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  1. 1. <ul><li>ESOPHAGUS </li></ul><ul><li>Extends from C6 to T11 or T12 </li></ul><ul><li>Atresia and Fistulas </li></ul><ul><li>a) part of esophagus with a “blind pouch” </li></ul><ul><li>i) usually associated with fistula </li></ul><ul><li>b) associated anomalies: </li></ul><ul><li>i) CH disease </li></ul><ul><li>ii) neurologic disease </li></ul><ul><li>iii) GI malformations </li></ul><ul><li>iv) genitourinary disease </li></ul>
  2. 3. <ul><li>Webs, Rings and Stenosis </li></ul><ul><li>a) webs: shelf-like protrusions into lumen (max ~ 5 mm) </li></ul><ul><li>b) when upper esophageal web is associated with iron deficiency anemia, glossitis and cheilosis </li></ul><ul><li>  “ Plummer-Vinson Syndrome” </li></ul><ul><li>i)  risk of post cricoid esophageal CA </li></ul><ul><li>c) Rings protruding into distal esophagus. </li></ul>
  3. 6. i) at squamocolumnar junction of lower esophagus  Schatzki ring or “B” ring.
  4. 7. d) encountered most often in women > 40 yrs. i) etiology unknown ii) episodic dysphagia with solid food iii) pain infrequent
  5. 8. MOTOR DYSFUNCTION 1. Achalasia a) “failure to relax” i) aperistalsis ii) incomplete relaxation of LES with swallowing iii)  resting tone of LES b) 1 o - etiology poorly understood i) dysfunction of inhibitory neurons in distal esophagus - NO - VIP
  6. 11. ii) degenerative changes in neural innervation - extraesophageal vagal - dorsal motor nucleus c) 2 o – Chagas disease i) Trypanosoma cruzi
  7. 12. ii) destruction of myenteric plexus of esophagus, duodenum, colon, ureter  dilation of the structures d) most cases present as 1 o achalasia e) diabetic neuropathy, infiltrative disorders, etc. f) young adulthood g) Clinical: i) progressive dysphagia ii) nocturnal aspiration iii) 5% incidence of CA
  8. 13. 2. Hiatal Hernia a) sliding (~ 95% of cases) i) protrusion of stomach above diaphragm  bell shaped dilation ii) ~ 10% suffer from reflux b) paraesophageal i) separate portion of stomach enters thorax c) etiology unknown d) Clinical: i) strangulation (b) ; ulceration
  9. 14. 3. Diverticula a) “outpouching” of all visceral layers i) false – only mucosa and sub - mucosa b) types: i) Zenker - above UES ii) traction - midpoint of esophagus iii) epiphrenic - above LES
  10. 17. 4. Lacerations (Mallory-Weiss syndrome) a) longitudinal tears i) esophagogastric junction b) severe retching and vomiting i) commonly seen in alcoholics ii) massive dilation with tearing c) underlying hiatal hernia is also known factor d) 5-10 % of upper GI bleeds i) easily treated ii) rare rupture “Boerhaave”
  11. 20. <ul><li>Esophageal Varices </li></ul><ul><li>portal hypertension </li></ul><ul><li>a) induces collateral circulation </li></ul><ul><li> wherever portal and caval systems </li></ul><ul><li> communicate </li></ul><ul><li>b) in area of lower esophagus </li></ul><ul><li>i)  pressure in esophagus </li></ul><ul><li>- tortuous vessels called “varices” </li></ul><ul><li>c) develop in ~ 90% of patients with cirrhosis (USA) </li></ul><ul><li>d) world  schistosomiasis </li></ul>
  12. 22. <ul><li>e) 40-50% of patients die with first bleeding episode </li></ul><ul><li>i) does not stop spontaneously </li></ul><ul><li>Esophagitis </li></ul><ul><li>Inflammation of mucosa </li></ul><ul><li>a) ~ 5% in USA </li></ul><ul><li>b) GERD (gastroesophageal reflux disease) </li></ul><ul><li>i) reflux of gastric contents is most important cause of esophagitis </li></ul>
  13. 23. c) causes: i)  LES tone ii) sliding hiatal hernia iii) slowed esophageal clearance iv) delayed gastric emptying or  gastric volume v)  repair due to chronic acid exposure d) inflammation: i) neutrophils, eosinophils, lymphocytes in squamous epithelial layer
