Esophagus

Question 1

What do each of the letters in ‘VITAMIN’ of the surgical sieve categories of disease discussed in lecture stand for?

Answer 1

• Vascular
• Infectious/Inflammatory
• Traumatic
• Anatomic
• Metabolic
• Idiopathic
• Neoplastic

Question 2

Auerbach’s myenteric plexus is located in the muscularis propria or mucosal layer?

Answer 2

Muscularis propria

Question 3

Which sphincter approximates the gastroesophageal junction (GEJ)?

Answer 3

Lower esophageal sphincter

Question 4

The squamocolumnar junction (SCJ) is also called what?

Answer 4

Z line

Question 5

How is the anatomic GEJ defined?

Answer 5

Takeoff of gastric folds

Question 6

Normally the SCJ approximates the GEJ, but what happens in Barrett’s esophagus?

Answer 6

Proximal displacement of SCJ off GEJ

Question 7

Name 3 ways to visualize the esophagus

Answer 7

1. Gross exam (autopsy)
2. Barium swallow (diagnostic)
3. Endoscopy (diagnostic and therapeutic)

Question 8

What is pyrosis in relation to the esophagus? What is water brash? What is globus? Eructation?

Answer 8

pyrosis: heartburn
water brash: hyper salivation
Globus: lump in the throat
Eructation: belching

Question 9

If an infant has choking, coughing, cyanosis with onset of feeding, what should you check for?

Answer 9

Tracheo-esophageal fistula

Question 10

Achalasia is a failure of the LES to relax with progressive destruction of the myenteric plexus. It results in dysphagia and an increased risk of what cancer?

Answer 10

carcinoma

Question 11

Secondary achalasia is associated with what diseases (2)?

Answer 11

Chaga’s disease (trypanosome cruzi)

Scleroderma

Question 12

Scleroderma results in fibrosis of which muscular layer of the esophagus?

Answer 12

INNNER CIRCULAR LAYER

Question 13

If you have scleroderma, you will get unopposed reflux and have a greater propensity to develop what?

Answer 13

Barrett’s esophagus

Question 14

T/F- a hiatal hernia (protrusion of the stomach above diaphragm) is usually symptomatic

Answer 14

False, most patients are asymptomatic but some have reflux symptoms, bleeding, ulceration, perforation

Question 15

What type of hernia (sliding or paraesophageal (PE)) is more common?

Answer 15

Sliding (95%)

Paraesophageal (rolling) (5%)

Question 16

What is a serious complication of paraesophageal hernias?

Answer 16

strangulation (infarction of incarcerated hernia)

Question 17

Name the most common characteristic of diverticula in each category

1. congenital or acquired
2. True (all gut layers) or false
3. Pulsion (peristalsis against a closed sphincter or traction (extrinsic pull secondary to inflammation)

Answer 17

1. acquired>congential
2. False>true
3. Pulsion>traction

Question 18

What is a zenker diverticulum?
Midesophageal?
Epiphrenic?

Answer 18

• zenker- usually pulsion type which forms above UES
• midesophageal- usually due to traction
• epiphrenic- pulsion, forms above LES

Question 19

What symptoms would you expect in a zenker diverticulum?

Answer 19

Dysphagia, globus, food impaction, regurgitation, aspiration, HALITOSIS

Question 20

Mallory Weiss syndrome is hematemesis from laceration of GEJ mucosa/submucosa, what causes this and who is at greatest risk?

Answer 20

Cause: forceful retching/coughing/vomiting
Risks: alcoholics, eating disorders

Question 21

T/F- ruptured varices (dilated submucosal veins) are a frequent cause of death in alcoholics

Answer 21

True

Question 22

What is an esophageal web and what condition is it associated with?

Answer 22

• web: shelf of tissue (eccentric) that can be congenital or post-inflammatory
• Plummer-vinson syndrome (sideropenic dysphagia): glossitis, dysphagia, iron deficiency

Question 23

What is an esophageal ring?

Answer 23

• ring: circumferential (“Schatzki” if at SCJ)

- esophagitis related

Question 24

Stenosis/stricture of the esophagus is commonly due to what factor?

