What scale is used to grade erosive esophagitis?
The Los Angeles grading system, which is a 4 pt. scale going from A-D
The Los Angeles Grading System is the most thoroughly evaluated esophagitis classification tool and is gaining acceptance in the United States and Europe as a standard to gauge the extent of EE in patients undergoing upper endoscopy
Upper endoscopic findings of esophagitis are 90%-95% specific to GERD and are the clinical standard for determining the extent of esophagitis and excluding other causes of the patient’s acid reflux symptoms. Only 20%-60% of patients with acid esophageal reflux found in pH testing are found to have endoscopic findings consistent with esophagitis
T or F. The Los Angeles grade has no correlation to the severity of heartburn symptoms
T. Grade D may have mild heartburn and A may have terrible symptoms
What if you perscribe a PPI to someone with gastric reflux and after taking it as directed, the pt. doesnt see any relief?
Dont up the dose- your diagnosis is wrong and something else besides gastric reflux is going on
Men with chronic GERD symptoms need an endoscopy to exclude progression/occurrence of Barrett's esophagus. Women DO NOT- Barrett's is almost exclusively a male disease
So the pt. with GERD will be scoped, graded on the LA system, adviced not to smoke, and most likely started on a PPI (take before eating in the morning)
Really all you need for reflux diagnosis is eosinophils or EO granules- everything else is just helpful. But again most ppl with suspected GERD are not scoped
Normal Esophagus Epithelium
Heartburn can lead to cancer in the sense that it can lead to Barrett's esophagus, which is the major precursor to adenocarcinoma (almost exclusive to men)
GERD is usually a symptom based diagnosis without the need for endoscopy to diagnose (endoscopy is typically normal in these pts.- i.e. no erosive esophagitis)
If you endoscope someone and find erosive esophagitis, youve made the diagnosis of GERD and no further imaging is needed. But again, most pts. with heartburn/GERD have a normal endoscopy anyways so its not necessary
So what are the main indications for endoscopy?
You wouldnt normally use endoscopy for diagnosis of GERD but may want to for:
-evaluating other symptoms such as dysphagia
-to rule other things such as eosinophilic esophagitis
-screen for Barrett's esophagus
What is eosinophilic esophagitis (EoE)?
This is an allergic inflammatory condition (also known as allergic esophagitis) predominantly of young males characterized by a history of atypical heartburn, intermittent dysphagia, food impaction, vomiting, and often trouble finishing meals due to pain
Food allergy may play a role. Many people with EoE have other autoimmune and allergic disease. This includes asthma and celiac disease.
How does the esophagus look on endoscopy with EoE? Biopsy?
it will take on a ringed appearance (O shaped) with linear furrows and narrow caliber lumen. Eosinophils are inflammatory cells that release a variety of chemical signals which inflame the surrounding esophageal tissue. This results in the signs and symptoms of pain, visible redness on endoscopy, and a natural history that may include stricturing
How should suspected EoE be treated?
start them on a PPI (if they respond the diagnosis is PPIrEE) and if not, they may need topical/swallowed steroids (diagnosis is EoE)
EoE- The diagnosis is made via biopsy with 15+ eosinophils/hpf
Note that the diagnosis of Barrett's esophagus can only be made with endoscopy and has to be confirmed histologically with biopsy.
The distal esophagus should be whiteish-grey colored
What is the tx for Barrett's esophagus?
there is no direct tx. so the tx is the treat is underlying reflux
Again, what is the pt. population for barrett's esophagus?
usually older, white men with obesity
probably wont get a path report that says the diangosis is Barrett's, you will get intestinal metaplasia most likely
Barretts metaplasia is protective- want to see columnar cells and goblet cells to make the diagnosis
The nuclei moving toward the lumen suggests abnormal maturation in low-grade metaplasia
What are the major differences on biopsy between Barrett's metaplasia and the onset of dysplasia (which may suggest eminent transition into cancer)?
Barrett's is marked by the appearance of goblet cells, columnar cell metaplasia, and some hyperchromasia, while
dysplasia is marked by failure of epithelial cells to mature, increased hyperchromasia, and **abnormal architecture* of glands (might still see goblet cells in low-grade dysplasia but very hard to differentiate)
For something to be metastatic via lymphatics in the GI, what layer must it reach?
the submucosa (this is not real lymph in the lamina propria)
What mutation is involved in progression of Barrett's to dysplasia?
What are the two main types of esophageal cancers?
adenocarcinoma and SCC
What kind of esophageal cancer is this?
What kind of esophageal cancer is this?
What is the common pt. pop for esophageal SCCs?
AA (8x) males (4:1 to females) over the age of 45
T or F. Esophageal adenocarcinoma is most common in white people
What are the risk factors for esophageal SCC?
Alcohol and tobacco use,
caustic esophageal injury,
achalasia (failure of smooth muscle fibers to relax, which can cause a sphincter to remain closed and fail to open when needed)
mediastinal radiation (delayed)