[07.01] Pathology of the Esophagus V2.pdf

Esophageal manometry

What diagnostic tool detects the pressure of esophageal movement to differentiate functional dysmotility?

Nutcracker esophagus

What form of esophageal dysmotility presents with high amplitude contractions of the distal esophagus?

Normal

What is the typical result of a barium swallow test in a patient with nutcracker esophagus?

Diffuse esophageal spasm

In which condition does the entire length of the esophagus contract with very minute movements?

Corkscrew esophagus

What characteristic finding is seen on a barium swallow for diffuse esophageal spasm?

Lower esophageal sphincter (LES) dysfunction

Which functional obstruction may lead to small diverticula in the epiphrenic region due to increased wall stress?

Immediately above the lower esophageal sphincter

Where are epiphrenic diverticula anatomically located?

Zenker diverticulum

What is the alternative name for a pharyngoesophageal diverticulum?

Immediately above the upper esophageal sphincter (UES)

Where is a Zenker diverticulum anatomically located?

Age 50

After what age does a Zenker diverticulum usually develop?

Regurgitation and halitosis

What are two common symptoms of a large Zenker diverticulum caused by rotting food accumulation?

Fibrous thickening of the submucosa

What is the primary cause of benign esophageal stenosis?

Atrophy of the muscularis propria

Benign esophageal stenosis is associated with secondary epithelial damage and what muscular change?

Chronic GERD, caustic injury, or inflammation

Besides congenital causes, what are three common causes of acquired esophageal stenosis?

Esophageal mucosal webs

What are semi-circumferential, ledge-like protrusions of mucosa less than 5mm in size?

Females over 40

What demographic is most commonly affected by esophageal mucosal webs?

Non-progressive dysphagia

What is the main clinical symptom of esophageal mucosal webs?

Chronic Graft-versus-host (GvH) or blistering skin disease

Besides GERD, what are two systemic conditions associated with esophageal mucosal webs?

Plummer-Vinson syndrome

Which syndrome is characterized by upper esophageal webs, iron deficiency anemia, glossitis, and cheilosis?

Patterson-Brown-Kelly syndrome

What is another name for Plummer-Vinson syndrome?

Esophageal (Schatzki) rings

Which esophageal protrusions are circumferential and thicker than webs, involving mucosa, submucosa, and hypertrophic muscle?

Distal esophagus

Where are Schatzki "A rings" located?

Squamous epithelium

What type of epithelium covers Schatzki A rings?

Squamocolumnar junction

Where are Schatzki "B rings" located?

Gastric cardia-type mucosa

What type of mucosa is found on Schatzki B rings?

Incomplete LES relaxation, increased LES tone, and aperistalsis

What is the classic triad of characteristics for achalasia?

Beak sign

What radiographic finding is characteristic of the distal esophagus in achalasia?

Difficulty in belching

Besides dysphagia and chest pain, what is a common symptom of achalasia?

Nitric oxide and vasoactive intestinal polypeptides

The release of which two substances from inhibitory neurons normally allows the LES to relax during swallowing?

Primary achalasia

Which type of achalasia is idiopathic and involves the degeneration of nitric oxide-producing neurons?

Extraesophageal vagus nerve or dorsal motor nucleus

Degenerative changes in which neural structures are associated with primary achalasia?

Chagas disease (T. cruzi)

What is a major cause of secondary achalasia that destroys the myenteric plexus?

Diabetic autonomic neuropathy

Name a systemic metabolic condition that can cause secondary achalasia.

Malignancy, amyloidosis, and sarcoidosis

Name three infiltrative disorders that can cause secondary achalasia.

Allgrove (triple-A) syndrome

Which autosomal recessive syndrome includes achalasia, alacrima, and ACTH-resistant adrenal insufficiency?

Down syndrome

Which chromosomal abnormality is associated with lower esophageal sphincter dysfunction?

Laparoscopic myotomy, pneumatic balloon dilation, or Botox

What are three treatment methods used to overcome the obstruction in achalasia?

Hematemesis

What is the usual clinical presentation for both Mallory-Weiss and Boerhaave syndromes?

Mallory-Weiss syndrome

Which syndrome is characterized by linear mucosal lacerations due to severe retching?

Acute alcohol intoxication

What is the most frequent clinical scenario leading to the vomiting that causes Mallory-Weiss tears?

Gastroesophageal junction

Mallory-Weiss lacerations usually cross which anatomical landmark?

Boerhaave syndrome

Which condition involves transmural tearing and rupture of the distal esophagus?

Mediastinitis

What severe inflammatory condition follows the rupture in Boerhaave syndrome?

Myocardial infarction

Because it causes severe chest pain, shock, and tachypnea, Boerhaave syndrome can be mistaken for what?

Surgical emergency

How is the management of Boerhaave syndrome classified due to its catastrophic nature?

Odynophagia

What is the medical term for pain during swallowing?

Muriatic acid

What specific caustic chemical was mentioned as a cause of outright necrosis in the source case?

NSAIDs

Which class of medication is described as the "most notorious" for causing pill-induced esophagitis?

Doxycycline, KCl, Ferrous Sulfate, and Alendronate

Besides NSAIDs, name four other medications associated with pill-induced ulceration.