  14. 24. e) clinical: i) > 40 yrs. ii) dysphagia iii) heartburn iv) hematemesis or melena v) damage associated with chronic acid exposure - bleeding - chest pain - ulceration - stricture - Barrett esophagus
  15. 25. <ul><li>Barrett Esophagus </li></ul><ul><li>Complication of long standing GERD </li></ul><ul><li>Most important risk factor for </li></ul><ul><li>adenocarcinoma </li></ul><ul><li>distal squamous mucosa replaced by </li></ul><ul><li>metaplastic columnar epithelium as </li></ul><ul><li>response to chronic injury (protective!) </li></ul><ul><li>criteria for diagnosis: </li></ul><ul><li>a) endoscopic evidence of columnar </li></ul><ul><li> cells (  gastroesophageal junction) </li></ul><ul><li>b) histology evidence of metaplasia </li></ul>
  16. 29. <ul><li>patients have long history of heartburn </li></ul><ul><li>Dysplasia may represent areas of </li></ul><ul><li>adenocarcinoma </li></ul><ul><li>clinical: </li></ul><ul><li>a) local ulceration with bleeding and stricture </li></ul><ul><li>b) short vs. long Barrett </li></ul><ul><li>- short segment < 3 cm (? % CA) </li></ul><ul><li>- long segment > 3 cm </li></ul><ul><li> (40-fold risk of CA) </li></ul>
  17. 31. <ul><li>Infections and Chemical Esophagitis </li></ul><ul><li>GERD (chemical injury) </li></ul><ul><li>mucosal irritants </li></ul><ul><li>a) alcohol </li></ul><ul><li>b) hot fluids (Tea in Iran) </li></ul><ul><li>c) cytotoxic drugs </li></ul><ul><li>d) infections </li></ul><ul><li>i) HSV </li></ul><ul><li>ii) CMV </li></ul><ul><li>e) uremia (via renal failure) </li></ul><ul><li>f) radiation </li></ul><ul><li>g) autoimmune disease </li></ul>
  18. 34. <ul><li>Tumors </li></ul><ul><li>Malignant </li></ul><ul><li>a) in USA ~ 6% of all CA of GI tract </li></ul><ul><li>i) disproportionate death rate </li></ul><ul><li>- “silent” killer </li></ul><ul><li>b) in USA - squamous cell and adenocarcinoma </li></ul><ul><li>i) worldwide – 90% are squamous </li></ul><ul><li>ii) rare tumors from submucosa </li></ul>
  19. 35. c) Squamous cell CA i) most common type (Worldwide) ii) adults > 50 yrs iii) Iran, China, South Africa and Brazil have  incidence iv) in USA mainly adult males (4:1); blacks 4x higher v) diet and environmental factors (see table 17-1) - nitrosamines (p53) China! - in USA, alcohol and tobacco use
  20. 36. TYLOSIS A genetic disorder characterized by thickening (hyperkeratosis) of the palms and soles, white patches in the mouth (oral leukoplakia ), and risk of esophageal cancer . Only genetic syndrome known to predispose to squamous cell carcinoma . Autosomal dominant inheritance. The gene has been mapped to chromosome 17q25 but has not been identified. The syndrome is also called nonepidermolytic palmoplantar keratoderma.
  21. 37. vi) insidious onset - dysphagia - obstruction - aspiration via fistula - recurrence (local and distant) is common following surgery d) adenocarcinoma i) most arise from the Barrett mucosa (NOT gastric mucosa) ii) white men, > 40 yrs - more common in USA
  22. 38. iii) clinical: patient usually present with the following - dysphagia - bleeding - weight loss - GERD - sliding hiatal hernia - poor prognosis - elimination of Barrett esophagus NOT yet shown to prevent adenocarcinoma
  23. 39. e) benign i) Leiomyoma is most common - Usually asymptomatic         - May produce dysphagia or hematemesis if large          - typically occurs in young males          - Found most often in distal third of esophagus          - Usually solitary, but may be multiple (3%)
  24. 40. Large filling defect with sharply-marginated border is seen in distal esophagus.