Answer 24

radiation

Question 25

Name common causes of esophagitis

Answer 25

1. topical injury (alcohol, corrosive substances (acid, lye), hot liquids 2. cytotoxic chemo (radiation, GVHD) 3. stuck pills (doxycycline, aspirin, iron, alendronate) 4. Infectious (see next flashcard)

Question 26

Review Characteristics of infectious esophagitis

Answer 26

- Immunocompromised (DM, post-chemotherapy, transplant, HIV, older) vs. immunocompetent - Odynophagia is a common symptom!!!!!!!!!!!!!!!!!! - Candida – white plaques; PMN’s; parakeratosis - Herpes – punched out ulcers; squamotropic; cytopathic effect (CPE) at edge of ulcers - Cytomegalovirus (CMV) – single deep ulcer; endothelial/ stromal cells, columnar epithelium; CPE in depth of ulcer

Question 27

Distinguish GERD vs reflux esophagitis (RE)

Answer 27

GERD: “condition that develops when reflux of stomach contents causes troublesome symptoms and/or complications” RE: endoscopic or histologic evidence of reflux-associated injury

Question 28

T/F- GERD is more prevalent in the west than in Asia

Answer 28

True (10-20% in west vs <5% in asia)

Question 29

Name 3 causes of GERD

Answer 29

LES dysfunction, decreased acid clearance, defective barrier function

Question 30

Name 3 symptoms of GERD

Answer 30

heartburn, regurgitation, dysphagia

Question 31

Name 3 complications of GERD

Answer 31

stricture, Barrett's esophagus, adenocarcinoma

Question 32

Name 2 important histologic features of reflux

Answer 32

- Epithelial hyperplasia (basal zone and papillary elongation) - Dilated intercellular spaces

Question 33

Name the normal cutoff percentages for papillary height (PE) and basal zone height (BZH)

Answer 33

PE: 67% BZH: 15%

Question 34

What is the key inflammatory cell you will see histologically in reflux?

Answer 34

intraepithelial eosinophils

Question 35

Define eosinophilic esophagitis

Answer 35

primary clinicopathologic disorder of the esophagus characterized by esophageal and/or upper GI tract symptoms in association with esophageal mucosal biopsy specimens containing ≥15 intraepithelial eosinophils per high-power field in 1 or more biopsy specimens and absence of pathologic GERD as evidenced by a normal pH monitoring study of the distal esophagus or lack of response to high-dose PPI medication

Question 36

Name the symptoms of eosinophilic esophagitis

Answer 36

Symptoms include food impaction, dysphagia (adults); GERD type symptoms, feeding intolerance (children)

Question 37

How would you diagnose eosinophilic esophagitis? How would you treat it?

Answer 37

- Diagnosis – esophageal symptoms + mucosal biopsy + exclusion of GERD (lack of response to PPI or normal pH monitoring) - Treatment – elimination and elemental diets, acid suppression, topical corticosteroids, dilatation of strictures

Question 38

Define Barrett's esophagus

Answer 38

Definition (US): Endoscopically evident apparent columnar mucosa proximal to the anatomic GEJ with biopsy demonstrating intestinal metaplasia (i.e., goblet cells)

Question 39

How is Barrett's esophagus diagnosed?

Answer 39

Diagnosis – 2 EGD’s with bx within 1 yr (confirm dx; rule out prevalent dysplasia)

Question 40

How is Barrett's esophagus treated?

Answer 40

Treatment – PPI for GERD; endoscopic ablative tx or surgery for dysplasia/carcinoma

Question 41

What factors is the need for "surveillance" of the barrett's esophagus determined by?

Answer 41

Determined by absence or presence of dysplasia, grade of dysplasia

Question 42

Name 2 advanced techniques for treating Barrett associated neoplasia?

Answer 42

- endoscopic mucosal resection | - radiofrequency ablation

Question 43

T/F- The Incidence of Esophageal Cancer Increasing at Alarming Rate due to Adenocarcinoma

Answer 43

True

Question 44

Compare the etiology of adenocarcinoma and squamous cell carcinoma

Answer 44

- adenocarcinoma: GERD, tobacco, obesity | - Squamous cell carcinoma: tobacco, alcohol, hot beverages

Question 45

What determines a tumor "grade"?

Answer 45

-Based on microscopic features -Refers to how well or poorly a tumor resembles the normal cells it recapitulates -Correlates with outcome (but less so than STAGE) (well-differentiated=low grade)

Question 46

What determines tumor "stage"?

Answer 46

- Refers to anatomic extent of disease - Assigned at the time of diagnosis: clinical and/or pathologic - Most powerful predictor of outcome T(umor) N(ode) M(etastasis)