Chapter 28 - Pharynx and Esophagus (CHERI NOTES) Flashcards
(156 cards)
1
Q
The _____ ; also called a ___ ;is a barium examination of the alimentary tract from the pharynx to the ligament of treitz. (p.734)
A
UPPER GASTROINTESTINAL (UGI)SERIES (aka BARIUM MEAL)
2
Q
A ____ or _____ is a study more dedicated
to the evaluation of swallowing disorders and suspected
lesions of the pharynx and esophagus. (p.734)
A
BARIUM SWALLOW or ESOPHAGOGRAM
3
Q
Distention of the pharynx is provided by
having the patient ____. (p.734)
A
PHONATE
4
Q
Distention of the esophagus is attained by
having the patient __.
(p.734)
A
HAVE THE PATIENT INGEST GAS-PRODUCING
CRYSTALS
5
Q
___ views are collapsed views of the bariium-coated
esophagus. (p.734)
A
MUCOSAL VIEWS
6
Q
TRUE OR FALSE.
CT is poor at evaluating the musosa and
generally cannot differentiate inflammatory and
neoplastic conditions. (p.734)
A
TRUE
MR is preferred over CT for evaluation of the
nasopharynx and is an alternative to CT for
demonstrating the extent of disease.
7
Q
____ is useful for demonstration of tumor
penetration of the esoophageal wall. (p.734)
A
ENDOSCOPIC SONOGRAPHY
8
Q
7 symptoms of abnormal oral or pharyngeal
swallowing. (p.737)
A
- Difficulty initiating swallowing
- Globus sensatuib (lump in throat)
- Cervical Dysphagia
- Nasal Regurgitation
- Hoarseness
- Coughing
- Choking
9
Q
4 symptoms suggesting ESOPHAGEAL
DYSFUNCTION. (p.737)
A
- HEARTBURN
- DYSPHAGIA
- “INDIGESTION”
- CHEST PAIN
10
Q
___ is defined as the awareness of swallowing
difficulty during the passage of solids or liquids
from mouth to stomach. (p.734)
A
DYSPHAGIA
- odynophagia (painful swallowing)
11
Q
TRUE OR FALSE.
In Esophageal Motility disorders; the patient’s
subjective assessment of the location of the
abnormality is not reliable. (p.737)
A
TRUE
12
Q
4 signs of PHARYNGEAL DYSFUNCTION
p.737
A
- PHARYNGEAL STASIS
- LARYNGEAL PENETRATION
- ASPIRATION
- NASAL REGURGITATION
- LARYNGEAL PENETRATION and tracheobronchial ASPIRATION are associated with increased risk of developing pneumonia especially in hospitalized patients.
13
Q
_____; indicative of impaired pharyngeal transport;
is seen as increased residual volume of swallowed
material filling the valleculae and piriform sinuses.
(p.737)
A
PHARYNGEAL STASIS
14
Q
____ is defined as entry of barium into the laryngeal
vestibule without passage below the vocal cords.
(p.737)
A
LARYNGEAL PENETRATION
15
Q
____ implies barium passage below the vocal cords
p.737
A
ASPIRATION
16
Q
____ occurs when the soft palate does not make a
good seal against the posterior pharyngeal wall.
(p.737)
A
NASAL REGURGITATION
-causes include neurologic impairment;
muscular dystrophies; and structural
defects in the palate.
17
Q
______ is attibutable to failure of complete relaxation
of the UES ; commonly resulting in dysphagia and
aspiration. (p.737)
A
CRICOPHARYNGEAL ACHALASIA
18
Q
In CRICOPHARYNGEAL ACHALASIA;
barium swallo demonstrates a shelf-like impression
(CRICOPHARYNGEAL BAR) on the barium column
at the pharyngoesophageal junction at the level
of ____. (p.737)
A
C5-C6 level
- the pharynx is distended and barium may overflow
into the larynx and trachea.
19
Q
Narrowing of the lumen greater than ___ %
is generally accepted as a definite cause of dysphagia
(p.737).
A
greater than 50%
- cricopharyngeal dysfuntion is commonly associated
with neuromuscular disorders of the pharynx.
20
Q
_____ of the esophagus is a disease of unknown
eitology characterized by:
1. absence of peristalsis in the body of the esophagus
2. marked increase in resting pressure of the LES
3. failure of the LES to relax with swallowing
(p.737)
A
ACHALASIA
- the abnormal peristalsis and LES
spasm result in a failure of the
esophagus to empty - pathologically; cases show a deficiency
of ganglion cells in the myenteric plexus
(Auerbach plexus) throughout the esophagus. - clinical presentation is insidious;
usually at 30 to 5 years; with dysphagia;
regurgitation; foul breath and aspiration.
21
Q
5 Radiographic signs of
ACHALASIA (p.738)
A
1. Uniform dilatation of the esophagus; usually with an air-fluid level present 2. Absence of peristalsis; with tertiary waves common in the early stages of the disease 3. Tapered "beak" deformity at the LES because of failure of relaxation 4. Findings of esophagitis including ulceration 5. Increased incidence of Epiphrenic Diverticulum and Esophageal CA
- treatment of Achalasia is BALLOON DILATION
or HELLER MYOTOMY
22
Q
3 Diseases that may mimic
Esophageal Achalasia. (p. 738)
A
- Chagas Disease
- Carcinoma of the GEJ
- Peptic Strictures
23
Q
\_\_\_\_\_ is caused by the destruction of ganglion cells of the esophagus due to a neurotoxin released by the protozoa; Trypanosoma cruzi; endemic to South America; esp. eastern Brazil. (p.738)
A
CHAGAS DISEASE
- The radiographic appearance of the esophagus is identical to achalasia.
