esophagus Flashcards
(90 cards)
Primary MUSCLE motility disorders?
Typically affect the proximal third of the esophagus because it is striated muscle
Myasthenia gravis
Myotonic dystrophy
Polymositis and dermatomyositis
Amyotrophic lateral sclerosis (Lou Gehrigs disease)
Myopathies secondary to steroids and abnormal thyroid function
oculopharyngeal myopathy
What is oculopharyngeal myopathy?
a rare disease occurring in families of French Canadian ancestry that presents relatively late in life with ptosis and dysphagia
Primary NEURAL motility disorders?
peripheral or central cranial nerve palsy
cerebrovascular occlusive disease affecting the brain stem
high unilateral cervical vagotomy
Bulbar poliomyelitis, syringomyelia, Huntingtons chorea, familial dysautonomia (riley-day syndrome, multiple sclerosis, diphtheria, and tetanus)
ABNORMALITIES OF SMOOTH MUSCLE AND INNERVATION OF THE BODY OF THE ESOPHAGUS
Scleroderma, SLE, RA, polymositis, dermatomyositis, Achalasia, Chagas, Metastasis, Esophagitis (from corrosive, reflux, infectious or radiation-induced causes), Alcoholic neuropathy, Diabetic neuropathy, Presbyesophagus, Anticholinergic medication, Myxedema, Amyloidosis, Muscular dystrophy
Esophageal diverticula
Zenker’s
Epiphrenic
Thoracic traction
Intramural
Zenker’s diverticula overview?
Is thought to be related to premature contraction or other motor incoordination of the cricopharyngeus muscle, which produces increased intraluminal pressure and a pulsion diverticulum at a point of anatomic weakness between the oblique and circular fibers of the muscle (a point known as Killians dehiscence)
Zenker’s diverticula findings and complications?
The neck of the diverticulum lies in the midline of the posterior wall and the pharyngeoesophageal junction (about C5-6 level)
Many are asymptomatic
As enlarges may cause regurgitation of food and aspiration pneumonia
Can become so large to cause obstruction of the esophagus
Barium and food may be retained in a zenkers for hours or even days after ingestion
On plain films of the neck will see a widened retrotracheal soft tissue space often with an air fluid level
Best demonstrated on at lateral barium swallow view
EPIPHRENIC DIVERTICULA?
(1) Usually the pulsion type occurring in the distal 10cm of the esophagus
(2) Probably related to a motor abnormalities of the esophagus and are probably related to incoordination of esophageal peristalsis and sphincter relaxation, resulting in lower esophageal segment being subjected to increased intraluminal pressure
(3) Seen in association with curling phenomenon
(4) Usually asymptomatic, unless it is large enough to cause mass effect
(5) Radiographically see a broad short neck that when small can mimic an esophageal ulcer
THORACIC TRACTION DIVERTICULA?
all esophageal layers are involved
(1) Seen in the middle third of the esophagus opposite the bifurcation of the trachea
(2) Caused by adhesions from lymph nodes in the hila
(3) Rarely symptomatic although mediastinal abscess or esophagorespiratory fistula may occur
(4) Rarely can be of the pulsion type
(5) Radiographically
(a) Barium swallow shows a diverticular collection of contrast that may have a funnel, cone, tent, or fusiform shape. Best seen in LAO projection
(b) May see associated lymph node calcification
INTRAMURAL DIVERTICULOSIS?
AKA pseudo diverticulosis
Rare
Multiple small flask shaped outpouchings in longitudinal rows parallel to the long axis of the esophagus represent dilated ducts coming from submucosal glands
necks of these are 1mm or less
90% will have associated esophageal narrowing M/C in upper third of esophagus
Some may occur with an increase in pressure due to obstruction. These usually resolve with treatment of the underlying condition
Radiographically there appearance has been likened to a chain of beads and to the Rokitansky-Aschoff sinus of the gallbladder
Candida Albicans can be cultured from half the patients with this disorder (Is an associated finding not a cause)
Esophagitis overview?
The most common disease of the esophagus
Regardless of the cause will look similar radiographically:
Erosions, nodularity, thickened folds, luminal narrowing, diffuse ulceration with strictures, or any combination of these
Diseases that cause esophagitis?
