are overexpressed - inflammation likely plays a role |
|
|
Term
| what is the overall 5 yr survival rate for pts with esophageal adenocarcinoma? |
|
Definition
|
|
Term
| what is the difference in ability to detect esophageal SCC vs an esophageal adenocarcinoma? |
|
Definition
| there are not usually many good markers for impending esophageal SCC but with esophageal adenocarcinomas, if a pt has barrett esophagus - then the dr should know to keep and eye out for adeno CAs in that area |
|
|
Term
| what are other less common kinds of CA that may be seen in the esophagus? |
|
Definition
| carcinoid tumors (chronic, button-like), melanoma (usually metastatic dark patches, but can be white if poorly differentiated), lymphoma, sarcoma, leiomyomas (benign smooth muscle CA), fibromyomas, and lipomas |
|
|