- Associated abnormalities include cardiomyopathy;
megaduodenum; megaureter and megacolon
24
Q
\_\_\_\_\_ may mimic achalasia but tends to involve a longer (> 3.5 cm) segment of the distal esophagus; is rigid; and tends to show more irregular tapering of the distal esophagus and mass effect. (p.738)
A
CARCINOMA OF THE GEJ
25
```
When findings of achalasia are present
on barium studies; it is important
to evaluate the ____________ and
____to rule out an underlying
malignant tumor at the GEJ as the
cause of these findings. (p.738)
```
GASTRIC CARDIA and FUNDUS
```
- The cardia and fundus is however not
adequately evaluated radiographically
in all patients because of
delayed emptying of barium from the
esophagus.
- Therefore; it is important to be aware
of the limitations of barium studies in
evaluating the cardia and fundus in
patients with suspected achalasia.
```
26
```
___ strictures are usually
associated with normal
primary esophageal peristalsis.
A hiatal hernia is usually
present. (p.738)
```
PEPTIC STRICTURES
27
```
____ is a syndrome of unknown
cause characterized by multiple
tertiary esophageal contractions;
thickened esophageal wall; and
intermittent dyphagia and chest
pain. (p.738)
```
DIFFUSE ESOPHAGEAL SPASM
```
- primary peristalsis is usually present
but contractions are infrequent.
- Most patients are middle-aged
- The LES is frequently dysfunctional
and the conditions commonly improves
with injection of Clostridium botulinum
toxin at the GEJ wth endoscopic balloon
dilatation of the LES.
```
28
```
___ is characterized on barium
studies by intermittently absent
or weakened primary esophageal
peristalsis with simultaneous;
nonperistaltic contractions that
compartmentalize the
esophagus; producing a
classic corkscrew appearance. (p.738)
```
DIFFUSE ESOPHAGEAL SPASM
- CT reveals circumferential thickening
(5 to 15 mm) of the wall of the
distal 5 cm of the esophagus in
20% of patients.
29
______ disorders are a common
cause of abnormalities of the
oral; pharyngeal; or esophageal
phases of swallowing. (p.738)
NEUROMUSCULAR disorders
30
The most common cause
of neurologic dysfunction is
_____ and ____. (p. 738)
CEREBROVASCULAR DISEASE and
STROKE
- additional causes include Parkinsonism;
Alzheimer disease; multiple sclerosis;
neoplasms of the CNS and posttraumatic
CNS injury.
31
```
Diseases of the striated
esophageal muscle; such as
muscular dystrophy; myasthenia
gravis; and dermatomyositis;
predominantly affect the ___
and ______ of the esophagus.
(p.738)
```
PHARYNX and PROXIMAL THIRD
(striated muscle portion) of the
esophagus.
32
```
____ is a systemic disease
of unknown cause characterized
by progressive atrophy of smooth
muscle and progressive fibrosis
of affected tissues. (p.739)
```
SCLERODERMA
```
- women are most commonly affected;
usually aged 20 to 40 years at the onset
of disease.
- the esophagus is affected in 75% to
80% of patients
```
33
4 Radiographic findings of
| Scleroderma (p.739)
```
1. Weak to absent peristalsis in the
distal two-thirds (smooth muscle
portion) of the esophagus.
2. Delayed esophageal emptying
3. A stiff dilated esophagus that does
not collapse with emptying
4. Wide gaping LES with free
gastroesophageal reflux.
```
- despite free reflux; tight strictures
of the distal esophagus are uncommon.
34
```
TRUE OR FALSE.
Postoperative states; including
surgery for malignancy of the
tongue;larynx and the pharnyx;
commonly impair swallowing
function as well as alter the morphology.
```
TRUE
- surgical resection is aimed at providing
at least a 1-cm margin free of tumor and
often results in removing large blocks of
tissue and functionally altering the
structures that remain.
35
```
____ frequently results in
abnormal esophageal motility
and esophageal motility and
visualization of tertiary
esophageal contractions. (p.739)
```
ESOPHAGITIS
36
```
____ occurs as a result of
incompetence of the LES.
The resting pressure of the LES
is abnormally decreased and fails
to increase with raised
intraabdominal pressure. (p.739)
```
GASTROESOPHAGEAL REFLUX
DISEASE (GERD)
- as a result; increases in intraabdominal
pressure exceed LES pressure;
and gastric contents are allowed to
reflux into the esophagus.
- GERD is classified as a spectrum of
conditions: nonerosive reflux disease;
erosive esophagitis; and Barett esophagus.
37
3 symptoms of GERD.
| p.739
```
1. SUBSTERNAL BURNING PAIN
("heartburn")
2. POSTURAL REGURGITATION
(in supine position)
3. DEVELOPMENT OF
REFLUX ESOPHAGITITS;
DYSPHAGIA AND ODYNOPHAGIA.
```
38
3 complications of GERD (p.739)
1. REFLUX ESOPHAGITIS
2. STRICTURE
3. DEVELOPMENT OF BARRETT
ESOPHAGUS
39
```
TRUE OR FALSE.
