Flashcards in Esophagus Deck (51):
At what point are esophageal folds abnormal? (size)
Differentiate reflux esophagitis from varices.
2-3 mm in diameter
Varices will be more serpentine and change shape during fluoro
What do transverse folds represent? How do they differ from those in a feline esophagus?
Develop as a result of prior linear ulceration with scar formation with the longitudinal muscle layer
Transverse folds are fixed, coarser, and shorter. They also do NOT cross the entire esophageal lumen
Describe the imaging/pathology of intramural pseudodiverticulosis.
Who gets it and what is the association?
Multiple tiny outpouchings diffuely/segmentally in the esophagus with an apparent LACK OF COMMUNICATION with the esophageal lumen. Represent dilated submucosal glands (like GB adenomyomatosis).
Elderly patients with chronic reflux, complain of progressive dysphagia. 90% have association with upper/mid esophageal stricture.
Where is a barretts stricture seen? what is the pathology?
What are the other types of stricture and where are they seen?
Focal esophageal stricture above the GE junction in the mid esophagus with associated reticulation. Metaplasia of normal squamous epithelium to adenomatous mucosa. Occur at mid esophagus because adenomatous mucosa is resistant.
Medication induced - points of anatomical narrowing (thoracic inlet, aortic arch, left mainstem bronchus)
Caustic - long segment of narrowing.
What percentage of reflux patients develop barrets? What is the risk for cancer transformation?
Give 3 diagnoses for multiple nodular filling defects of varying size
Candida - symptomatic
Glycogen acanthosis - asymptomatic elderly patient. Due to increased cytoplasmic glycogen in squamous epithelial cells. Margins are hazy.
How does crohns present in the esophagus?
Aphthous ulceration - discrete ulcers with mounds of edema
Describe the appearance of candidal esophagitis.
Differentiate between reflux, glycogen acanthosis, and herpes
Discrete plaquelike lesions are most common. Can have nodular and granular appearance with fold thickening. Severe disease will have SHAGGY IRREGULAR luminal surface.
Reflux - usually distal esophagus
GA - asymptomatic elderly patient
Herpes - more commonly ulceration
Describe the appearance of herpes esophagitis
Differentiate between CMV
discrete ulcerations in an otherwise normal esophageal mucosa
CMV is usually a large, solitary, discrete ulcer
Large solitary ulcer in AIDS patient suggest what. What is seen on biopsy.
CMV esophagitis. Will see intranuclear inclusions
What is the pathology behind achalasia? What is the gold standard for diagnosis? What is the main differential?
Failure of the lower esophageal sphincter to relax.
Pseudoachalasia (due to carcinoma) - achalasia will show periodic relaxation
What is vigorous achalasia?
What are the complications of achalasia?
Less severe form with non-propulsive contractions on top of LES tightening
Squamous cell carcinoma (surveillance begins 10-15yrs after dx)
Candidiasis results from stasis
What is pseudoachalasia?
Fixed, rigid stricture at the GEJ due to carcinoma
When does caustic stricture develop? What is the risk of carcinoma?
Usually 1-3 months after injury
1-4% risk of esophageal cancer after 20 years
What is cicatricial pemphigoid strictures of the esophagus? Who gets it? Associated findings?
Differentiate between caustic strictures
Multifocal strictures throughout the esophagus in a patient with bullous disease. Will have blistering of all mucous membranes (mouth, eyes, nose, esophagus, larynx, urethra, anus). Usually between 60-80 yrs with transient skin lesions on back of head and neck.
Caustic usually isn't multifocal.
Distinguishing feature of radiation induced esophageal stricture? How high of a dose usually?
time frame for acute radiation injury? stricture development?
Spares the GE junction. >50 Gy
Acute= 1-4 weeks
Strictures= 4-8 months
Diffusely small caliber esophagus with ringlike indentations and granular mucosa +/- stricture?
How does lymphoma affect the esophagus?
Usually by mass effect from a mediastinal LN causing a focal stricture. Can also spread via stomach
With regard to strictures, give the main differential dx for the following findings:
smooth margins, immediately above GEJ
Abrupt, shouldered margins
GEJ stricture with transient relaxation
GEJ fixed stricture
Long and narrow stricture
Stricture with multiple rings
Differential for a smooth surfaced mass with an obtuse angle between mass and esophageal lumen
Duplication cyst - water attenuation
Most common submucosal neoplasm of the esophagus? Where does it present
mid to distal, high presence of smooth muscle cells
Differential for a lobulated filling defect in the distal esophagus? Which are malignant?
Adenoma - usually seen with barretts. Malignant potential, higher risk if larger lesion
Papilloma - no malignant potential
Inflammatory esophagogastric polyp - extend from the stomach
What are inflammatory esophagogastric polyps?
Enlarged polypoid fold arising from the fundus of the stomach into the lower esophagus. No malignant potential, but has similar appearance to adenoma so endoscopy is advised.
Differential for a smooth intraluminal esophageal mass arising from a stalk in the cervical esophagus
Fibrovascular polyp > Spindle cell carcinoma (usually more distal) > Adenomatous polyp (usually smaller)
What is a fibrovascular polyp in the esophagus?
