Pathology: Diseases of the Esophagus

the esophagus extends from what structure to what structure?

from cricoid cartilage to esophagogastric junction

what type of epithelium characterizes the esophagus?

normal non-keratinizing squamous epithelium

what is the function of the lower esophageal sphincter?

prevents reflux of gastric contents into esophagus

what type of muscle is the upper portion of the esophageal wall? lower portion?

upper → striated muscle

lower → smooth muscle

esophageal obstructions can be divided into 2 main categories:

1. mechanical (atresia, stenosis)

2. functional (achalasia)

when are esophageal obstructions often discovered?

shortly after birth due to regurgitation while feeding (atresia and fistulas)

what is atresia?

thin, non-canalized cord replaces part of esophagus

where are atresias often located?

usually near tracheal bifurcation

atresia results in what symptoms?

aspiration, suffocation, pneumonia

what are 2 types of mechanical esophageal obstructions?

atresia and stenosis

what is stenosis?

narrowing of esophagus due to fibrous thickening of submucosa and atrophy of muscularis propria

(can be congenital or acquired)

t/f: stenosis is most commonly acquired rather than congenital

true

atresia is often associated with ______.

fistula (connects esophageal pouch to bronchus or trachea)

stenosis may result from…?

inflammation and scarring (caused by chronic GERD or irradiation)

examples of atresia

functional obstructions can result from…?

impaired smooth muscle relaxation of LES

achalasia is associated with a triad of:

• incomplete relaxation fo LES

• increased LES tone

• esophageal aperistalsis

characteristics of primary achalasia?

• idiopathic

• Failure of distal esophageal inhibitory neurons

• Can affect vagus nerve

characteristics of secondary achalasia?

• Failure of LES to relax

• esophageal dilatation

• destruction of myenteric plexus

secondary achalasia can arise in what disease?

Chagas disease (caused by Trypanosoma cruzi infection)

esophageal varices result from…?

portal hypertension

esophageal varices are seen in 50% of patients with what condition?

cirrhosis

what is the first pass effect?

Venous blood from gastro-intestinal tract goes to liver via portal vein

t/f: esophageal varices can be asymptomatic

true

what are esophageal varices?

• Results from portal hypertension

  • Important cause of esophageal bleeding

  • Dilated vessels that can protrude into lumen of distal esophagus

• can rupture and cause massive bleeding

esophageal varices

what are 2 possible causes of lacerations of the esophagus? which is the most common cause?

Mallory-Weiss syndrome (most common)

Boerhaave syndrome (severe)

Mallory-Weiss syndrome results from…?

acute alcohol intoxication with severe vomiting

what type of lacerations are caused by Mallory-Weiss syndrome?

Esophagus will have linear and superficial tears and crosses gastro-esophageal junction

what type of lacerations are caused by Boerhaave syndrome?

• Rupture of distal esophagus

• Transmural tears can affect mediastinum and result in mediastinitis

which cause of esophageal lacerations requires surgery?

• Mallory-Weiss syndrome = no surgery

• Boerhaave syndrome = surgery needed

MALLORY–WEISS TEAR

why is Boerhaave’s syndrome more severe than mallory-weiss?

Boerhaave’s is a complete rupture → chest pain + shock

mallory-weiss is an incomplete tear only affecting mucosa and submucosa

what is inflammation of esophagus?

esophagitis

what are the various types/causes of esophagitis?

• infectious

• eosinophilic

• reflux

infectious esophagitis is more common in what pt populations?

immunosuppressed

what are the most common infections that cause infectious esophagitis?

• Fungal (Candidiasis)

• Cytomegalovirus

  • shallow ulvers and nuclear/cytoplasmic inclusions

• Herpes simplex virus

  • “punched out” ulcers

INFECTIOUS ESOPHAGITIS-HERPES SIMPLEX VIRUS

INFECTIOUS ESOPHAGITIS-CYTOMEGALOVIRUS

what is the Chronic immunologic disorder characterized by symptoms related to esophageal dysfunction + eosinophilic inflammation?

Eosinophilic esophagitis

Eosinophilic esophagitis is associated with what type of diseases?

atopic diseease (atopic dermatitis, asthma, allergic rhinitis)

what the symptoms of Eosinophilic esophagitis in adults? children?

adults → food impaction and dysphagia

children → food intolerance or GERD-like symptoms

what is the histopathology of Eosinophilic esophagitis?

