Diseases Of The Esophagus PDF

PROFILE W E MA K E D O C TO R S DISEASES OF THE ESOPHAGUS Ximena Paredes Limon, MD Emily Paez Morales, MD OBJECTIVES Apply knowledge of GI anatomy, histology, and physiology to explain the clinicopathologic features, diagnostic criteria, and therapy of disorders resulting in inflamm...

PROFILE W E MA K E D O C TO R S DISEASES OF THE ESOPHAGUS Ximena Paredes Limon, MD Emily Paez Morales, MD OBJECTIVES Apply knowledge of GI anatomy, histology, and physiology to explain the clinicopathologic features, diagnostic criteria, and therapy of disorders resulting in inflammation, abnormal GI motility, and gastrointestinal tract obstruction. Describe the pathophysiology and clinicopathological features of disorders (Zenker diverticulum, achalasia, esophagitis, esophageal reflux, Mallory Weiss syndrome, hiatal hernias.) Exploring treatment and management options for Esophageal Diseases including lifestyle modifications, pharmacological interventions, and surgical procedures. ESOPHAGUS It is a hollow, highly distensible muscular tube that extends from the epiglottis in the pharynx to the gastroesophageal junction. 18- to 26-cm long hollow muscular tube. The esophagus acts as a conduit for the transport of food from the oral cavity to the stomach. Structurally, the esophageal wall is composed of 4 layers: innermost mucosa, submucosa, muscularis propria, and Esophagus outermost adventitia. Esophageal constriction ESOPHAGUS ESOPHAGUS  ESOPHAGUS MUCOSA Lined by nonkeratinizing stratified squamous epithelium that transitions to columnar epithelium at the gastroesophageal junction.  ESOPHAGUS SUBMUCOSA Contains blood vessels, Meissner’s plexus, and glandular epithelium.  ESOPHAGUS MUSCULAR Contains inner circular and outerlongitudinal muscle fibers. The Auerbach’s plexus lies in between the two layers. Proximal 1/3 - mostly striated muscle. Distal 2/3 - mostly smooth muscle.  ESOPHAGUS ADVENTITIA Consists of dense connective tissue and elastic fibers that attaches the esophagus to the rest of the body. ESOPHAGUS ESOPHAGEAL DISORDERS Esophagitis Achalasia Reflux Esophagitis Esophageal varices Zenker diverticulum Mallory-Weiss syndrome Hiatal Hernia ESOPHAGITIS Definition: Inflammation of the esophageal mucosa secondary to direct mucosal injury (e.g., gastroesophageal reflux or GERD, substance- induced esophagitis) or to an inflammatory Gastroesophageal reflux disease (GERD) process (e.g., eosinophilic esophagitis). Mucosal injury Infections Substance-induced esophagitis Radiotherapy Specific Eosinophilic esophagitis infiltrates Lymphocytic esophagitis 2% https://next.amboss.com/us/article/-q0Dah?q=ESOPHAGUS#Z1008bce41f8744f992503016c5762590 ESOPHAGITIS EOSINOPHILIC ESOPHAGITIS Definition: Chronic immune-mediated eosinophil-predominant inflammation of the esophageal mucosa. Associated with allergic diseases (allergic asthma, allergic rhinitis) in 50% of cases. Etiology: Young individuals Males Allergies/atopy https://next.amboss.com/us/article/-q0Dah#Zb42361e65713e74410d6ae7002959c43 ESOPHAGITIS EOSINOPHILIC ESOPHAGITIS Clinical features: Dysphagia Food bolus impaction Symptoms can be worsened by ingestion of food containing allergens https://next.amboss.com/us/article/-q0Dah#Zb42361e65713e74410d6ae7002959c43 ESOPHAGITIS EOSINOPHILIC ESOPHAGITIS Diagnostics: Symptoms of esophageal dysfunction + histopathologic confirmation. Histopathology Intraepithelial accumulation of eosinophils. https://next.amboss.com/us/article/-q0Dah#Zb42361e65713e74410d6ae7002959c43 ESOPHAGITIS EOSINOPHILIC ESOPHAGITIS Treatment: Responds with proton pump inhibitors PPIs for 8 weeks Dietary restrictions to prevent exposure to food allergens. Cow’s milk, eggs, soy or legumes, and wheat from the diet can be beneficial. https://next.amboss.com/us/article/-q0Dah#Zb42361e65713e74410d6ae7002959c43 ESOPHAGEAL DISORDERS Esophagitis