Path_ Non-neoplastic Esophagus Describe the common presenting symptoms of esophageal disorders and what they mean pathologically

y o Dysphagia: difficulty swallowingsolids (stricture, obstruction, carcinoma), liquids and solids (motility problem) o Odynophagia: pain upon swallowing o Heartburn: retrosternal burning pain o Hematemesis: vomiting of blood o Melena: blood in stools (may be of upper GI origin) Describe the structural pathology of the esophagus and their common associations o Hiatal hernias are caused by widening of space between esophagus and diaphragm (portion of stomach protrudes above diaphragm that occurs in 1-20% of adults and is significant because they may contribute to reflux); sliding hernia where the stomach protrudes above the diaphragm to create a bell-shaped dilation bound below by the diaphragmatic narrowing (95%), rolling/paraesophageal hernia where a portion of the stomach-usually the greater curvature-enters the thorax through the widened foramen (5%) o Esophageal fistula/atresia is an abnormal connection to another organ that usually occurs in newborns with aspiration, pneumonia and feeding problems; most common variant is atresia of the upper esophagus with a fistula between the trachea and lower esophagus (type C) o Esophageal webs are protrusions of mucosa into the esophageal lumen that can be semicircumferential or eccentric; most common in the upper esophagus; microscopically shows squamous mucosa and a vascularized submucosal core; associated with congenital, long-standing reflux esophagitis, chronic graft-versus-host disease (GVHD), or blistering skin disease Patterson-Brown-Kelly / Plummer-Vinson syndrome is when an upper esophageal web is accompanied by an iron-deficiency anemia, glossitis, and cheilosis; has an attendant risk for postcricoid esophageal carcinoma (DIG mneumonicdysphagia, iron-deficiency anemia, glossitis) o Achalasia is failure of the lower esophageal sphincter to relax following swallowing due to a disorder of innervation, not muscle (absence myenteric Auerbachs-ganglia with esophageal body) causing functional obstruction and dilation of the upper esophagus (birds beak appearance on Barium swallow); can be either primary or secondary (ex: Chagas disease, DM, infiltrative disorders); presents with dysphagia, nocturnal regurgitation and aspiration; causes increased risk of squamous cell carcinoma o Mallory-Weiss Tears are longitudinal tears at the G-E junction that can be superficial or transmural (Boer-Haave Syndrome/Been-Heaving Syndrome); inadequate relaxation of muscles of LES following retching or vomiting (mostly in alcoholics; an underlying hiatal hernia is a predisposing factor); complications include infection, upper GI bleeding or massive hemorrhage

Esophageal Varices are due to portal hypertension (collateral bypass channels where the portal and systemic circulation communicate) and presents with dilated tortuous veins in the submucosa (lower 1/3); occurs in 2/3 of all cirrhotic patients; asymptomatic until rupture, when massive bleeding occurs; 50% mortality and most survivors rebleed within one year Describe the esophageal pathophysiology associated with alcoholism and cirrhosis Describe the common causes of esophagitis (infections, eosinophilic, reflux) and Describe the pathophysiology of reflux esophagitis, its outcomes and associations o Esophagitis can be caused by: Reflux esophagitis occurs in 10-20% of adults in Western countries (adults and children) and presents with heartburn, regurgitation and chest pain (severity of symptoms does not correlate with anatomic findings); PATH: usually multifactorial and includes incompetent LES, sliding hiatal hernia, delayed gastric emptying and increased gastric volume; grossly shows mucosal redness, erosions and/or ulceration; microscopically shows eosinophils +/- other inflammatory cells (neutrophils and lymphocytes), elongation of vascular papillae and basal layer hyperplasia; SEQUELAE: bleeding, stricture, Barretts esophagus Esophageal Stenosis/Stricture is a stenosis/narrowing of the esophagus that occurs with longstanding reflux Barretts Esophagus is a complication of longstanding reflux (up to 10% reflux patients) where there is a replacement of normal distal stratified squamous mucosal by intestinal-type glandular mucosa (ex: the goblet cell that makes protective mucosa); SINGLE MOST IMPORTANT RISK FACTOR FOR ESOPHAGEAL ADENOCARCINOMA o Barretts esophagus Dysplasia Carcinoma Corrosive/irritants Radiation/Chemotherapy Infection Viral Herpetic Esophagitis presents with marked ulceration and hemorrhage of the esophagus; microscopically shows multinucleated giant cells with nuclear inclusions (herpetic inclusions) Fungal Candidal esophagitis presents with yellow exudate in esophagus; on culture, methenamine silver stain stains Candida black (Candida is pink with PAS stain) Bacterial Eosinophilic esophagitis refers to an allergic type of esophagitis; can have symptoms similar to GERD, but no responsive to anti-reflux medications; frequent association with extra-intestinal allergic symptoms such as asthma, eczema, and chronic rhinitis; 24hr pH probe testing is usually normal; ringed appearance (felinization) of esophagus in endoscopy; large number or

intraepithelial eosinophils microscopically; TX: unresponsive to anti-reflux therapy and responsive to steroids and restricted diet; SEQUELAE: if left untreated, can lead to esophageal stricture