What is the blood supply of the upper, middle, and lower thirds of the esophagus?
Upper - inferior thyroid
Middle - branches of thoracic aorta
Lower - left gastric artery
What causes of dysphagia are progressive?
- SCC/adenocarcinoma
- systemic sclerosis/CREST
- esophageal strictures
- achalasia
- Zenker diverticulum
What are examples of functional esophageal dysphagias?
- nutcracker esophagus
- diffuse esophageal spasm
- systemic sclerosis/CREST syndrome
- GERD
- achalasia
What is nutcracker esophagus?
(symptoms and diagnosis)
Functional esophageal obstruction
-nomral coordination of contractions, but with increased LES pressure
Symptoms:
- dysphagia (intermittent)
- chest pain
Diagnostic:
-manometry wil show elevated LES pressure (>180 mmHg)
What is diffuse esophageal spasm?
(symptoms and diagnosis)
Functional esophageal obstruction
-uncoordinated contractions, normal LES tone
Symptoms:
- dysphagia (intermittent)
- chest pain
Diagnostic:
-barium swallow study show “corkscrew” or “rosary bead” esophagus
What are examples of structural esophageal dysphagias?
- esophageal webs
- Schatzki rings
- strictures
- Zenker diverticulum
- cancer
What are esophageal webs and Schzatzki rings?
(epi and compare)
diaphragm-like protrusion of mucosa in the esophagus
both more common in females
can be associated with GERD
Webs:
- proximal and not fully circumferential
- associated with Plummer-Vinson syndrome
Schatzki rings:
-distal and fully circumferential
How are esophageal webs and Schatzki rings diagnosed and treated?
Diagnosed:
-barium swallow
Treatment:
- dilation
- if persistent, PPI for GERD
What is Plummer-Vinson syndrome?
What condition is it associated with and increased risk of?
Triad:
- iron deficiency anemia
- beefy red tongue (glossitis w/ angular chelitis)
- esophageal webs (dysphagia)
increased risk of esophageal SCC
What are esophageal strictures?
What odd feature is present in its course?
complication of esophagitis (most commonly GERD) resulting in fibrosis and narrowing of esophagus
-most frequently occurs at the gastroesophageal junction
As stricture worsens -> GERD improves (stricture prevents reflux)
What is Zenker’s diverticulum?
(symptoms and diagnosis)
herniation of the esophageal mucosa and submucosa (false diverticula) posteriorly through cricopharyngeus muscle in Killian’s triangle, just above the UES
Symptoms:
- coughing or discomfort
- dysphagia (progressive)
- entrapment of food
- halitosis (bad breath)
- aspiration
Diagnosis:
- video esophagography
- barium swallow
- no EGD -> risk of perforation
What is achalasia?
(etiology)
loss of NO producing inhibitory neurons -> increased LES tone and loss of peristalsis in lower 2/3 of esophagus
Primary/idopathic:
-loss of ganglion cells in myenteric plexus of esophagus
Secondary:
-most commonly from Chagas disease leading to destrucion of ganglion
How is achalasia diagnosed and treated?
Diagnosis:
- “bird beak” esophagus on barium swallow; constriction of LES with proximal dilation
- manometry confirms; absence of peristalsis w/ incompelete LES relaxation during swallowing
- peripheral smear to detect T. cruzi
Treatment:
- nitrates and calcium channel blockers
- dilation
- myotomy (risk of GERD development)
What is pseudoachalasia?
tumor at the gastroesophageal junction causing obstructive “bird beak” pattern similar to achalasia
What are the common types of esophageal bleeding?
- Mallory-Weiss syndrome
- Boerhaave syndrome
- ruptured varices
What is Mallory-Weiss syndrome?
(etiology, presentation, and treatment)
superficial tear of the esophagus at gastroesophageal junction
-caused by increased stress on esophagus, such as forceful vomiting; frequently associated with alcohol use and bulemia
Presentation
- painful hematemesis
- common cause of upper GI bleed
Treatment:
-normally self-limited
What is Boerhaave syndrome?
(etiology, presentation, and treatment)
transmural tear of the esophagus at gastroesophageal junction -> esophageal rupture
-caused by increased stress on esophagus, such as forceful vomiting; frequently associated with alcohol use
Presentation:
- pneumomediastinum -> Hamman’s sign (crunching sound on ascultation of heart)
- subcutaneous emphysema
- hematemesis
- chest pain
- acute distress
Treatment:
- LIFE THREATENING
- surgery to repair
What are esophageal varices?
dilation of veins in the esophagus due to portal hypertension (cirrhosis)
-asymptomatic themselves but can rupture
What complication is associated with esophageal varices?
(epidemiology and risk factors)
Variceal hemorrhage (rupture of varices)
- occurs in 1/3 of patients with varices
- 1/3 die and 50% recur within 1 year
Risk factors:
- large varices (>5mm)
- red wale marking on endoscopy
- severe liver disease
- alcohol abuse
What is the presentation of variceal hemorrage?
How is it treated?
Presentation:
- actue onset typically preceeded by retching/vomiting
- upper GI bleed -> melena, hematochezia, and hematemesis
- hypovolemia/shock
Treatment:
- MEDICAL EMERGENCY
- blood, FFP, and vitamin K transfusion
- emergent EGD w/ variceal banding
- beta-blockers and banding help prevent recurrence
What symptom differentiates cause of esophageal bleeding?
painful hematemesis:
-Mallory-Weiss/Boerhaave syndrome
painless hematemesis:
-variceal hemorrhage
What are causes of pneumomediastinum and subcutaneous emphysema?
