Podcast
Questions and Answers
What characterizes gastroesophageal reflux disease (GERD)?
What characterizes gastroesophageal reflux disease (GERD)?
Which of the following is a common symptom of GERD?
Which of the following is a common symptom of GERD?
What histological change is noted in reflux esophagitis?
What histological change is noted in reflux esophagitis?
Which risk factor is NOT commonly associated with GERD?
Which risk factor is NOT commonly associated with GERD?
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What treatment option is indicated for refractory GERD?
What treatment option is indicated for refractory GERD?
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What is a potential consequence of untreated GERD?
What is a potential consequence of untreated GERD?
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Ingestion of lye can lead to which complication in the esophagus?
Ingestion of lye can lead to which complication in the esophagus?
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Barrett's esophagus is characterized by which change in the esophageal epithelium?
Barrett's esophagus is characterized by which change in the esophageal epithelium?
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What confirms a diagnosis of Barrett's Esophagus during surveillance endoscopy?
What confirms a diagnosis of Barrett's Esophagus during surveillance endoscopy?
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Which type of esophageal cancer is most commonly found in the United States?
Which type of esophageal cancer is most commonly found in the United States?
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What is a common risk factor for developing Adenocarcinoma of the esophagus?
What is a common risk factor for developing Adenocarcinoma of the esophagus?
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Which symptom typically progresses from solids to liquids in esophageal cancer?
Which symptom typically progresses from solids to liquids in esophageal cancer?
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Where does Squamous cell carcinoma of the esophagus typically develop?
Where does Squamous cell carcinoma of the esophagus typically develop?
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What type of pathogen is Candida that can lead to esophagitis?
What type of pathogen is Candida that can lead to esophagitis?
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Which condition is often related to upper esophageal damage leading to cancer?
Which condition is often related to upper esophageal damage leading to cancer?
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What is a possible symptom of upper esophageal cancer due to its anatomical location?
What is a possible symptom of upper esophageal cancer due to its anatomical location?
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Study Notes
Esophageal Disorders
-
Gastroesophageal Reflux Disease (GERD)
- Gastric juice moves from stomach to esophagus
- "Reflux" back into esophagus
- Lower esophageal sphincter (LES) dysfunction
- Decrease in LES tone
- Precise mechanism not fully understood
-
Reflux Esophagitis
- Inflammation of the epithelial layer
- Mucosa: erythema and edema
- Erosions (damage/loss of epithelial layer)
- Histology:
- Basal zone (epithelium) hyperplasia
- Lamina propria papillae elongate
- Eosinophils and neutrophils
Pediatric GERD
- Immature lower esophageal sphincter (LES)
- Vomiting
- Crying
GERD Risk Factors
- Alcohol
- Smoking
- Obesity
- Fatty foods
- Caffeine
- Hiatal hernia
GERD Symptoms
- Heartburn (retrosternal burning sensation)
- After meals or lying flat
- Dysphagia (difficulty swallowing)
- Painful esophagitis
- Respiratory symptoms (reflux into respiratory tract)
- Asthma (adult-onset)
- Cough
- Dyspnea
- Damage to tooth enamel
GERD Treatment
- Weight loss
- Dietary modification (avoid triggers)
- Fatty foods
- Caffeine
- Chocolate
- Spicy foods
- Carbonated beverages
- Peppermint
- Refractory GERD: Nissen fundoplication
- Histamine (H2) blockers
- Famotidine, Ranitidine, Nizatidine, Cimetidine
- Block histamine receptors in parietal cells
- Proton Pump Inhibitors (PPIs)
- Omeprazole, Pantoprazole, Lansoprazole, Esomeprazole
- Inhibit H+/K+ pump in parietal cells
Potential GERD Complications
-
Ulcers, Fibrosis, Strictures
- Acid destroys mucosa (causes ulcers)
- Mucosa replaced with fibrous tissue
- Strictures can lead to dysphagia
-
Lye Ingestion
- Alkali substances (sodium or potassium hydroxide)
- Accidentally ingested by children
- Found in household cleaners, drain openers
- Causes liquefactive necrosis
- Rapid damage through mucosa into esophagus wall
- Neutralized in stomach by acid
- Child usually recovers
- Can result in strictures
Barrett's Esophagus
- Result of long-standing GERD
- Metaplasia of esophagus