Achalasia Reflux Esophagitis Esophageal varices Zenker diverticulum Mallory-Weiss syndrome Hiatal Hernia ACHALASIA Incomplete lower Achalasia triad: esophageal sphincter relaxation Increased lower Aperistalsis of the 18% esophageal sphincter esophagus. Kumar, V., Abbas, A. K., & Aster, J. C. (2021). The gastrointestinal tract. In Robbins & Cotran Pathologic Basis of Disease ( 10th ed., pp. 753–822). Elsevier. ACHALASIA Etiology Primary achalasia (most common): cause is unknown Degeneration of nitric oxide (NO) producing neurons that normally induce lower esophageal sphincter relaxation Secondary achalasia (pseudoachalasia): by a mechanical cause of obstruction that mimics achalasia. Chagasdisease: causes destruction of the myenteric plexus, failure of peristalsis, and esophageal dilation. Esophagealcancer Stomachcancer Amyloidosis 18% Kumar, V., Abbas, A. K., & Aster, J. C. (2021). The gastrointestinal tract. In Robbins & Cotran Pathologic Basis of Disease ( 10th ed., pp. 753–822). Elsevier. ACHALASIA Pathophysiology Degeneration of inhibitory neurons (containing NO and VIP) in the myenteric (Auerbach) plexus of esophageal wall. Increased resting pressure of the LES, as well as dysfunctional peristalsisàesophageal dilation proximal to LES. Clinical manifestations Progressive dysphagia --> solids + liquids Regurgitation Retrosternal pain Weight loss 18% Kumar, V., Abbas, A. K., & Aster, J. C. (2021). The gastrointestinal tract. In Robbins & Cotran Pathologic Basis of Disease (10th ed., pp. 753–822). Elsevier.  ACHALASIA 18% Kumar, V., Abbas, A. K., & Aster, J. C. (2021). The gastrointestinal tract. In Robbins & Cotran Pathologic Basis of Disease (10th ed., pp. 753–822). Elsevier. ACHALASIA Manometry findings include uncoordinated or absent peristalsis with LES resting pressure. Barium swallow shows dilated esophagus with area of distal stenosis (“bird’s beak”). 18% Kumar, V., Abbas, A. K., & Aster, J. C. (2021). The gastrointestinal tract. In Robbins & Cotran Pathologic Basis of Disease (10th ed., pp. 753–822). Elsevier. ACHALASIA ESOPHAGEAL MANOMETRY Peristalsis is absent or uncoordinated in the lower two thirds of the esophagus. Incomplete or absent LES relaxation High LES resting pressure No evidence of mechanical obstruction 18% https://next.amboss.com/us/article/ug0pC2#Lfe167be960955994ed36b067b5584921 ACHALASIA Treatment Surgery: goal is to relieve the functional obstruction of the lower esophageal sphincter (LES) while preventing reflux. - HELLER MYOTOMY + PARTIAL FUNDOPLICATION Endoscopy procedures (eg, botulinum toxin injection) https://next.amboss.com/us/article/ug0pC2#Lfe167be960955994ed36b067b5584921 ESOPHAGEAL DISORDERS Esophagitis Achalasia Reflux Esophagitis Esophageal varices Zenker diverticulum Mallory-Weiss syndrome Hiatal Hernia REFLUX ESOPHAGITIS Reflux of gastric contents into the lower esophagus is the most frequent cause of esophagitis and the most common outpatient GI diagnosis in the United States. The associated clinical condition, termed gastroesophageal reflux disease (GERD), occurs because the esophageal epithelium is sensitive to acid despite being resistant to abrasive injury. The most common endoscopic finding associated with esophageal mucosa injury is reflux esophagitis. Kumar, V., Abbas, A. K., & Aster, J. C. (2021). The gastrointestinal tract. In Robbins & Cotran Pathologic Basis of Disease (10th ed., pp. 753–822). Elsevier. REFLUX ESOPHAGITIS Pathogenesis Transient lower esophageal sphincter relaxation is thought to be a major cause of GERD. - Relaxation is mediated via vagal pathways and triggered by gastric distention Gastroesophageal reflux can also occur: Following abrupt increases in intra-abdominal pressure(after coughing, straining, or bending). Alcohol + tobacco use Obesity Pregnancy Hiatal hernia Kumar, V., Abbas, A. K., & Aster, J. C. (2021). The gastrointestinal tract. In