this lecture is a continuation of the esophageal disorder lecture, the second in the GI series by Dr. Thom. we finished up the obstructive esophageal disorders: extrinsic compression, esophageal cancers, barrett esophagus, schatzki ring, plummer vinson, inflammation, candida. extrinsic compression of the esophagus causes dysphagia and results from a number of sources such as abnormal subclavian artery, diverticulosis, mediastinal masses, enlarged heart, cervical spurs. cancer of the esophagus is divided into two main categories: 75% of cases are squamous cell carcinoma, which affects the non keratinizing stratified squamous epithelium and is from tobacco, alcohol, and other carcinogens. adenocarcinoma results from metaplasia of stratified squamous cells, which then turn into barrett's epithelium, which can then undergo more dysplasia and turn into adenocarcinoma. adenocarcinoma does not have a clear link to alcoholism but is connected with smoking, scleroderma/other motor disorders, obesity, drugs, diet. schatzki rings and plummer vinson both involve an extra esophageal growth of some sort; schatzki rings are lower esophageal rings that cause intermittent dysphagias while plummer vinson is an esophageal web, accompanied by fe deficiency anemia.
GERD is gastric reflux caused by relaxation of the LES for various reasons. normally the regurgitation of gastric contents is protected by the LES constriction, downward peristaltic motion, and alkaline saliva mixing. the LES tone can be decreased by a number of factors such as drugs, hormones, certain foods, and GERD symptoms can be worsened with smoking, obesity, and pregnancy. a patient with GERD often experiences heartburn symptoms in addition to possible respiratory complaints due to aspiration of gastric contents, dysphagia / odynophagia, and waterbrash, which is copious salivary secretions in response to GERD. diagnosis is made by endoscopy with biopsy, esophagram with barium swallow, EGD to detect esophagitis (associated in 50% of cases), barrett's esophagus, and to rule out peptic ulcer disease.
the last two esophageal disorders are related to bleeding: mallory weiss is upper GI bleeding caused by lacerations at the gastroesophageal junction and can result in hematemesis, vomiting, or in more severe cases, blood in the stool. it has been shown to be correlated to high consumption of alcohol and aspirin. esophageal varices are varicose veins in the esophagus caused by increased portal hypertension (hep B, C, cirrhosis, alcoholism, fatty liver can all cause), which might rupture and cause massive bleeding in the stomach and out of the mouth.
questions
obstructive esophageal disorders, cont'd...
1. what is esophageal extrinsic compression due to? †
2. what percentage of esophageal cancers are due to SCC vs. adenocarcinoma? √
3. what is the etiology of SCC of the esophagus and what tissue layer does it affect? †
4. what is the treatment of SCC in the esophagus? √
5. what part of the esophagus is adenocarcinoma likely to affect? √
6. describe the pathogenesis of adenocarcinoma of the esophagus. †√
7. what is barrett epithelium? √
8. patients with barrett esophagus are more likely to have... √
9. what are the risk factors for esophageal adenocarcinoma? XX
10. what is a schatzki ring? †√
11. how common is a schatzki ring and what is the prognosis? †√
12. what is plummer vinson syndrome? X√
13. what is the etiology of plummer vinson syndrome? √
14. plummer vinson is resolved by treatment of... √
15. what are some factors that cause inflammation of the esophagus? X√
16. ∂escribe the clinical picture of a patient that has esophageal inflammation due to candida. X†
17. describe the imaging findings of the above patient. X
GERD...
18. what is GERD? √
19. reflux of acid into the esophagus is normally protected by... √
20. what are the causes of GERD? †
21. what can decreased LES pressure be caused by? X
22. what are some typical symptoms of a patient with GERD?
23. what are some extra-esphageal symptoms of a patient with GERD? X
24. patients with GERD are often misdiagnosed with... √
25. what are the imaging techniques used to diagnose GERD? †
26. what is the EGD technique useful for in the diagnosis of GERD? √
27. what are the complications of GERD? X
28. what are the treatments for GERD? X
bleeding problems...
29. what is mallory weiss syndrome?
30. what are the symptoms of mallory weiss?
31. what are the less common symptoms of mallory weiss?
32. what are two substances that have been linked to mallory weiss?
33. what are esophageal varices due to?
34. esophageal varices might lead to...
answers
1. mediastinal masses, aberrant right subclavian artery, enlarged heart, cervical spurs, divertuculi.
2. 2/3 SCC 1/3 adenocarcinoma.
3. tobacco, alcohol, other carcinogens, affects non keratinizing stratified squamous cell epithelium.
4. if surgery, involves removing most of the neck because of the high lymph node concentration.
5. mid and distal esophagus.
6. gastric reflux causes metaplasia of normal stratified squamous cells, turning them into "barrett epithelium", then dysplasia, then adenocarcinoma.
7. specialized intestinal epithelial layer containing goblet cells.
8. lower LES pressure and worse esophageal peristalsis, therefore more acid reflux.
9. not alcohol (!), smoking, scleroderma/other motor disorders, obesity, drugs, diet.
10. a lower esophageal ring that causes intermittent dysphagias.
11. 6-14% of patients who undergo GI exams; usually asymptomatic.
12. dysphagia for solids, esophageal webs (thin mucosal membrane that grows across lumen), fe deficiency anemia.
13. excess smoking and drinking.
14. anemia.
15. chronic debilitating disease, steroids, antibiotics, immunosuppresants, chemo, estrogen. [chronic drugs drugs drugs rays boobs]
16. dysphagia with intense pain of short duration, often tolerate only liquids, oral thrush.
17. barium swallow would show shaggy mucosa or filling defects, endoscopy would show white mucosa and swelling.
18. gastric esophageal reflux disease, a common condition characterized by heartburn and acid regurgitation symptoms.
19. LES, downward peristaltic motion, alkaline saliva.
20. decrease of LES pressure, smoking, pregnancy, obesity.
21. drugs (morphine, diazepam, calcium channel blocker, nitrates, beta-blockers), hormones (secretin, cholecystokinin, glucagon), foods (alcohol, caffeine, lipids, chocolate).
22. heartburn felt usually after eating or bending over, respiratory complications from regurgitation, dysphagia, odynophagia, waterbrash. [heartburn, breathe, swallow, swallow, water]
23. coughing/wheezing, aspiration pneumonia, fatigue, chest pain. [cough, pneumonia, tired, pain]
24. asthma because of the cough which is caused by aspiration.
25. endoscopy with biopsy, barium esophagram, esophagogastroduodenoscopy.
26. identifying esophagitis, barrett esophagus, ruling out peptic ulcer.
27. esophagitis (50% of cases), barrett's esophagus, stricture of distal esophagus, respiratory complications.
28. improve diet, cut out alcohol, stay elevated, heel drops, avoid constricting clothing. [diet, elevation, dropping, clothing]
29. gastroesophageal junction lacerations and upper GI bleeding.
30. hematemesis, followed by wretching / vomiting.
31. hematochezia, melena, syncope, abdominal pain.
32. exceess alcohol and aspirin.
33. anything that increases portal hypertension: Hep B, Hep C, cirrhosis, alcoholism, fatty liver.
34. rupture, massive bleeding into the stomach and out of the mouth (a life threatening emergency).
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