Thhe radiographic diagnosis of
GERD may be difficult because
20% of normal individuals
show spontaneous reflux on UGI
examination; and patients with
pathologic GERD may not
demonstrate reflux without
provocative tests. (p.739)
```
TRUE
40
5 Findings associated with
GERD on barium esophagrams.
(p.739)
```
1. HIATAL HERNIA; associated with
presence of reflux esophagitis
2. SHORTENING OF THE ESOPHAGUS;
a finding of importance to treating
GERD surgically
3. IMPAIRED ESOPHAGEAL MOTILITY
4. GASTROESOPHAGEAL REFLUX;
often demonstrated by provocative
maneuvers such as Valsalva; leg raising;
and cough
5. Prolonged clearance time of refluxed
gastric contents.
```
- low volume reflux is not considered a
significant finding.
41
Most sensitive means of
diagnosing abnormal GERD
(p.739)
MONITORING OF ESOPHAGEAL pH for
24 hours in an ambulatory patient.
- GERD is managed medically with agents
that inhibit gastric acid production or
surgically with fundoplication
42
___ hernia is often considered
| synonymous with GERD. (p.739)
HIATUS hernia
```
- most patients with hiatus hernia do not
have gastroesophageal reflux or
evidence of esophagitis.
- Hiatus hernia is therefore NOT LIKELY
as a PRIMARY CAUSE OF REFLUX.
- However; up to 90% of patients with
GERD have a hiatus hernia.
- The presence of hiatus hernia delays
the clearance of reflux and promotes
development of RE.
```
43
Simply defined as protrusion
of any portion of the stomach
into the thorax. (p.740)
HIATUS hernia
- highly prevalent affecting
40% to 60% of adults.
44
3 types of hiatal hernia (p.740)
1. SLIDING HIATUS HERNIA
2. PARAESOPHAGEAL HIATUS HERNIA
3. MIXED OR COMPOUND HIATAL
HERNIA
45
Most common type of hiatal hernia (95%).
| p.740
SLIDING HIATUS HERNIA
46
```
Type of hiatal hernia where the
the GEJ is displaced more than
1 cm above the hiatus. The
esophageal hiatus is often
abnormally widened to 3 to 4 cm.
(p.740)
```
SLIDING HIATUS HERNIA
- the gastric fundus may be displaced above
the diaphragm and present as a
retrocardiac mass on chest radiographs.
- the presence of an air-fluid level in the
mass suggests the diagnosis.
- small; sliding hiatus hernias commonly
reduce in the upright position.
- the function of the LES and the presence
of pathologic gastroesophageal reflux
are the crucial factors in producing
symptoms and causing complications.
47
The upper limit of normal hiatal
width is __ mm; most easily
measured by CT. (p.740)
15 mm
48
```
type of hiatal hernia where the
the GEJ remains in normal
location; while a portion of the
stomach herniates above the
diaphragm. (p.740)
```
PARAESOPHAGEAL HIATUS HERNIA
49
```
_____is the most common type
of paraesophageal hernia.
The GEJ is displaced into the
thorax with a large portion of the
stomach; which is usually
abnormally rotated.
```
MIXED OR COMPOUND HIATAL HERNIA
50
```
TRUE OR FALSE.
Paraesophageal hernis; esp.
when large with most of the
stomach in the thorax; are at risk
for volvulus; obstruction and
ischemia.
(p.740)
```
TRUE
51
___ are protrusions of pharyngeal
mucosa through areas of
weakness of the lateral
pharyngeal wall. (p.741)
LATERAL PHARYNGEAL DIVERTICULA
52
Most common regions of
Lateral Pharyngeal Diverticula.
(p.741)
TONSILLAR FOSSA and the
| THYROHYOID MEMBRANE
53
These condition reflects
increased intrapharyngeal pressure and are seen most
commonly in wind instrument
players. (p.741)
LATERAL PHARYNGEAL DIVERTICULA
54
```
____ arises in the hypopharynx
just proximal to the UES.
It is located in the posterior
midline at the cleavage plane,
known as Killian dehiscence;
between the circular and the
oblique fibers of the crico-
pharyngeus muscle. (p.741)
```
ZENKER DIVERTICULUM
```
- the diverticulum has a small neck that
is higher than the sac; resulting in food
and liquid being trapped within the
sac.
- the distended sac may compress the
cervical esophagus
- symptoms include dysphagia; halitosis
and regurgitation of food.
```
55
```
_____ diverticula which
originate on the anterolateral
wall of the proximal cervical
esophagus in a gap just below
the cricopharyngeus and lateral
to the longitudinal tendon
of the esophagus (i.e. the Killian-
Jamieson space). (p.741)
```
KILIAN-JAMIESON DIVERTICULA
```
- less common and considerably smaller
than Zenker diverticulum and appear on
pharyngoesophagography as persistent
left-sided or; less frequently; bilateral
outpouchings from the proximal cervical
esophagus below the cricopharyngeus.
```
- less likely to cause symptoms
and are less likely to be associated with
overflow aspiration or gastroesophageal
reflux than is Zenker Diverticulum
56
Midesophageal diverticula
may be ___ or ___ diverticula.
(p.742)
PULSION or TRACTION DIVERTICULA
- midesophageal diverticula have large
mouths; empty well and are usually
asymptomatic
57
____ diverticula occur as a result
of disordered esophageal
peristalsis. (p.742)
PULSION DIVERTICULA
58
```
____ diverticula occur because of
fibrous inflammatory reactions
of adjacent lymph nodes and
contain all esophageal layers.