GERD Barret's esophagus Caustic agents, radiation, oral meds Infection (bacterial, Viral) Ulcerative esophagitis
GERD overview?
related to inappropriate relaxation or incompetence of the lower esophageal sphincter
Commonly occurs in the presence of Hiatal hernia
GERD severity?
Severity of esophagitis depends on:
(a) Frequency of reflux
(b) Length of time fluid remains in the esophagus before being cleared
(c) PH of refluxed fluid (whether acid or alkaline (bile)
GERD clinical sx?
(a) Most common symptom is heartburn
(b) Regurgitation of gastric contents into mouth
(c) Some have dysphagia
(d) Symptoms can be precipitated by any change in position that increases intra-abdominal pressure
GERD radiographic eval tecnhiques?
(a) Raise intra-abdominal pressure by a variety of methods
(b) Another approach is the Water-siphon test
(c) Can do a radionuclide scan in which pt swallows the substance
1. Can then add abdominal pressure
2. Has a 90% accuracy in demonstrating reflux
By what ever method if you cant demonstrate reflux it does not mean the patients esophagitis is not due to reflux
GERD radiographic findings?
Earliest finding on double contrast is superficial ulcerations
Ulcers may a linear component, and often have radiating mucosal folds surrounding and retraction of esophageal wall
Single contrast shows a hazy, serrated border of the outer wall of esophagus
Marginal serrations must be differentiated from FELINE ESOPHAGUS
Fixed transverse folds in the esophagus producing a step-ladder appearance on barium swallow reflect longitudinal scarring from reflux esophagitis
A smudgy irregular pattern of residual barium is seen, in contrast to the fine sharply demarcated longitudinal folds of the collapsed esophagus in normal pts
May see the associated presence of a hiatal hernia
Causes of GERD?
Frequently associated with sliding hiatal hernias
Prolonged of repeated vomiting due to: Peptic ulcer, biliary colic, intestinal obstruction, acute alcoholic gastritis, pancreatitis, migraines, post-surgical or during pregnancy
Nasogastric intubation allows for reflux and the development of long strictures
Chalasia
Drugs such as anticholinergics, nitrites, B-adrenergic agents and some tranquilizers
Barrett’s esophagus overview?
- Is a result of chronic reflux
- This is thought to be acquired and is associated with sliding hiatal hernia
- Occurs in 10 to 20% of pts with chronic reflux
- Predisposes to cancer
- Normal squamous epithelium is denuded and replaced with metaplastic columnar epithelium
Barrett’s esophagus cancer risk?
a. Barretts esophagus has been detected in more than 40% of adenocarcinomas of the gastroesophageal junction and up to 80% of adenocarcinomas of the esophagus
b. Barretts adenocarcinoma comprise from 30 to 50% of all esophageal cancers
Barrett’s esophagus radiographically?
Ulceration typically happens at or near the squamocolumnar junction (well above the cardia and even as high as the aortic arch)
Unlike the shallow ones of GERD, barretts ulcers are deep and penetrating
Stricture formation is usually present in association with ulcerations, but occasionally only see strictures
1. Presence of a delicate reticular pattern of multiple barium filled grooves or crevices in the esophagus adjacent to a stricture and extending distally a short but variable distance is a specific radiographic indication of barrett’s esophagus
2. In reality this pattern is non-specific and seen in candidal and viral esophagitis, superficial spreading carcinoma and areae gastricae in a small hiatal hernia
c. Radionuclide examination reveals continuous concentrations of isotope in the area of barretts esophagus
7. Mucosal biopsy is usually used for definitive dx
Radiation of the esophagus?
Often responsible for severe symptomatic esophagitis, and strictures may occur many years later
Usually a side effect of mediastinal radiation therapy
Dose greater than 4500 rad (45 Gy) frequently lead to severe esophagitis with irreversible stricture formation
Radiographically can look very similar to candida esophagitis a far more common condition in pts undergoing chemotherapy and radiation therapy
Medications that frequently cause esophagitis?
(b) Antibiotic medication (Tetracycline, Doxycycline), Potassium chloride, quinidine, vitamin C, aspirin and oral ferrous sulfate
Solitary or multiple shallow ulcers seen on one wall or circumferential pattern, Typically near the aortic arch, Dramatic healing within 7 to 10 days with removal of offending agent
Common infections organisms of the esophagus?
MC = CANDIDIA Also: HERPES CMV HIV TUBERCULOSIS