- Squamous epithelium changes to intestinal epithelium
Barrett's Esophagus - Diagnostics
- Endoscopy often performed in GERD patients
- If Barrett's seen → regular surveillance endoscopy
- Biopsies to look for carcinoma
Esophageal Cancer
-
Squamous cell or adenocarcinoma
-
Both types: increased risk in smokers
-
Often presents late with advanced disease/mets
-
Presents with "progressive" dysphagia
- Starts with solids
- Progresses to liquids
-
Other symptoms:
- Weight loss
- Hematemesis
-
Adenocarcinoma - most common in the US
- Normally no glandular tissue lining the esophageal lumen
- Need GERD → Barrett's → Glandular epithelium
- Develops in lower 1/3 of esophagus (near stomach acid)
- Obesity is a risk factor (also GERD)
-
Squamous cell – most common worldwide
- Usually in middle or upper esophagus
- Results from processes that damage upper esophagus – Food (alcohol, hot tea) – Achalasia (backup of food) – Esophageal webs (backup of food) – Zenker's – Lye ingestion – Can cause special symptoms due to upper location – Hoarse voice (recurrent laryngeal nerve) – Cough (tracheal involvement)
Lymph Nodes (Esophageal Cancer)
- Upper esophagus (neck): cervical nodes
- Middle (chest): mediastinal, tracheobronchial nodes
- Lower (abdomen): celiac, gastric nodes
Infectious Esophagitis
- Candida (white membranes, pseudohyphae on biopsy)
- HSV-1 (oral herpes, can involve esophagus, "punched out" ulcers)
- CMV ("punched out" ulcers)
- AIDS (CD4 < 50), linear ulcers
Eosinophilic Esophagitis
- Allergic reaction (unknown antigen)
- Immune-mediated
- Esophageal dysfunction (dysphagia)
- Biopsy: eosinophil-predominant inflammation
- Diagnosis of exclusion: rule out other causes of esophagitis (i.e., GERD)
- Classic scenario:
- Dysphagia
- Poor response to GERD treatment
- Eosinophils on biopsy
Achalasia
- Inability to relax lower esophageal sphincter (LES)
- Due to loss of ganglion cells in Auerbach's plexus
- Found in muscular layer (below submucosa)
- Causes:
- Often idiopathic
- Chronic Chagas Disease (Protozoa: Trypanosoma cruzi)
- Symptoms:
- Dysphagia to solids and liquids
- Closed LES
- Contrast with obstruction (solids only)
- Bad breath
- Accumulation of food in esophagus
- Diagnostic Testing:
- Dilation of esophagus
- "Bird's beak" on barium swallow
- Esophageal manometry
- Helpful in dysphagia
- Measures pressure change with contraction
- Shows ↑ LES tone in achalasia
- Contrast with scleroderma (LES tone)
Esophageal Varices
- Dilated submucosal veins (usually in lower 1/3 of esophagus)
- Usually due to portal hypertension (cirrhosis)
- Can lead to upper GI bleeding (variceal rupture)
- Painless bleeding
- Common cause of death in liver disease
- Cirrhotic patients often screened with endoscopy
- Treatment for variceal bleed:
- Emergent endoscopy for banding/ligation
Mallory-Weiss Syndrome
- Damage to esophageal mucosa at GE junction
- Causes painful hematemesis
- Epigastric pain or pain in the back
- Caused by severe, chronic vomiting
- Alcoholism
- Bulimia
Boerhaave Syndrome
- Transmural rupture of esophagus
- Result of severe, chronic vomiting or retching
- Air exits esophagus
- Air in mediastinum on chest X-ray (pneumomediastinum)
- Air under skin in neck ("subcutaneous emphysema")
Esophageal Webs and Rings
- Extension/protrusion of mucosa into lumen of esophagus
- Obstructs food movement → dysphagia
- Webs: Common in upper esophagus
- Rings: Common in lower esophagus
- Risk of squamous cell carcinoma
Schatzki Ring
- Ring at squamocolumnar junction
- Common cause of dysphagia to solids
- Squamous mucosa proximally, columnar distally
Plummer-Vinson Syndrome
- Rare condition; poorly understood cause
- Triad:
- Iron deficiency anemia
- Beefy red tongue
- Damage to tongue mucosal layer (bright red from blood vessel exposure)
- Esophageal web
- Common in middle-age, white women
Zenker's Diverticulum
- Occurs at junction of esophagus and pharynx
- Mucosa/submucosa through muscular wall
- Usually the result of a chronic swallowing problem
- Cricopharyngeal muscle must relax for food to pass
- Failure to relax = difficulty swallowing
- Chronic high pressure in pharynx to force food down = diverticulum
- Classic location: Killian's Triangle
- In the hypopharynx
- Just proximal to upper esophageal sphincter
- Cleavage plane between thyropharyngeus and cricopharyngeus muscles
- Symptoms:
- Dysphagia
- Halitosis (bad breath due to food trapped in diverticulum)
Video Swallowing Study
- Used to diagnose swallowing issues
- Usually part of an upper endoscopy
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Description
This quiz explores the various aspects of esophageal disorders, with a focus on Gastroesophageal Reflux Disease (GERD). It covers the mechanisms, symptoms, risk factors, and pediatric considerations related to GERD. Test your knowledge on the anatomy, physiology, and pathology associated with this common condition.