(p.742)
```
TRACTION DIVERTICULA
59
_____ diverticula occur just above
the LES; usually on the right side.
They are rare and usually found
with esophageal motility disorders.
- because of a small neck;
higher than the sac; they may trap
food and liquids and cause symptoms
(p.742)
EPIPHRENIC DIVERTICULA
60
____ are small outpouchings
of the esophagus that
usually occur as a sequela of
severe esophagitis. (p.742)
SACCULATIONS
```
- thought to result from the healing
and scarring of ulcerations
- tend to change in size and shape
during fluoroscopic observation
- smooth contours help to differentiate
sacculations from ulcerations
```
61
```
_____ are the dilated excretory
ducts of deep mucous glands of
the esophagus.
- they appear as flask-shaped
barium collections that extend
from the lumen or as lines
and flecks of barium outside the
esophageal wall. (p.742)
```
INTRAMURAL PSEUDODIVERTICULA
```
- tend to occur in clusters and in
association with strictures.
- linear tracks of barium ("intramural
tracking") commonly bridge adjacent
pseudodiverticula.
```
62
7 radiographic signs of
| ESOPHAGITIS (p.743)
```
1. Thickened esophageal folds
(>3 mm)
2. Limited esophageal distensibility
(asymmetric flattening)
3. Abnormal motility
4. Mucosal plaques and nodules
5. Erosions and ulcerations
6. Localized stricture
7. Intramural pseudodiverticulosis
(barium filling of dilated 1 to 3 mm
submucosal glands)
```
63
____ are a hallmark finding of
| esophagitis. (p. 743)
ULCERS
- CT usually reveals non-specific findings
of :
1. thickening of the wall (>5 mm)
2. target sign with hypoattenuating thickened wall
and high attenuating enhancing mucosa
64
```
SMALL ULCERS (< 1 cm) are found
with _____(give 5). (p.743)
```
1. reflux esophagitis
2. herpes
3. acute radiation
4. drug-induced esophagitis; and
5. benign mucous membrane pemphigoid
65
```
LARGER ULCERS (>1 cm) are
characteristic of ___. (give 4).
(p. 743)
```
1. CYTOMEGALOVIRUS
2. HIV
3. BARETT ESOPHAGUS
4. CARCINOMA
66
____ is the result of esophageal
mucosal injury owing to exposure
to gastroduodenal secretions.
(p.743)
REFLUX ESOPHAGITIS
- severity depends on the concentration
of the caustic agent and duration of the
contact with the esophageal mucosa.
67
The findings of reflux esophagitis
is always most prominent in the
___ and _____. (p.743)
DISTAL ESOPHAGUS and GEJ
68
```
Early changes of REFLUX
ESOPHAGITIS include ____;
which is manifest as granular or
nodular pattern of the distal
esophagus. (p.743)
```
MUCOSAL EDEMA
69
```
TRUE OR FALSE.
In contrast to the distinct borders
of Candida plaques and nodules;
REFLUX ESOPHAGITIS nodules
have poorly defined borders.
```
TRUE
70
Inflammatory exudates and
pseudomembrane formation
may mimic fulminant ____
esophagitis. (p.743)
- patient has symptoms of reflux
rather than severe odynophagia.
CANDIDA esophagitis
71
____ is the most common cause
| of esophageal ulcerations. (p.743)
REFLUX ESOPHAGITIS
- ulcers appear as discrete linear;
punctate;or irregular collections of
barium; usually surrounded by a
radiolucent mound of edema. (p.743)
72
```
TRUE OR FALSE.
Prominence of ulcerations in the
DISTAL rather than proximal
or midesophagus is the key to
differentiating reflux esophagitis
ulcers from those of herpes
or drug-induced esophagitis.
(p.743)
```
TRUE
73
4 Complications of reflux
| esophagitis. (p.743)
1. Ulceration
2. Bleeding
3. Stricture
4. Barett esophagus
74
```
____ is an acquired condition
of progressive columnar
metaplasia of the distal
esophagus caused by chronic
gastroesophageal reflux.
```
BARRETT ESOPHAGUS
```
- Columnar rather than squamous
epithelium lines the distal esophagus.
- PREMALIGNANT; with 30 ro 40-times
increased risk of developing
adenocarcinoma; resulting in a 15%
prevalence of adenocarcinoma in patients
with Barrett esophagus.
- AdenoCA may develop at any age
```
75
```
The prevalence of Barrett
Esophagus in patients with RE
is about __%; but increases
to __ % in patients with
scleroderma. (p.743)
```
BARRETT ESOPHAGUS prevalence:
10 % (RE)
37% (Scleroderma)
76
The characteristic radiographic
appeaerance of BARRETT
ESOPHAGUS is a ___.
(p.743)
HIGH (MIDESOPHAGEAL) STRICTURE
OR DEEP ULCER IN A PATIENT WITH
GERD
```
- a reticular mucosal pattern of the
esophageal mucosa; resembling
areae gastricae of the stomach;
is also suggestive.
- the diagnosis is confirmed by
endoscopy and biopsy
```
77
___ esophagitis is found most
commonly in patients with
compromised immune system.
(p.743)
INFECTIOUS esophagitis
- increasingly common because of the
use of steroids and cytotoxic drugs
and because of the increasing
prevalence of AIDS
78
____ is by far th most common
cause of infectious esophagitis
and is highly prevalent in patients
with AIDS. (p.744)
CANDIDA ALBICANS
- additional risk factors include
malignancy; radiation; chemotherapy
and steroid treatments.
