Esophageal Disorders PDF

Esophageal Disorders Jason Ryan, MD, MPH GERD Gastroesophageal Reflux Disease Gastric juice from stomach to esophagus “Reflux” back into esophagus Represents a failure of lower esophageal sphincter Decrease in LES tone Precise mechanism not well established Reflux Esophagitis...

Esophageal Disorders Jason Ryan, MD, MPH GERD Gastroesophageal Reflux Disease Gastric juice from stomach to esophagus “Reflux” back into esophagus Represents a failure of lower esophageal sphincter Decrease in LES tone Precise mechanism not well established Reflux Esophagitis Inflammation of epithelial layer Mucosa: erythema and edema Erosions (loss of epithelial layer) Samir@enwiki/Wikipedia Reflux Esophagitis Histology: Basal zone (epithelium) hyperplasia Lamina propria papilla elongate Eosinophils and neutrophils Samir@enwiki/Wikipedia Bobjgalindo/Wikipedia Pediatric GERD Immature lower esophageal sphincter Vomiting Crying Voiceboks/Wikipedia GERD Risk Factors Alcohol Smoking Obesity Fatty foods Caffeine Hiatal Hernia GERD Symptoms Heartburn Retrosternal “burning” sensation After meals, or when lying flat Dysphagia Painful esophagitis Respiratory symptoms Reflux into respiratory tract Asthma (adult-onset) Cough Dyspnea Damage to enamel of teeth GERD Treatment Weight loss Dietary modification (avoid triggers) Fatty foods Caffeine Chocolate Spicy foods Carbonated beverages Peppermint Wikipedia/Public Domain Refractory GERD: Nissen fundoplication GERD Treatment Histamine (H2) blockers Famotidine, Ranitidine, Nizatidine, Cimetidine Block histamine receptors in parietal cells Proton Pump Inhibitors Omeprazole, Pantoprazole, Lansoprazole, Esomeprazole Inhibit H+/K+ pump in parietal cells Ulcers, Fibrosis, Strictures Potential consequences of GERD Acid destroys mucosa (causes ulcers) Replaced by fibrous tissue Can lead to strictures → dysphagia Ingestion of Lye Alkali substances Contain sodium or potassium hydroxide Usually ingested accidentally by children Found in household cleaners, drain openers Causes liquefactive necrosis Rapid injury through mucosa into wall of esophagus Neutralized in stomach by acid Child usually recovers Can result in strictures Wikipedia/Public Domain Barrett’s Esophagus Result of long-standing GERD Metaplasia of esophagus Squamous epithelium → intestinal epithelium Olek Remesz/Wikipedia Barrett’s Esophagus Normal Esophagus Barrett’s Esophagus Non-keratinized Intestinal Mucosa Squamous epithelium Non-ciliated Columnar Epithelium Samir@enwiki/Wikipedia Goblet Cells Nephron/Wikipedia Barrett’s Esophagus Endoscopy often performed in GERD patients If Barrett’s seen → regular surveillance endoscopy Biopsies taken to look for carcinoma Normal (squamous): White Intestinal: Pink/Red Samir/Wikipedia Esophageal Cancer Squamous cell or adenocarcinoma Both types: ↑ risk in smokers Often presents late with advanced disease/mets Presents with “progressive” dysphagia Starts with solids Progresses to liquids as tumor grows Other symptoms Weight loss Hematemesis Esophageal Cancer Adenocarcinoma most common in 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 risk factor (also GERD) Olek Remesz/Wikipedia Esophageal Cancer 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 Upper esophagus (neck): Cervical nodes Middle (chest): Mediastinal nodes Tracheobronchial nodes Lower (abdomen): Celiac nodes Gastric nodes Wikipedia/Public Domain Esophagitis Infectious causes Candida White membranes Pseudohyphae on biopsy HSV-1 Samir/Wikipedia Usually causes oral herpes Can involve esophagus “Punched out” ulcers CMV AIDS (CD4