Robbins & Cotran Pathologic Basis of Disease (10th ed., pp. 753–822). Elsevier. REFLUX ESOPHAGITIS Morphology Simple hyperemia in mild GERD Mucosal histology is often unremarkable More significant gastric reflux is associated with erosions Kumar, V., Abbas, A. K., & Aster, J. C. (2021). The gastrointestinal tract. In Robbins & Cotran Pathologic Basis of Disease ( 10th ed., pp. 753–822). Elsevier. REFLUX ESOPHAGITIS Kumar, V., Abbas, A. K., & Aster, J. C. (2021). The gastrointestinal tract. In Robbins & Cotran Pathologic Basis of Disease (10th ed., pp. 753–822). Elsevier. BARRET ESOPHAGUS Is a complication of chronic GERD Glandular metaplasia that occurs in the distal esophagus as a result of chronic reflux of gastric acid into the esophagus. 10% of individuals with symptomatic GE White males 40-60 years of age Increased risk of esophageal adenocarcinoma The normal squamous cell lining of the esophagus cannot handle gastric acid, so the epithelium converts to glandular epithelium (metaplasia). If the cause of the reflux is removed, the metaplasia will regress. If the reflux continues, metaplasia can lead to dysplasia, which leads to carcinoma. Kumar, V., Abbas, A. K., & Aster, J. C. (2021). The gastrointestinal tract. In Robbins & Cotran Pathologic Basis of Disease ( 10th ed., pp. 753–822). Elsevier. BARRET ESOPHAGUS Morphology: Can be recognized as tongues of red, velvety mucosa extending upward from the gastroesophageal junction. Kumar, V., Abbas, A. K., & Aster, J. C. (2021). The gastrointestinal tract. In Robbins & Cotran Pathologic Basis of Disease ( 10th ed., pp. 753–822). Elsevier. BARRET ESOPHAGUS Diagnosis Diagnosis of Barrett esophagus requires endoscopic evidence of metaplastic columnar mucosa above the gastroesophageal junction. Kumar, V., Abbas, A. K., & Aster, J. C. (2021). The gastrointestinal tract. In Robbins & Cotran Pathologic Basis of Disease ( 10th ed., pp. 753–822). Elsevier. BARRET ESOPHAGUS BARRET ESOPHAGUS Microscopically, intestinal-type metaplasia is seen as replacement of the squamous esophageal epithelium with goblet cells. Goblet cells are diagnostic of Barrett esophagus and have distinct mucous vacuoles that stain pale blue and impart the shape of a wine goblet to the remaining cytoplasm Kumar, V., Abbas, A. K., & Aster, J. C. (2021). The gastrointestinal tract. In Robbins & Cotran Pathologic Basis of Disease ( 10th ed., pp. 753–822). Elsevier. BARRET ESOPHAGUS ESOPHAGEAL DISORDERS Esophagitis Achalasia Reflux Esophagitis Esophageal varices Zenker diverticulum Mallory-Weiss syndrome Hiatal Hernia ESOPHAGEAL VARICES Common in patients with cirrhosis, most frequently due to alcoholic liver disease. Dilated veins within the lower esophagus. Although most small varices never bleed, rupture of large varices can result in exsanguination. Esophageal varices are caused by portal hypertension, which is due to impaired blood flow through the portal venous system and liver. https://next.amboss.com/us/article/Zs0Zth?q=esophageal+varices ESOPHAGEAL VARICES Clinical features: Nonbleeding varices: typically asymptomatic Bleeding varices: sudden onset of severe symptoms of gastrointestinal bleeding - Signs of hemorrhagic shock - Hematochezia - Melena - Hematemesis Diagnosis of esophageal varices --> Esophagogastroduodenoscopy (EGD - Presence of varices Treatments include: Beta-blockers to reduce portal blood flow and endoscopic variceal ligation. https://next.amboss.com/us/article/Zs0Zth?q=esophageal+varices ESOPHAGEAL DISORDERS Esophagitis Achalasia Reflux Esophagitis Esophageal varices Zenker diverticulum Mallory-Weiss syndrome Hiatal Hernia ZENKER DIVERTICULUM Outpouching of the lower pharyngeal mucosa and submucosa caused by inadequate relaxation of the upper esophageal sphincter and increased intraluminal pressure. Most common: older males Presenting symptoms: Dysphagia Obstruction Gurgling Aspiration Halitosis Neckmass ZENKER DIVERTICULUM Pathophysiology Inadequate relaxation of the esophageal sphincter and increased intraluminal pressure outpouching of the esophageal wall. Esophageal dysmotility causes herniation of mucosal tissue at an area of weakness between the thyropharyngeal and cricopharyngeal parts of the inferior pharyngeal constrictor (Killian triangle). Arises above upper esophageal sphincter at junction of esophagus and pharynx. Schlottmann F, & Patti M.G. (2025). Esophagus & diaphragm. Doherty G.M.