79
Candida of the oropharynx
| p.744
THRUSH
- odynophagia is a prominent symptom
- discrete plaque-like lesions demonstrated
by double-contrast esophagrams are most
characteristic
- plaques appear as longitudinally oriented
linear or irregular discrete filling defects
etched in white with intervening normal-
appearing mucosa.
- the lesions may be tiny and nodular or giant
and coalescent with pseudomembranes
- ulcers tend to be small (<1 cm) and may
be punctate; round; oval or linear.
- fulminant disease produces the "foamy
esophagus" with a pattern of tiny bubbles
at the top of the barium column
80
____ esophagitis begins as
discrete vesicles that rupture to
to form discrete mucosal ulcers.
(p.744)
HERPES SIMPLEX ESOPHAGITIS
- ulcers may be linear; punctate or
ring-like and have a characteristic
radiolucent halo.
81
Discrete ulcers on a background
of normal mucosa involvong
the midesophagus are most
characteristic of ____. (p. 744)
HERPES
- nodules and plaques are
usually absent
82
___ is cause of fulminant
esophagitis in patients with
AIDS. (p.744)
CYTOMEGALOVIRUS
```
- CMV esophagitis is is characteristically
manifest as one or more large; flat
mucosal ulcers
- endoscopic biopsy or culture confirms
the diagnosis
```
83
____ esophagitis causes giant
ulcers and severe odynophagia.
(p.744)
HIV esophagitis
- the ulcers are large; flat and usually
in the midesophagus
84
The ___ is the least common
portion of the GI tract to be
involved by tuberculosis.
(p.744)
ESOPHAGUS
- manifestations of esophageal TB:
ulceration; stricture; sinus tract and
abscess formation
85
```
____ esophagitis is the result
of intake of oral medications
that produce a focal
inflammation in areas of contact
with mucosa. (p.744)
```
DRUG-INDUCED ESOPHAGITIS
- drugs that cause this condition include:
tetracycline; doxycyclne; quinidine;
aspirin; indomethacin; ascorbic acid;
potassium chloride and theophylline.
- radiographic appearance may be
identical to herpes esophagitis;
with discrete ulcers separated by
normal mucosa in the midesophagus.
- history is suggested by a history of
recent drug ingestion
86
Healing of drugi-induced
esophagitis occurs within
__ to __ days of discontinuing
the offending medication. (p.744)
7 to 10 days
87
____ ingestion usually occurs
as an accident in children or a
suicide attempt in adults.
(p.744)
CORROSIVE ingestion
- alkaline agents (liquid lye)
produce deep (full thickness)
coagulation necrosis.
- acid agents tend to produce
more superficial injury
- ulceration; esophageal
perforation and mediastinitis
may complicate the acute
injury.
- late complications are fibrosis long
or multiple strictures
88
___ may rarely manifest as
discrete apthous ulcers in the
esophagus. (p.744)
CROHN DISEASE
- involvement of the small
or large bowel by CROHN DISEASE
is virtually always present.
89
```
TRUE OR FALSE.
Crohn disease of the esophagus
should not be considered unless
Crohn disease of the bowel is
already evident. (p.744)
```
TRUE
90
____ esophagitis occurs in
patients with a history of
thoracic radiation therapy
for malignant disease. (p.745)
RADIATION ESOPHAGITIS
```
- acute radiation may cause shallow
or deep ulcers in the area of
involvement.
- with the development of fibrosis;
the peristaltic wave is interrrupted
and a long smooth stricture may develop
within the radiotherapy field.
- UGI shows a variable length segment of
esophageal narrowing multiple discrete
ulcers or a granular mucosal pattern
within the radiation field.
```
91
Higher radiation dose in the
range of ___ to ____ R
is associated with development
of strictures. (p.745)
4500 to 6000 R
```
- simultaneous radiotherapy
and doxorubicin hydrochloride
(Adriamycin) chemotherapy
greatly accentuates esophageal
inflammation.
```
92
__ defined as any persistent
intrinsic narrowing of the
esophagus. (p.745)
STRICTURES
93
The most common causes of
esophageal strictures are ____.
(p.745)
FIBROSIS induced by INFLAMMATION
AND NEOPLASM
- because radiographic findings are not
reliable in differentiating benign from
malignant strictures; all should be
evaluated endoscopically.
94
DISTAL ESOPHAGEAL
STRICTURES are caused by
__ (give 3). (p.745)
1. GERD
2. SCLERODERMA
3. PROLONGED NASOGASTRIC
INTUBATION
95
UPPER AND MID-ESOPHAGEAL
STRICTURES most commonly
results from ____ (give 4).
(p.745)
1. BARRETT ESOPHAGUS
2. MEDIASTINAL RADIATION
3. CAUSTIC INGESTION
4. SKIN DISEASES associated with
mucosal ulceration such as pemphigoid;
erythema multiforme and epidermolysis
bullosa dystrophica
96
BENIGN vs MALIGNANT
ESOPHGEAL STRICTURES
(p.745)
BENIGN STRICTURES
- typically show smoothly tapering
concentric narrowing
```
MALIGNANT STRICTURES
- are characteristically abrupt;
assymetric; eccentric narrowings
with irregular; nodular mucosa
- tapered margins may occur because
of the ease of submucosal spread
of tumor
```
97
TRUE OR FALSE.
Acute and chronic findings of
esophagitis commonly overlap.