- Boerhaave syndrome
- iatrogenic esophageal perforation
- pulmonary causes (ie. COPD with bleb rupture)
- trauma
What is Hamman’s sign?
crunching sound that is synchronized w/ heartbeat in the setting of pneumomediastinum
What is esophagitis?
(associated symptoms)
What are the main causes?
Inflammation of the esophagus
- can cause pain with swallowing (odynophagia)
- can cause obstruction
Causes:
- radiation
- chemical irritation (pills/caustic substances)
- infections
- eosinophilic
- reflux
What are the main causes of infectious esophagitis?
- CMV
- HPV
- candida
What are the endoscopic findings for CMV, HSV, and candida based infectious esophagitis?
CMV:
-shallow, linear ulcers
HSV:
-punched-out lesions
Candida:
-white pseudomembrane
What is eosinophilic esophagitis?
(presentation)
eosinophil infiltration of esophagus
-associated with allergic/atopic conditions
Presentation:
-dysphagia
-**food impaction**
- regurgitation
- possible asthma or atopic rash
GERD-like presentation though slightly more severe; also more likely to present in children than GERD
How is eosinophilic esophagitis diagnosed and treated?
Diagnosis:
- “tracheal/feline” esophagus on EGD; multiple esophageal rings
- eosinophil infiltrate on biopsy (15-20 eosinophils per field); eosinophil also seen with GERD but less numerous
Treatment:
- swallowing, instead of inhaling, inhaled glucocorticoids
- allergist referral/elimination of food allergens
- esophageal dilation
What is GERD?
(presentation)
reflux of stomach acid into esophagus due to relaxation of LES or increased intra-abdominal pressure
Presentation:
- “heart burn“/chest pain
- dysphagia
- regurgitation of gastric contents (sour taste)
What are extrapharyngeal symptoms that are rather indicative of GERD?
- nocturnal cough
- nocturnal asthma
What are causes of GERD?
- decreased LES tone
- increased intra-abdominal pressure
Causes:
- vagus nerve dysfunction
- alcohol and tobacco
- obesity
- pregnancy
- stress
- hiatal hernia
- gastroparesis
What are concerning features in GERD?
What complications can occur?
Concerning symptoms:
- s/x of UGIB -> ulceration
- constant severe pain -> ulceration
- odynophagia -> ulceration
- dysphagia -> stricture
- persistent vomiting -> dehydration
- palpable mass/weight loss ->adenocarcinoma
Complications:
- ulceration
- stricture
- Barrett esophagus -> adenocarcinoma
How is GERD treated?
No alarming features:
-emperical
- possible acid suppressing medications
- treatment of H. pylori if present
-lifestyle changes
Alarming features:
- endoscopy
- imaging
- surgical evaluation
What is a common symptom that occurs with esophageal impaction/foriegn body obstruction?
hypersalivation
What is Barrett esophagus?
(presentaiton, diagnosis, and management)
distal esophageal metaplasia
- squamous -> intestinal columnar w/ goblet cells
- highly associated with GERD
Presentation:
- asymptomatic itself
- underlying GERD symptoms
Diagnosis:
- endoscopy (“pink tongues” extending from gastroesophageal juction)
- metaplasia on biopsy; columnar epithelium w/ goblet cells
Management:
- can progress to adenocarcinoma -> survelience endoscopy
- PPI (reduces progression risk)
- ablation of high-grade dysplasia
What are the most common tumors of the esophagus?
(epi)
Benign:
-leiomyoma (smooth muscle/mesenchymal)
Malignant:
- adenocarcinoma
- SCC
How do benign and malignant esophageal tumors appear different on a barium swallow?
Benign/leiomyoma appear as a smooth, rounded obstruction of the esophageal lumen
Malignant appear as asymmetrical, ulcerated or infiltrative masses that obstruct lumen
What is the epidemiology of esophageal adenocarcinoma and SCC?
Adenocarcinoma:
- men
- western countries/caucasians (rapidly increasing prevalence)
SCC:
- men
- Asia and African Americans
- more commonly globally
What are risk factors associated with esophageal adenocarcinoma?
- GERD/Barrett esophagus
- H. pylori
- tobacco
- achalasia
- radiation
What is the clinical presentation of esophageal adenocarcinoma?
Frequently goes undiscovered until too late unless incidentally detected early duing evaluation of GERD
Early presentation:
-asymptomatic
-underlying GERD s/x possible
Late presentation:
- dysphagia (progressive)
- weight loss
- chest pain
- hematemesis
How is esophageal adenocarcinoma diagnosed and where is it typically found?
(appearance)
EGD with biopsy:
- glandular/mucinous appearing high-grade dysplasia
- adjacent Barrett mucosa is common (columnar epithelium with goblet cells)
Typically in lower 1/3 of esophagus (due to high association with Barrett esophagus)
What are risk factors associated with esophageal SCC?
- alcohol/tobacco
- low fruit/vegetable intake
- chemical/thermal injuries (hot beverages)
- achalasia
- radiation
- tylosis
- HPV
- Plummer-Vinson syndrome
- poverty
What is the clinical presentation and prognosis of esophageal SCC?
Insidious onset with aggressive course:
- dysphagia
- odynophagia
- obstruction -> shift of diet from solids to liquids
-weight loss
Frequently caught late, after LN metastasis -> poor survival
If caught early (typically through screening, not symptoms) significant increase in surival
How is esophageal SCC diagnosed and where is it typically found?
(appearance)
EGD with biopsy:
- early grey/white plaque-like thickening -> late polypoid/exophytic growth
- squamous dysplasia with keratinization/keratin pearls
Typically in middle 1/3 of esophagus