Puncturing the aorta

How can a lodged pill in the esophagus cause fatal internal bleeding?

Irradiation injury

Which etiology of chemical esophagitis causes intimal proliferation and luminal narrowing of submucosal blood vessels?

Basal epithelial cell apoptosis

What microscopic feature characterizes Graft-versus-host (GvH) disease in the esophagus?

Neutrophils

Which inflammatory cell is usually present in dense infiltrates in chemical esophagitis?

Immunocompromised

Which patient population is most susceptible to HSV, CMV, and fungal esophageal infections?

Adherent, gray-white pseudomembranes

What is the gross endoscopic appearance of candidal esophagitis?

Densely matted fungal hyphae

What is seen upon biopsy of a patient with candidal esophagitis?

Herpesvirus

Which virus causes "punched-out" ulcers in the esophagus?

Nuclear viral inclusions

What microscopic finding is seen within the degenerating epithelial cells at the margin of a herpes ulcer?

Cytomegalovirus (CMV)

Which virus causes shallow ulcerations and nuclear/cytoplasmic inclusions within capillary endothelium?

Reflux esophagitis

What is the most frequent cause of esophagitis and the most common outpatient G.I. diagnosis?

Transient lower esophageal sphincter relaxation

What is the primary mechanism of GERD pathogenesis?

Gastric distention

What trigger, mediated via vagal pathways, can cause transient LES relaxation?

Coughing, straining, or bending

What three actions can increase intra-abdominal pressure and trigger reflux?

Alcohol, tobacco, obesity, and pregnancy

Name four associated conditions or risk factors for GERD.

Hyperemia

In mild cases of GERD, what might be the only finding seen during endoscopy?

1-5

In reflux esophagitis, approximately how many eosinophils are seen per high power field?

Basal zone hyperplasia and elongation of lamina propria papillae

Besides eosinophil influx, what are two other microscopic findings in GERD?

Heartburn and regurgitation of sour-tasting contents

What are the two hallmark symptoms of GERD?

Proton-pump inhibitors (PPI)

What is the primary medical treatment for GERD?

Barrett’s esophagus

What is considered the most important complication of chronic GERD?

Atopic disease (asthma, allergic rhinitis, atopic dermatitis)

Eosinophilic esophagitis is strongly associated with what type of systemic condition?

Felinization

What endoscopic term describes the appearance of the esophagus when stacked circular rings are present in EoE?

Feeding intolerance

How does eosinophilic esophagitis commonly present in children?

Linear furrows

Besides rings and strictures, what other finding is seen during endoscopy in EoE?

Clusters and sheets of intraepithelial eosinophils (eosinophilic abscesses)

What microscopic feature distinguishes EoE from reflux esophagitis?

Dietary restriction (elimination of milk, eggs, soy, etc.)

What is the first-line treatment to prevent exposure to allergens in EoE?

Sliding hiatal hernia

What is the most common type of hiatal hernia where the stomach slides above the diaphragm?

Diaphragmatic crura

In a hiatal hernia, the stomach protrudes through a gap in which structure?

Paraesophageal hiatal hernia

Which less common hernia penetrates through a defect in the phrenoesophageal membrane?

Portal hypertension

What is the underlying cause of esophageal varices?

Alcoholic liver disease (cirrhosis)

What is the most common cause of portal hypertension leading to varices?

Hepatic schistosomiasis

What is the second most common cause of esophageal varices worldwide?

Tortuous dilated veins in the mucosa/submucosa

What is the gross morphology of esophageal varices?

Hemorrhagic shock

Rupture of esophageal varices often leads to death via what mechanism?

15 to 20%

What is the mortality risk associated with each episode of variceal bleeding?

Sclerotherapy, ligation, or balloon tamponade

What are three endoscopic or mechanical treatments for varices?

Beta blockers

Which class of medication is used to induce splanchnic vasoconstriction for varices?

Intestinal metaplasia

What histologic change defines Barrett’s esophagus?

White males aged 40-60

What is the typical demographic for Barrett’s esophagus?

Preinvasive neoplastic change

Because it contains driver mutations, how is Barrett’s esophagus (BE) classified?

Salmon-colored tongues

How is the red, velvety mucosa of Barrett’s described when extending from the gastroesophageal junction?

Long-segment Barrett’s

A metaplastic segment that is 3 cm or longer is classified as what?

Increased risk of adenocarcinoma

What is the clinical significance of a long-segment vs. a short-segment of Barrett's?

Goblet cells

Which cell type is diagnostic for Barrett’s in the USA but not required in Japan?

Low-grade and high-grade

What are the two classifications of Barrett’s dysplasia?

Nuclear hyperchromasia and atypical mitoses

What are two microscopic features suggestive of high-grade dysplasia in Barrett’s?

Regression

What is the likely outcome for most low-grade dysplasia lesions in Barrett's?

Endoscopic surveillance and biopsy

What is the recommended management for single focus high-grade dysplasia?

Esophagectomy, photodynamic therapy, or laser ablation

Name three treatments for intramucosal or invasive carcinoma arising from Barrett's.

"Pencil-like" nuclei

What phrase is used to describe the nuclear appearance in low-grade dysplasia?