• Infiltration of eosinophils in superficial aspect of lamina propria and epithelium

• Helps to distinguish from GERD and Crohn disease

what are treatment options for Eosinophilic esophagitis?

• Dietary restrictions to food allergens

• Corticosteroids

• Proton pump inhibitors

Eosinophilic esophagitis (increase eosinophils noted)

what is the most frequent cause of esophagitis and most common outpatient gastrointestinal diagnosis?

Reflux esophagitis (GERD)

what is Reflux esophagitis (GERD)?

• Gastric contents enter the lower esophagus

  • Lower esophageal sphincter is relaxed or decreased in tone

  • Increased abdominal pressure, Alcohol/tobacco use, Pregnancy, Hiatal hernia contribute to GERD

• common in adults 40+

what are symptoms of Reflux esophagitis (GERD)?

• heartburn

• dysphagia

• Regurgitation of sour-tasting gastric contents

what are some complications of Reflux esophagitis (GERD)?

• Esophageal ulceration

• Hematemesis-vomiting blood

• Stricture development

• Barrett esophagus

what is the treatment for Reflux esophagitis (GERD)?

Proton pump inhibitors

what is the Separation of diaphragmatic crura with protrusion of stomach into the thorax called?

hiatal hernia

t/f: hiatal hernias can be cause for LES incompetence

true

what are the symptoms of hiatal hernias?

• can be asymptomatic

• similar to GERD symptoms (heartburn, regurgitation of gastric juices)

what are the 2 types of hiatal hernias?

• Sliding

• Paraesophageal (Rolling)

which type of hiatal hernia is this?

Stomach herniates through diaphragmatic hiatus through which the lower esophagus normally passes

sliding

which type of hiatal hernia is this?

Stomach protrudes through a separate defect alongside the esophagus

Paraesophageal (Rolling)

how is Barrett esophagus diagnosed?

endoscopy and biopsy

what is the clinical presentation of Barett esophagus?

• Patches of red, velvety mucosa

• Extends upward from gastro-esophageal junction

Barrett esophagus is a complication of what other condition?

chronic gastro-esophageal reflux disease (GERD) (10%)

Barrett esophagus presents and increased risk for _________.

adenocarcinoma but most do not develop (0-2-1% per year)

what condition is a premalignant condition characterized by metaplasia of columnar squamous cells to tall, columnar glandular epithelium?

Barrett esophagus (affects lower 1/3 of esophagus)

BARRETT ESOPHAGUS

Esophageal adenocarcinoma Can arise from …?

• Barrett esophagus

• long-standing gastro-esophageal reflux disease (GERD)

Esophageal adenocarcinoma is 7 times more common in men/women?

men

which portion of the esophagus do esophageal adenocarcinomas usually occur?

distal or lower third of esophagus & can invade gastric cardia (stomach)

what are some symptoms of esophageal adenocarcinomas?

• Dysphagia

• Progressive weight loss

• Chest pain

• Vomiting

what is the histopathology of esophageal adenocarcinomas?

• Formation of glands

• Mucin production

pts w esophageal adenocarcinomas have a 5-year survival rate of…?

<25%

ESOPHAGEAL adenocarcinoma

what are risk factors of Esophageal squamous cell carcinoma?

• Alcohol and Tobacco use

• Achalasia

• Frequent consumption of very hot beverages

• Plummer-Vinson syndrome

what portion of the esophagus does Esophageal squamous cell carcinoma usually occur?

middle 1/3

what are some symptoms of Esophageal squamous cell carcinoma usually occur?

• Dysphagia-difficulty swallowing

• Odynophagia-pain on swallowing

• Obstruction

epidemiology of Esophageal squamous cell carcinoma?

• adults >45 yo

• 4x more common in men than women

what is the 5-year survival rate of Esophageal squamous cell carcinoma?

<10%

ESOPHAGEAL SQUAMOUS CELL CARCINOMA

Plummer-Vinson syndrome is a risk factor for …?

esophageal squamous cell carcinoma

epidemiology of Plummer-Vinson syndrome?

• Have severe iron deficiency anemia

• Affects middle-aged and elderly women of Scandinavian origin

Squamous cell carcinoma occur where? (plummer-vinson syndrome)

upper one-third in posterior cricoid area