(p.745)
TRUE
- Chronic inflammation induces
progressive firbrosis that eventually
narrows the esophageal lumen
98
___ (____) is the most common
cause of esophageal stricture.
(p.745)
REFLUX ESOPHAGITIS (GERD)
```
- reflux strictures are usually confined
to the DISTAL ESOPHAGUS
- may be tapered; smooth and
circumferential (the classic appearance)
or assymetric and irregular
- small smooth sacculations and fixed
transverse folds are characteristic and
caused by scarring.
```
99
Long segment esophageal
stricture may be induced by
long-term_____ . (p.745)
long-term NASOGASTRIC INTUBATION
```
- nasogastric tubes prevents closure
of the LES; resulting in continuous
bathing of the distal esophagus with
acid reflux from the stomach
- Zollinger-Ellison syndrome can lead
to severe reflux esophagitis because
of the high acid content of refluxed
gastric contents.
```
100
```
A _____ is pathologic ring-like
esophageal stricture at the
level of the B ring;
caused by reflux esophagitis.
(p.745)
```
SCHATZKI RING
101
```
TRUE OR FALSE.
BARRETT ESOPHAGUS strictures
tend to be high in the
midesophagus and may be
smooth and tapered or ring-like
narrowings. (p.745)
```
TRUE
```
- the high position is because of a
tendency for strictures to occur at the
squamocolumnar junction; which has
been displaced to a position well
above the GEJ
```
102
TRUE OR FALSE.
CORROSIVE STRICTURE are long
and symmetrical. They commonly develop years
after the initial injury. (p.745)
TRUE
103
___ esophagitis may occur
in patients who have undergone
partial or total gastrectomy. (p.745)
ALKALINE REFLUX ESOPHAGITIS
```
- reflux of bile or pancreatic secretions
into the esophagus results in the
development of severe alkalkine reflux
esophagitis and distal esophageal
strictures whose length and severity
increase rapidly over a short period of
time.
```
104
```
Performing a __ reconstruction
at the time of surgery helps
prevent reflux of bile and
pancreatic secretion into the
esophagus. (p.745)
```
ROUX-EN-Y reconstruction
105
```
TRUE OR FALSE.
An alkaline reflux stricture
should be suspected when
barium examination performed
in patients who have undergone
partial or total gastrectomy or
gastrojejunostomy reveals a
long stricture in the distal
esophagus. (p.745)
```
TRUE
106
```
___ esophagitis is an
increasingly common diagnosis
made most often in young men
with a history of allergies.
(p.745-746)
```
EOSINOPHILIC ESOPHAGITIS
```
- some have a peripheral
eosinophilia
- patients present with a long-
standing history of dysphagia
and food impaction
```
107
```
DIAGNOSIS?
Barium studies demonstrate
smooth long-segment
narrowing of the esophagus
or a series of ring-like strictures;
called the "RINGED ESOPHAGUS"
(P.746)
```
EOSINOPHILIC ESOPHAGITIS
```
- biopsy reveal eosinophilic infiltration
of the wall of the esophagus
- the cause may be related to ingested
food allergens
- treatment is STEROIDS
```
108
```
Radiation strictures are
confined to the radiotherapy
field. They are smooth and
tapered and usually in the
___ or ___ -esophagus. (p.746)
```
UPPER or MID-ESOPHAGUS
109
```
An irregular; ulcerated;
circumferential narrowing with
nodular shoulders is most
typical of ___ esophageal
stricture. (p.746)
```
MALIGNANT stricture (esophageal)
```
- infiltrative tumors may cause smooth;
rigid narrowing of the esophagus without
a clear zone of transition
- the mucosa may not be altered
until tumor spread is substantial
```
110
```
TRUE OR FALSE.
Because longitudinal spread
of tumor along the length
of the esophagus is typical;
long-segment strictures caused
by carcinoma are common.
(p.746)
```
TRUE
111
___ are thin (1 to 2 mm);
delicate membranes that
sweep partially across the
esophageal lumen. (p.746)
ESOPHAGEAL WEBS
```
- they occur in both the pharynx
esophagus and are commonly
multiple.
- most are incidental findings;
however; they occasionally cause
sufficient obstruction to result in
dysphasia.
```
112
Pharyngeal webs arise most
commonly from the ____ wall
of the hypopharynx. (p.746)
ANTERIOR wall of the hypopharynx
113
Esophageal webs may occur
anywhere; but they are most
common in the _____. (p.746)
CERVICAL ESOPHAGUS just distal
| to the cricopharyngeus impression
114
```
TRUE OR FALSE.
Malignancy or inflammation
in the mediastinum may
encase the esophagus and
narrow its lumen. (p.746)
```
TRUE
```
- causes of esophageal extrinsic
compression include Lung CA;
Lymphoma; metastatsis to
mediastinal nodes; TB and
histoplasmosis.
```
115
TRUE OR FALSE.
Thick folds occur most commonly
with reflux esophagitis. (p.746)
TRUE
- additional findings associated with
esophagitis ; such as ulcerations and nodules; are commonly present.
116
```
___ appear as serpiginous filling
defects that change in size with
changes in intrathoracic pressure and that
collapse with esophageal
peristalsis distension. (p.746)
```
ESOPHAGEAL VARICES
117
Esophageal varices are best
best demonstrated on UGI
with ___ views. (p.746)
MUCOSAL REFIEF VIEWS.
118
```
TRUE OR FALSE.
