Esophagus Disorders Notes

Esophagus Disorders Notes

Tracheoesophageal Fistula (TE Fistula)

  • Definition: An abnormal connection between the trachea and the esophagus, a congenital defect.
  • Common Variant:
    • Proximal esophagus is atretic (ends in a blind pouch).
    • Distal esophagus connects to the trachea via the fistula.
  • Clinical Features:
    • Vomiting: Food enters the blind pouch and regurgitates.
    • Polyhydramnios: Excess amniotic fluid because the fetus cannot swallow, leading to accumulation.
    • Abdominal Distension: Air enters the distal esophagus and traps gas, causing distension.
    • Aspiration: Contents from the stomach can go back to the trachea, potentially leading to aspiration pneumonia.
  • Diagnosis: Understanding the anatomy is crucial for diagnosis.

Esophageal Web

  • Definition: A protrusion of the mucosa that causes obstruction or partial obstruction, leading to dysphagia for poorly chewed food.
  • Anatomy: Composed of mucosa, submucosa, muscularis propria, and serosa. A web is a thin mucosal protrusion.
  • Clinical Features:
    • Dysphagia: Especially for poorly chewed food.
    • Increased Cancer Risk: Higher risk of squamous cell carcinoma.
    • Plummer-Vincent Syndrome Association: Features include iron deficiency anemia, esophageal web, and a beefy red tongue due to atrophy of the mucosa.

Zenker Diverticulum

  • Definition: An outpouching of the pharyngeal mucosa resulting from abnormal pressure during swallowing, leading to mucosal protrusion through the muscular wall.
  • Location: Occurs just above the upper esophageal sphincter at the junction of the esophagus and pharynx.
  • Clinical Features:
    • Feeling of Throat Obstruction: Sensation of a mass.
    • Dysphagia and Halitosis: Food can get trapped, rot, and cause bad breath.
    • False Diverticulum: Only one wall layer protrudes (mucosa via acquired defect).

Mallory-Weiss Syndrome

  • Definition: A longitudinal laceration of the esophageal mucosa at the gastroesophageal (GE) junction due to severe vomiting.
  • Risk Factors: Alcoholism, bulimia, severe vomiting.
  • Presentation:
    • Hematemsis: Blood in vomit, often painful.
    • Boerhaave Syndrome Risk: Potential esophageal rupture, leading to mediastinal air and subcutaneous emphysema.

Esophageal Varices

  • Definition: Dilated submucosal veins in the lower esophagus secondary to portal hypertension.
  • Mechanism: Blood drains from the esophagus into the portal vein; portal hypertension causes venous dilation.
  • Clinical Features:
    • Often Asymptomatic Until Rupture: Rupture causes hematemesis, usually painless (differentiates from Mallory-Weiss).
    • Risk in Cirrhosis: Most common cause of death via rupture and associated coagulopathy.

Achalasia

  • Definition: Inability to relax the lower esophageal sphincter and disordered esophageal motility.
  • Pathophysiology: Damage to ganglion cells in the myenteric plexus affects motility and sphincter relaxation.
  • Clinical Features:
    • Dysphagia for Solids and Liquids: Loss of peristalsis and high lower esophageal sphincter pressure (bird beak sign on imaging).
    • Putrid Breath: Food accumulation leads to rotting and odor.
    • Risk of Squamous Cell Carcinoma: Due to stasis and irritation.

Gastroesophageal Reflux Disease (GERD)

  • Definition: Backflow of stomach acid into the esophagus due to decreased lower esophageal sphincter tone.
  • Risk Factors: Alcohol, tobacco, obesity, fat-rich diet, caffeine, hiatal hernia.
  • Clinical Features:
    • Heartburn: Mimics cardiac chest pain.
    • Adult-Onset Asthma and Cough: Irritation of airways by gastric acid.
    • Dental Erosion: Due to acid exposure.
    • Complications:
      • Ulceration with Stricture: Damage to mucosa leads to healing and narrowing.
      • Barrett's Esophagus: Metaplasia of squamous to columnar epithelium with potential adenocarcinoma progression.

Esophageal Carcinoma

  • Adenocarcinoma:
    • Occurrence: Arises from Barrett's esophagus in the lower one third of the esophagus.
    • Presentation: Progressive dysphagia for solids then liquids, weight loss, pain, and hematemesis.
  • Squamous Cell Carcinoma:
    • Most Common Worldwide: Occurs in middle or upper third of the esophagus.
    • Risk Factors: Alcohol, tobacco, hot tea, achalasia, esophageal webs, severe esophageal injury (e.g., lye ingestion).
    • Presentation: Progressive dysphagia, weight loss, may include hoarseness, cough, and metastasization patterns based on esophageal section.
  • Metastasis:
    • Upper Third: Cervical nodes.
    • Middle Third: Mediastinal/tracheobronchial nodes.
    • Lower Third: Celiac/ gastric nodes.