Esophageal Pathology

Question 1

Achalasia results from the failure of what process to occur?


Answer 1

Relaxation of the lower esophageal sphincter


Question 2

In a man with high lower esophageal sphincter resting pressure/uncoordinated peristalsis, you see innervation loss from which plexus?


Answer 2

The myenteric (Auerbach) plexus, which innervates the LES


Question 3

What is the most common presenting symptom of achalasia?


Answer 3

Progressive dysphagia to both solids and liquids (vs. obstruction, which presents as dysphagia to solids only)


Question 4

After you diagnose a man with achalasia, you should advise him that he has increased risk for what malignancy?


Answer 4

Esophageal squamous cell carcinoma


Question 5

A man is diagnosed with new achalasia. He recently traveled to South America. What parasitic disease did he likely contract while there?


Answer 5

Chagas disease (associated with secondary achalasia)


Question 6

What is the etymology of the word achalasia?


Answer 6

A = absence of, and chalasia = relaxation

Question 7

What is the underlying pathophysiology of dysphagia associated with CREST?


Answer 7

Esophageal dysmotility (poor peristalsis) and low esophageal pressure proximal to the lower esophageal sphincter


Question 8

A man has dysphagia. Work-up shows esophageal smooth muscle atrophy, poor peristalsis, low LES pressure, reflux, and a stricture. Diagnosis?


Answer 8

Sclerodermal esophageal dysmotility (part of CREST syndrome)


Question 9

A man complains of dry cough and chest pain not associated with activity and worse when supine. If not treated, he is at risk for what?


Answer 9

Barrett esophagus (a complication of GERD)


Question 10

A man has increasing asthma frequency, as well as nocturnal cough and mild chest discomfort before falling asleep. What might you prescribe?


Answer 10

Proton pump inhibitor or H2 receptor blocker (GERD can cause adult-onset asthma, and nocturnal cough and dyspnea are common)


Question 11

A 45-year-old woman comes to the ED with vomiting. Her vomitus becomes bloody and painful. What is the cause of her hematemesis?


Answer 11

Mallory-Weiss tears, which often result from vomiting associated with alcoholics and bulimics (cause painful bleeding)


Question 12

Ingestion of what compound classically causes esophageal strictures?


Answer 12

Lye (strictures are also seen with gastroesophageal reflux disease)


Question 13

Esophagitis is commonly caused along with what three etiologies?


Answer 13

Reflux, infection, and chemical ingestion


Question 14

Which of these infectious agents is least likely to be associated with esophagitis: HSV-1, cytomegalovirus, Candida, Helicobacter pylori?


Answer 14

H. pylori (this bacterium is associated with peptic ulcer disease but rarely with esophagitis)


Question 15

Esophagitis associated with HSV-1 shows ____ ulcers on endoscopy, whereas esophagitis associated with cytomegalovirus shows ____ ulcers.


Answer 15

Punched-out; linear


Question 16

Endoscopy performed on a patient with esophagitis shows white pseudomembranes. Is the patient immunocompromised?


Answer 16

Yes, as this is Candida esophagitis, which often occurs in immunocompromised patients


Question 17

Plummer-Vinson syndrome has what symptom triad?


Answer 17

Dysphagia due to esophageal webs, Iron deficiency anemia, and Esophageal webs (plumbers DIE)


Question 18

A patient has a food allergy that causes dysphagia, heartburn, and strictures. Does it respond to GERD therapy?


Answer 18

No, as this is eosinophilic esophagitis, which does not respond to typical GERD therapies


Question 19

A patient with numerous allergies and GERD unresponsive to therapy has an esophageal biopsy. What is it likely to show?


Answer 19

Eosinophilic infiltration (this is eosinophilic esophagitis, common in patients with atopy)

Question 20

Is Barrett esophagus an example of dysplasia, hyperplasia, neoplasia, or metaplasia?


Answer 20

Metaplasia


Question 21

In patients with Barrett esophagus, there is a replacement of ____ epithelium with ____ epithelium.


Answer 21

Nonkeratinized squamous; intestinal (columnar)


Question 22

What causes Barrett esophagus?


Answer 22

Chronic acid reflux resulting in glandular metaplasia


Question 23

What specific malignancy is associated with Barrett esophagus?


Answer 23

Adenocarcinoma (Barrett = Becomes adenocarcinoma, results from reflux)

Question 24

Name at least six risk factors associated with esophageal cancer.


Answer 24

Achalasia, Alcohol, Barrett esophagus, Cigarette smoking, Diverticula, Esophageal web, Familial, Fat, GERD, Hot liquids (AABCDEFFGH)


Question 25

A Mexican woman with dysphagia of solids now has difficulty with liquids as well. She also smokes. Which part of her esophagus is affected?


Answer 25

Likely affects the upper two-thirds of the esophagus (this is squamous cell carcinoma)


Question 26

Worldwide, which type of esophageal cancer is most common?


Answer 26

Esophageal squamous cell carcinoma


Question 27

A patient (native of the United States) presents with esophageal cancer. Which part of the esophagus is it most likely to affect?


Answer 27

The lower third (this is esophageal adenocarcinoma, which is more common than squamous cell esophageal cancers in the United States)


Question 28

A patient with a history of Barrett esophagus has dysphagia for solids and liquids and weight loss. What is the likely diagnosis?


Answer 28

Esophageal adenocarcinoma


Question 29

An alcoholic with a Zenker diverticulum has dysphagia with hot liquids. What type of esophageal cancer is he at high risk for?


Answer 29

Esophageal squamous cell cancer


Question 30

An obese patient with a very long history of GERD has started to have dysphagia to liquids. What finding is likely on esophageal biopsy?


Answer 30

Esophageal adenocarcinoma (long history of GERD is a risk factor for Barrett esophagus, which is followed by esophageal cancer)


Question 31

A smoker presents with progressive dysphagia and weight loss in the past few months. What is his likely diagnosis?


Answer 31

Esophageal squamous cell cancer or esophageal adenocarcinoma


Question 32

A patient with Hirschsprung disease has progressive dysphagia and other symptoms of achalasia. What type of cancer is he at high risk for?


Answer 32

Esophageal cancer