CT with bolus contrast
enhancement demonstrates
varices as enhancing vascular
structures within and adjacent
to esophageal wall near the GEJ.
(p.746)
```
TRUE
- MR is also effective in demonstrating
varices as vascular spaces; with signal
void because of flowing blood.
119
___ varices refer to the porto-
systemic veins that enlarge
because of portal HTN. (p.746)
UPHILL VARICES
- coronary vein collaterals connect
with gastroesophageal varices that
drain into the inferior vena cava through
the azygos system. (p.746)
120
Uphill varices are usually only
present in the ___ esophagus.
(p.746)
DISTAL esophagus
121
```
___ varices are formed as a
result of obstruction of the
superior vena cava with
drainage from the azygous
system through esophageal
varices to the portal vein.
(p.748)
```
DOWNHILL VARICES
122
Downhill varices usually
predominate in the ____
esophagus. (p.748)
PROXIMAL esophagus
123
TRUE OR FALSE.
Lymphoma may infiltrate the
submucosa and thicken the
folds. (p.748)
TRUE
| - lymphoma rarely involves the
esophagus directly and is virtually
never primary in the esophagus.
p.748
124
___carcinoma causes thick;
tortuous; longitudinal folds
that resemble varices but
are rigid and persistent. (p.748)
VARICOID carcinoma
125
TRUE OR FALSE.
Pharyngeal carcinoma are well
demonstrated by double
contrast pharyngography. (p.748)
TRUE
126
```
DIAGNOSIS? (pharynx)
Radiographic signs include:
1. intraluminal mass seen as
a filling defect; abnormal
luminal contour; or focal
increased density.
2. mucosal irregularity
owing to ulceration or
mucosal elevations
3. asymmetrical distensibility
due to infiltrating tumor or
extrinsic nodal mass.
```
PHARYNGEAL CARCINOMA
127
```
Most pharyngeal tumors are
_____ that may arise on the
base of the tongue; palatine
tonsil; posterior pharyngeal
wall or the piriform sinus. (p.748)
```
SQUAMOUS CELL CARCINOMAS
- LARYNGEAL tumors may impress
on the pharynx or extend into it.
- Staging is best performed by
CT or MR.
128
____ are benign lesions that
typically involve the valleculae
and should not be mistaken for
phargyngeal neoplasms.(p.748)
- arise from dilatation of mucus
glands caused by chronic inflammation.
PHARYNGEAL RETENTION CYSTS
- appear as small; smooth; well-defined;
round or oval-filling defects best
appreciated on frontal views.
- they are NEVER MALIGNANT.
129
____ usually manifest as a large;
bulky tumor of the lingual or
palatine tonsils. (p.748)
LYMPHOMA OF THE PHARYNX
- Lymphoma constitutes 15% or
oropharyngeal tumors
130
```
TRUE OR FALSE.
Esophageal CA is squamous
cell CA in 85% to 90% of cases;
and the remainder are
adenoCA arising in Barrett
esophagus.; undifferentiated;
or miscellaneous cell types.
(p.748)
```
TRUE
```
- because of rapid spread to adjacent
structures; esophageal CA is deadly;
with a 5-year survival of only 5% for
advanced disease.
- early stage disease treated surgically
has a 5-year survival of 50% to 80%.
```
131
4 basic radiographic patterns of
| ESOPHAGEAL CA. (p.748)
```
1. ANNULAR CONSTRICTING LESION;
appearing as an irregular ulcerated
stricture (MOST COMMON)
2. POLYPOID PATTERN causes
an intraluminal filling defect
3. INFILTRATIVE VARIETY
grows predominantly in the submucosa
and may simulate a benign stricture
4. ULCERATED MASS (LEAST COMMON)
```
132
```
Give 4 risk factors for
ESOPHAGEAL CA (p.748)
```
1. CIGARETTE SMOKING
2. ALCOHOL ABUSE
3. CORROSIVE INGESTION
4. CARCINOMA OF THE HEAD
AND NECK
-typical patient is a 65 year old man
133
TRUE OR FALSE.
Esophageal CA tumor spreads
quickly by direct invasion into
the adjacent tissues. (p.748)
TRUE
```
- because of the lack of a serosal
covering on the esophagus.
- Lymphatic spread may go to nodes
in the neck; mediastinum; or below
the diaphgragm; depending on the location
of the primary tumor in the esophagus.
```
134
Hematogeneous spread of
Esophageal CA is to __; __ and
___. (p.748)
1. LUNG
2. LIVER
3. ADRENAL GLAND
135
```
TRUE OR FALSE.
CT and endosopic US are used
primarily to define the extent of
disease and determine surgical
resectability of esophageal CA.
(p.748)
```
TRUE
```
- findings include irregular thickening
of the esophageal wall (>5mm);
eccentric narrowing of the lumen;
dilation of the esophagus above the
area of narrowing; invasion of
periesophageal tissues; and
metastases to mediastinal
lymph nodes and the liver.
```
```
- obliteration of the fat space
between the aorta; esophagus;
and vertebral body is highly
predictive of invasion of the
aorta.
```
136
```
TRUE OR FALSE.
GASTRIC ADENOCA spreads
from the fundus and GEJ
into the distal esophagus.
(p.748)
```
TRUE
- AdenoCA of the distal esophagus
may be either primary gastric or
primary esophageal ; arising in
Barrett esophagus.
