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Pathophys - Test 2 - GIT 3 - Disorders of the Esophagus
Terms in this set (26)
Explain esophageal function
Insertion by hypopharynx and relaxation fo teh UES
Transport by esophageal peristalsis
Delivery by peristalsis and relaxation of LES
List the esophageal symptoms
- Oropharyngeal (insertion)
- Esophageal (neuromuscular dysfunction, mechanical)
Gastroesophageal Reflux Disease (GERD)
Refluxate overcomes the antireflux barriers of the gastroesophageal junction
- Inappropriate, pathologic, spontaneous transient relaxation of the LES
- Reduced LES pressure
- Increased abdominal pressure
- Increased nocturnal HCL (eating late)
- Increased esophageal:HCL contact (at night) with decreased clearing of refluxate
- Delayed gastric emptying
- Sliding hiatal hernia (transient relaxation of LES, impaired lES function)
- Smoking, alcohol, caffeine, chocolate
- Negative H. pylori status (H. pylori is protective)
- Emotional stress (increases subjective severity of symptoms)
Hiatal hernia - sliding
Progressively increasing laxity of the phrenoesophageal membrane
Leads to hiatal hernia and gross incompetence
Hiatal hernia - paraesophageal
Most are small and asymptomatic
Larger paraesophageal hernia can cause:
- Epigastric pain
- Gastric obstruction
- Gastric volvulus
Requires surgical repair
Pulmonary symptoms of GERD (uncommon)
Ear-nose-throat symptoms of GERD (uncommon)
Vocal cord uclers
What 'alarm symptoms' can you see in GERD?
Possible barrett's esophagus (GERD sx > 5 years)
Inadequate therapeutic response
Narrowing or tightening of the esophagus that causes swallowing difficulties.
It can be caused by or associated with gastroesophageal reflux disease, esophagitis (inflammation of the esophagus), dysfunctional lower esophageal sphincter, disordered motility, lye ingestion, or a hiatal hernia.
Strictures can form after esophageal surgery and other treatments such as laser therapy or photodynamic therapy.
While the area heals a scar forms, causing the tissue to pull and tighten which leads to difficulty in swallowing
What are possible complications of GERD?
Stricture (causing dysphagia)
Ulcers (pain, bleeding)
Intractable, troublesome symptoms
Barrett's esophagus (increased risk for cancer)
Specialized intestinal metaplasia in the distal esophagus
Due to chronic severe reflux of acid and bile salts; severity based on esophageal exposure time
Can cause strictures (mid-esophagus)
Risk for progression of cancer:
- Large hiatal hernia
- Long Barrett's segment
- Dysplasia (high grade)
NOTE: 1/3 of patients are 'acid insensitive' (becomes asymptomatic until severe complications)
63yo male with history of progressive dysphagia
Associated with 15lb weight loss over past 3 monhts
Eating softer food to get it to go down
Smoking history - 40 pack years
Cancer of esophagus
Problems with swallowing solids only?
Problems with swallowing fluids only?
Relaxation problem (neuromuscular)
Obstructive dysphagia with weight loss
Squamous cell carcinoma (alcohol, smoking)
Adenocarcinoma (GERD, Barrett's esophagus)
Pathogenesis of esophageal adenocarcinoma
Intestinal metaplasia (Barrett's esophagus)
26yo male. Dysphagia associated with an esophageal food impaction
Occured while eating chicken
History of intermittent heartburn and occasional dysphagia over the last three years - no response to medications
You see concentric rings with white bumps
Eosinophilic esophagitis (EoE)
Affects all age groups
Males > femails
- Children (vomiting, feeding intolerance, failure to thrive)
- Adults (chest pain, heartburn, epigastric pain, dysphagia, food impaction, refractory GERD)
69yo male present with inability to swallow his own saliva
Eating steak at 7pm which "lodged in his throat"
Unable to swallow since that time.
Normally has no difficult, but noted that meet has a tendency to "hang-up" on occasion.
Acute esophageal obstruction (due to poor chewing)
Narrowing of the lumen of the esophagus
10% of the population
- < 13mm dysphagia
- 14-18mm may have dysphagia (poorly chewed)
Associated with GERD
55yo male with history of progressive dysphagia to both liquids and solids
15 lbs loss over last 6 months
Regurgitation, but not heartburn. Prilosec with not helpful.
Esophageal neuromuscular motility disorders
- Motility disorders
-- Distal (diffuse) esophageal spasm
"Failure to relax"
Degeneration of neurons (myenteric plexus)
- Inhibition by NO
- VIP neurons
Reduced relaxation of the LES with swallowing
- Hypertension of LES, increased pressure, cannot open
Loss of peristalsis in lower 2/3 of the esophagus
- Cannot move the food along
- Dysphagia to both liquids and solids
- Weight loss
- Increased risk of squamous carcinoma (if after age 50yo if untreated) - due to stasis and irritation
Bird's beak on barrium swallow (dilated esophagus with beak at sphincter)
19yo female complains of pain on swallowing. History of acne, which she takes doxycyline at night.
In the morning she had pain on swallowing when drinking a glass of orange juice.
Odynophgia due to Pill esophagitis
(Pill gets stuck due to lack of fluids --> ulceration and pain; heals rapidly)
What are the esophageal inflammatory lesions?
Idiopathic ulcer (AIDS)
- CMV (linear ulcers)
AIDS or uncontrolled diabetes
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