Hand Pain & Barrett Esophagus

Carpal Tunnel Syndrome

Compression of Median Nerve within Carpal Tunnel

Higher incidence in females: 3-10 times more common in females compared to

males

 Most common nerve compression of upper extremity

Risk factors include

 Prolonged wrist flexion or extension, exposure to vibration

 Conditions that affect fluid balance (pregnancy, congestive heart failure,

hypothyroidism, renal failure)

 Diabetes, alcoholism, toxins

Symptoms/signs include

 Numbness , burning, tingling, paresthesias (“pins and needles”), and pain in the

thumb, index finger, middle finger, and radial half of the ring finger.

 Pain and tenderness at the wrist

 Pain may radiate to the elbow, shoulder, neck

Durkan’s Test, Reverse Phalen’s Test, Phalen’s Test, Tinel’s Test

Transverse carpal ligament gets cut in surgery if needed

Cubital Tunnel Syndrome

Compression of Ulnar N within Cubital tunnel (medial side of elbow)

Epidemiology

 Higher incidence in males: 3-8 times more common in males compared to

females

 2nd most common nerve compression of upper extremity (behind median

nerve compression in carpal tunnel syndrome)

Risk factors include

 Repeatedly leaning on elbow

 Patients who sleep or position themselves with their elbows bent, their arms

overhead, or both

 Patients with occupations demanding prolonged time with elbows bent

 Athletes in throwing sports, racquet sports, weightlifting, and skiing

 Patients with end-stage renal disease on hemodialysis

 Prolonged bending of elbow during surgery or in ICU

 Diabetes, alcoholism, toxins

Tinel’s Test and Elbow Flexion Test, Electromyography/Nerve Conduction Test (EMG/NCS)

Cervical Radiculopathy

Compression of nerve root in cervical spine

Epidemiology

 Higher incidence in males: 1.5 times more common in

males compared to females

Risk factors include

 Trauma with resulting herniated cervical disc

 Arthritic disease of cervical spine

Spurling’s Test

Malingering

Psychiatric Illness or faking

Men with antisocial personality disorder

Angina Pectoris

Etiology

 Typically due to atherosclerotic coronary artery disease

Epidemiology

 Affects both males and females. Women have lower risk than men before

menopause. By age 65, risk is approximately equal.

Risk factors include

 Smoking

 Diabetes

 Hypercholesterolemia

 Hypertension

 Family history of premature coronary artery disease

 Obesity

 Metabolic syndrome

Chest pain down to arm

Tests

 Electrocardiogram (EKG)

 Exercise stress test

 Nuclear perfusion test

 Computed tomography (CT) angiography

 Cardiac catheterization

Clinicopathologic Template

***Etiology – What causes the disease/process?

***Pathogenesis – How do you go from normal to abnormal (steps)?

Clinical Features – How does the disease affect the patient? This includes

presentation, lesions or changes, laboratory values, imaging correlates, etc.

***Morphology –Gross and histologic features of the diseases (vs. normal).

Anatomy correlates to Gross Pathology (e.g. effects that you can see with your eyes).

Histology correlates to Microscopic features of disease.

***Natural history – What typically happens to the patient with the disease?

***Treatment – What is done to treat or control this disease?

Prognosis – Considering treatment and other factors, what happens with the disease

(per the experiences with similar lesions - e.g. grade and stage of tumors).

Normal tissues that compromise the esophagus

The esophagus consists of four main concentric tissue layers from inside out: the mucosa (non-keratinized stratified squamous epithelium, lamina propria, and muscularis mucosae), the submucosa (dense irregular connective tissue with glands), the muscularis propria (inner circular and outer longitudinal muscle layers), and the adventitia (outer connective tissue)

Stratified squamous epithelium of esophagus to glandular gastric epithelium

Stomach is source of acid that results in Barrett esophagus

— is an early sign that occurs with acid reflux

Inflammation (esophagitis)

Acid Reflux

normal squamous epithelium → chronic acid injury/inflammation → possible intestinal-type columnar metaplasia (Barrett esophagus) → dysplasia → possible adenocarcinoma.

Metaplasia

Metaplasia is a reversible change in which one

differentiated cell type (epithelial or

mesenchymal) is replaced by another cell

type. It often represents an adaptive response in

which one cell type that is sensitive to a

particular stress is replaced by another cell type

that is better able to withstand the adverse

environment. (Example shown is squamous

metaplasia of the bronchus. Look at the change

from the columnar to squamous epithelium in

both the drawing and the pathologic

photomicrograph.

What is dysplasia?

Dysplasia is abnormal growth and maturation of epithelial cells, characterized by cellular atypia and disorganized tissue architecture. Microscopically, you may see enlarged, hyperchromatic nuclei, increased mitotic activity, and loss of normal cell polarity and uniformity. It is not the same as cancer, because the abnormal cells have not invaded through the basement membrane

Dysplasia is considered a precancerous change and a marker of increased risk for progression to carcinoma. In the setting of Barrett esophagus, for example, chronic acid injury can lead to intestinal metaplasia, followed by low-grade dysplasia → high-grade dysplasia → invasive adenocarcinoma. Dysplasia can sometimes regress, particularly when the underlying injury is removed, but high-grade dysplasia carries a much higher risk of progression to cancer.