137
```
___; while; is still the most
common benign neoplasm of
the esophagus; accounting for
50% of all benign esophageal
neoplasms. (p.748)
```
LEIOMYOMA
```
- the tumor is firm; well-encapsulated
and arises in the wall.
- Ulceration is rare.
- Most cause no symptoms
and are discovered incidentally.
- Men aged 25 to 35 years are
affected most commonly
(male-to-female ratio=2:1)
```
138
TRUE OR FALSE.
GI stromal tumor (GISTs)
(748-749)
are RARE in the esophagus.
TRUE
139
```
TRUE OR FALSE.
LEIOMYOSARCOMA of the
Esophagus is exceedingly rare;
accounting for less than 1%
of the esophageal malignancy.
(p.749)
```
TRUE
140
TRUE OR FALSE.
Fibroepithelial or fibrovascular
polyps are a rare cause of
esophageal filling defect. (p.749)
TRUE
- They appear as a large ovoid or
elongated intraluminal masses in the
upper esophagus.
141
```
___ cysts are congenital
abnormalities that are usually
incidental findings presenting
without symptoms.
- most (60%) occur in the LOWER
ESOPHAGUS. (p.749)
```
ESOPHAGEAL DUPLICATION CYSTS
- CT shows a well-defined cystic mass
- Barium examination will show
extrinsic or intramural compression
due to close contact with the esophagus.
- differential diagnosis include
bronchogenic and neurenteric
cyst
142
3 extrinsic lesions that may
invade the esophagus or
simulate an esophageal mass
or filling defect. (p.749)
1. Mediastinal adenopathy
2. Lung CA
3. Vascular structures
143
___ artery which arises from the
aorta distal to the left
subclavian artery. (p.749)
- to reach its destination; it must
cross the mediastinum
behind the esophagus.
ABERRANT RIGHT SUBCLAVIAN artery
- it causes a characteristic upward-
slanting linear filling defect on the
posterior aspect of the esophagus.
144
More than half of ESOPHAGEAL
PERFORATION cases are related to
______. (p.749)
ESOPHAGEAL INSTRUMENTATION
```
- bleeding can be profuse and infection
is a great risk in esophageal perforations
- conventional radiographs demonstrate
subcutaneous; cervical or mediastinal
emphysema within 1 hour of perforation
- chest radiographs may show widened
mediastinum and pleural effusion or
hydropneumothorax.
```
145
Key imaging finding in the
diagnosis of ESOPHAGEAL
PERFORATION. (p.750)
FOCAL OR DIFFUSE EXTRAVASATION
OF CONTRAST OUTSIDE THE ESOPHAGUS
- CT demonstrates fluid collections;
extraluminal contrast and air in the
mediastinum. (p.750)
146
```
TRUE OR FALSE.
Blunt trauma may tear the
esophagus by an explosive
increase in intraesophageal
pressure. (p.750)
```
TRUE
147
____ syndrome refers to the
rupture of the esophagus wall
as a result of forceful vomiting.
(p.750)
BOERHAAVE syndrome
```
- the tear is virtually always in the
LEFT POSTERIOR WALL near the left
crus of the diaphragm
- esophageal contents usually escape
into the left pleural space or into the
potential space between the parietal
pleura and the left crus.
- tears may result in intramural
dissections and hematomas in the
wall of the esophagus.
```
148
_____ tear involves only the
MUCOSA and not the full
thickness of the esophagus.
(p.750)
MALLORY-WEISS TEAR
```
- endoscopy usually identifies
the lesion
- the lesion is commonly missed
on UGI.
- when seen; the tear appears
as a longitudinally oriented barium
collections; 1 to 4 cm in length;
in the distal esophagus.
- it may be a cause of
copious hematemesis.
```
149
Mallory-Weiss tears are usually
| caused by ____. (p.750)
VIOLENT RETCHING
150
```
TRUE OR FALSE.
Foreign body impaction
in adults is usually attributable
to bones or boluses of meat.
(p.750)
```
TRUE
- childeren may ingest any foreign
object including toys, coins and
jewelry.
151
IN FOREGN BODY IMPACTION:
Bones usually lodge in the
____; most often near the
_____ muscle. (p.750)
PHARYNX; CRICOPHARYNGEUS
| muscle.
152
IN FOREGN BODY IMPACTION:
Meat impacts in the ____ or
___ esophagus (p.750)
DISTAL or MIDESOPHAGUS
153
```
IN FOREGN BODY IMPACTION:
Perforation occurs in only
1% of cases, but the risk
increases if impaction
persists of more than
__ hours. (p.750)
```
MORE THAN 24 HOURS
154
```
TRUE OR FALSE.
Bones in the pharynx are
difficult to differentiate from
calcification of the thyroid and
cricoid cartilages. (p750)
```
TRUE
155
Contrast studies show
nonopaque foreign bodies as
___. (p750)
FILLING DEFECTS
```
- impacted foreign bodies may be
removed by use of a Foley balloon
catheter or wire basket or by gaseous
distention of the esophagus with gas-
producing crystals.
- CT demonstates the nature of the
foreign body and frequently any
associated pathology that
predisposed to impaction.
(p.751)
```
156
UGI and CT findings in LEIOMYOMA (p.749)
```
UGI: most appear as smooth; well-defined
wall lesions; although rarely they may
be pedunculated or polypoid.
- coarse calcifications are occasionally
present and strongly indicative of
leiomyoma
```
CT: demonstrates a smooth; well-defined
mass of uniform soft tissue density.
The esophageal wall is eccentrically
thickened.