Benign, pedunculated intraluminal lesion of various mesenchymal elements, covered by normal squamous epithelium. Considerable fatty component on CT
Usually longer than 7cm (bigger than adenoma)
Can propel into cervical esophagus and cause respiratory issues
What are findings of a malignant esophageal mass
Irregular contour of lumen
Ulcer that DOESNT extend beyond normal esophageal mucosa
Differential for bulky polypoid filling defect in the esophagus
Adenocarcinoma - usually distal
Spindle cell, lymphoma
SqCC is usually an annular constricting mass
What is the normal thickness of the esophageal wall?
Where is a spindle cell carcinoma usually located
Bulky, polypoid intraluminal mass in MID or DISTAL esophagus with pedunculation
DDx for multiple serpentine filling defects in distal esophagus?
Varicoid esophageal carcinoma - fixed
Varices - change in shape and size
Describe the physiology of "uphill" varices
Hepatic cirrhosis causes portal HTN
Increased portal venous pressure reverses normal venous bloodflow upwards from the portal vein to the left gastric vein, to the periesophageal venous plexus, to the azygos and hemiazygous collateral dumping into the SVC
Describe the physiology of "downhill: varices
Obstruction of the SVC due to mass or fibrosing mediastinitis causes enlargement of collaterals (supreme intercostal, bronchial, inferior thyroidal).
Blood flows DOWN to the left gastric and portal veins and dump into the lower SVC
What are the 3 foregut cysts? Differnetiation?
Esophageal duplication - squamous epithelium
Bronchogenic - respiratory epithelium
Neurenteric - associated vertebral body anomolies
What is the difference between foreign body impaction by a fishbone and meat?
Meat is distal, fishbone is proximal
What is the treatment plan for impacted foreign body? What is the risk?
Glucagon (1mg) decreases pressure of the LES
Endoscopic retrival with basket
Follow because if impacted >24hours, there is a risk of transmural ischemia
Small outpouchings from the lateral hypopharynx? Who gets them?
Lateral pharyngeal pouches
Arises through an unsupported weak area in the thyrohyoid membrane. Best seen if patient blows against pressure
Seen in glassblowers, trumpeters
Diverticulum from the posterior wall of cervical esophagus? Where does it go through?
Killian dehiscense/triangle - between oblique and horizontal fibers of esophageal wall just above cricopharyngeus.
Arise from abnormally increased pressure in the hypopharynx due to failure of the cricopharyngeus muscle to relax
"Z is in the back (posterior) of the alphabet"
Diverticulum off the lateral wall of the cervical esophagus
Protrudes through area of weakness below cricopharyngeus on cricoid cartilage and lateral to suspensory ligaments "Killian Jamieson" Space on ANTEROLATERAL wall
Triangular shaped/wide based outpouching in midesophagus, associated with TB adenitis/fibrosing disorders
Pulsion (more common) are round
Distal esophageal diverticulum associated with achalasia, doesnt empty with peristalsis
Epiphrenic pulsion diverticulum.
Define primary/secondary/tertiary contractions.
Primary - intiiated by swallow. Smooth, continuous contraction the length of esophagus.
Secondar - initiated by bolus/esophageal distenstion
Tertiary - nonpropulsive, irregular, do not move bolus, increased in the elderly
Dysphagia and chest pain with vigorous nonpropulsive contraction?
Diffuse esophageal spasm (nutcracker esophagus) - normal peristalsis will eventually show. Corkscrew appearance. "Nutcracker esophagus" is a precursor related to high manometry findings.
Vigorous achalasia will not have a normal stripping wave in response to swallowing
What is the muscular ring (A ring)?
Broad, smooth indentation in lower esophagus superior to vestibule. Changes shape and disappears at fluoroscopy (vs hiatal hernia).
What is the musocal ring (B ring)?
thin, fixed ring that doesnt change in appearance and marks location of esophagogastric junction.
Thin weblike ring at the level of the GEJ with symptoms. What is the usual diameter?
Schatzki ring - must be symptomatic, otherwise its a B ring
usually 10-15mm is when symptoms occur
Thin, smooth, shelflike filling defect along ANTERIOR wall of esophagus. Association? main differential?
Esophageal web - RARELY circumferential
Plummer vinson - esophageal web, anemia
Anterior venous plexus - will change and vary from swallow to swallow
Small shallow indentations along the lateral wall of the cervical esophagus,
Ectopic gastric mucosa - last place in the esophagus to undergo replacement with stratified squamous epithelium in embryogenesis.
How often does scleroderma affect the esophagus?
How does it affect the esophagus? What are the complications?
80% of scleroderma patients
Degeneration and atrophy of smooth muscle and fibrosis within distal 2/3 of esophagus.
Radiographically, there is absent peristalsis in the distal 2/3 of the esophagus with and incompetent LES. results in reflux
Complications - candidiasis due to stasis and aspiration
How high above the diaphragm is a hiatal hernia? How is it radiographically seen?
>2cm for confident diagnosis
Gastric folds will be seen above diaphragm
What are the two types of hiatal hernia? Which is more prone to complication?
Sliding - abnormal location of the GEJ
Paraesophageal - normal location of the GEJ with the stomach herniating through the diaphragm.
Paraesophageal are more prone to gastritis and bleeding, ulceration, and strangulation.