Reflux Esophagitis and Esophageal Carcinoma Thomas Rosenzweig, MD

Key Concepts

Functional Esophageal Obstruction  Zenker diverticulum  Cause by impaired relaxation and spasm of the cricopharyngeus muscle  above the upper esophageal sphincter.  after age 50  asymptomatic when small  larger Zenker diverticulae collects food, producing a mass

Mechanical Esophageal Obstruction Benign esophageal stenosis caused by thickening of the submucosa from inflam­mation and scarring that may be caused by chronic gastroesophageal reflux, irradiation, or injury Esophageal mucosal webs idiopathic ledge-like protrusions of mucosa in the upper esophagus women older than 40 webs may be accompanied by iron-deficiency anemia, glossitis, as part of the Plummer-Vinson syndrome The main symptom is nonprogressive dysphagia associated with incompletely chewed food. Esophageal rings (Schatzki rings) similar to webs, but thicker, and include mucosa, submucosa, and, occasionally, hypertrophic muscularis propria

Achalasia Characterized by the triad 1. incomplete LES relaxation 2. increased LES tone 3. aperistalsis of the esophagus  “Bird beak” sign seen on barium swallow Primary achalasia  distal esophageal neuronal (ganglion cell) degeneration. Secondary achalasia  Trypanosoma cruzi (Chagas disease)

Esophageal Lacerations Mallory-Weiss tears associated with severe retching or vomiting secondary to acute alcohol intoxication

Esophagitis Healthy Pt.  herpes simplex virus  nuclear inclusions in a rim of degenerating epithelial cells Not healthy Pt.  herpes simplex virus  cytomegalovirus (CMV)  Nuclear / cytoplasmic inclusions in capillary endothelium and stromal cells  candidiasis (fungi)  adherent, gray-white pseudo-membranes

Gastroesophageal Reflux Disease (GERD)  Caused by lower esophageal sphincter relaxation  People over 40  Complications: Barrett esophagus  Treatment with proton pump inhibitors  Most frequent cause of esophagitis  Lots of eosinophils  Unlike patients with GERD, acid reflux is not prominent so high doses of proton pump inhibitors usually do not provide relief.  The majority of individuals with eosinophilic esophagitis are atopic (inflammatory skin) Eosinophilic Esophagitis

Esophageal Varices Seen in half of the pts. with cirrhosis Venous blood: GI tract → liver (via the portal vein) portal hypertension from blocked flow → esophageal varices (esophageal bleeding when ruptured causing death)  Varices  tortuous dilated veins lying in the submucosa of the distal esophagus and proximal stomach.

Barrett Esophagus  Complication of chronic GERD  Risk of esoph­ageal adenocarcinoma  Diagnosis requires metaplastic columnar mucosa above the gastroesophageal junction  intestinal metaplasia (squamous mucosa replaced with goblet cells)  red, velvety mucosa  white males between 40 and 60  When dysplasia is present, it is classified as low or high (more severe) grade  Gland architecture is abnormal and is characterized by budding, irregular shapes, and cellular crowding

Adenocarcinoma  Most are from Barrett esophagus  Distal third of the esophagus  Caucasian Men  United States, the United Kingdom, Canada, Australia, the Netherlands, and Brazil  Tumors produce mucin and form glands with intestinal- type morphology  Barrett esophagus is usually next to the tumor  5-year survival is less than 25%

Squamous Cell Carcinoma  Middle third of the esophagus  African American males older than 45  Iran, central China, Hong Kong, Brazil, and South Africa  Risk factors: alcohol and tobacco, injury, achalasia, Plummer-Vinson syndrome, diets deficient in fruits or vegetables, and frequent consumption of very hot beverages  Symptoms: dysphagia, odynophagia (pain on swallowing), or obstruction  well-differentiated  5-year survival rate in the US is under 20%

Squamous Cell Carcinoma Morphology  Begins as an in situ lesion termed squamous dysplasia.  Early lesions appear as small, gray-white, plaque-like thickenings…

Key Concepts