(Ed.), Current Diagnosis & Treatment: Surgery, 16th Edition. ZENKER DIVERTICULUM Diagnostics: Barium Swallow with Videofluoroscopy. A contrast filled pouch protruding from the esophageal wall. Treatment: Surgery. Indicated for patients with symptomatic esophageal diverticula and can be considered for asymptomatic diverticula for >2 cm. Schlottmann F, & Patti M.G. (2025). Esophagus & diaphragm. Doherty G.M.(Ed.), Current Diagnosis & Treatment: Surgery, 16th Edition. ZENKER DIVERTICULUM ESOPHAGEAL DISORDERS Esophagitis Achalasia Reflux Esophagitis Esophageal varices Zenker diverticulum Mallory-Weiss syndrome Hiatal Hernia MALLORY WEISS SYNDROME Partial thickness, longitudinal lacerations of gastroesophageal junction, are most often associated with severe retching or vomiting secondary to acute alcohol intoxication. Often presents with hematemesis +/– abdominal/back pain. Usually found in patients with alcohol use disorder, bulimia nervosa. Confined to mucosa/ submucosa due to severe vomiting. https://next.amboss.com/us/article/9g0Nx2?q=mallory-weiss+syndrome MALLORY WEISS SYNDROME Etiology: Precipitating factors: Severe vomiting Blunt abdominal trauma Predisposing conditions: Alcohol use disorder Bulimia nervosa Hiatal hernia GERD https://next.amboss.com/us/article/9g0Nx2?q=mallory-weiss+syndrome MALLORY WEISS SYNDROME Clinical manifestations: May be asymptomatic Hematemesis Epigastric or back pain Possible shock with massive hemorrhage https://next.amboss.com/us/article/9g0Nx2?q=mallory-weiss+syndrome MALLORY WEISS SYNDROME Diagnosis: EGD is the gold standard test and can rule out other differential diagnoses of upper GI bleeding. Treatment: Surgical treatment --> Indication: only considered if EGD and angiographic treatment are unsuccessful and bleeding is ongoing Technique: surgical ligation of bleeding vessels https://next.amboss.com/us/article/9g0Nx2?q=mallory-weiss+syndrome ESOPHAGEAL DISORDERS Esophagitis Achalasia Reflux Esophagitis Esophageal varices Zenker diverticulum Mallory-Weiss syndrome Hiatal Hernia HIATAL HERNIA A hiatal hernia is the abnormal protrusion of an abdominal structure into the thoracic cavity through a lax esophageal hiatus. HIATAL HERNIA CLASSIFICATION HIATAL HERNIA Diagnosis: Barium swallow Most sensitive study for hiatal hernia Used to evaluate hiatal hernia size and type Treatment: Type I hiatal hernia Asymptomatic patients: no treatment necessary Symptomatic patients ⚬ Consider antireflux surgery in all patients with symptoms of GERD. All other types Asymptomatic patients ⚬ Usually managed conservatively. Symptomatic patients: surgery indicated  References Zenker's Diverticulum Law, Ryan et al. Clinical Gastroenterology and Hepatology, Volume 12, Issue 11, 1773 - 1782 Schlottmann F, & Patti M.G. (2025). Esophagus & diaphragm. Doherty G.M.(Ed.), Current Diagnosis & Treatment: Surgery, 16th Edition. McGraw Hill. https://bibliodig.uag.mx:2091/content.aspx?bookid=3532 &sectionid=291220618 (2021). Anatomy and physiology in gastroenterology. Huppert L.A., & Dyster T.G.(Eds.), Huppert’s Notes: Pathophysiology and Clinical Pearls for Internal Medicine. McGraw Hill. https://bibliodig.uag.mx:2091/content.aspx?bookid=3072 &sectionid=257402195 Schlottmann F, & Patti M.G. (2025). Esophagus & diaphragm. Doherty G.M.(Ed.), Current Diagnosis & Treatment: Surgery, 16th Edition.