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Esophagus, Esophagus Motor Dysfunction DIVERTICULA -False-just mucosa, submuc -True-whole thing 1. Zenker-above UES -disordered cricophar motor ->contain food ->regurg -NO DYSPHAGIA -mass in neck 2. Traction-midpoint, (-)Sx -scarring from MS LNs (TB) -or congenital 3. Epiphrenic-above LES -dicoord peristalsis, LES contraction -noct regurg of fluid, Esophagus Motor Dysfunction LACERATIONS (MALLORY-WEISS SYN) -Longitudinal tears -from severe retching (Alcoholics) -and other mechs -usually near EG jcn, prox gastric mucosa -can be just muc or can penetrate wall ->fresh hemorrhages, inflam, infx -infx->inflam ulcer, mediastinitis -5-10% of upper GI bleeds ->hematemesis Boerhaave Syndrome-esoph rupture, Esophagus Esophagitis REFLUX ESOPHAGITIS-heartburn, dysphagia -hematemesis, melena, regurg -dec LES tone:CNS depressants, hypothyroidism, preg, systemic sclerosing d/os, EtOH, tob, NG tube -sliding hiatal hernia -slowed esoph clearance of refluxate -delayed gastric emptying -reduction in reparative capacity ->inflam (eos(early), PMNs, lymphos) - neutrophils signal ulceration ->basal zone hyperplasie (up to 20% epith) ->elongated lam.prop papillae (congestion), Esophagus Esophagitis BARRETT ESOPHAGUS -distal squam->metaplastic col epith -tongues protrude up -moves squamocolumnar jcn cephalad -can look like hiatal hernia if all replaced -can even contain intestinal goblet cells-Dx -look for dysplasia -low-grade-nuclei basally oriented -high-grade-nuclei apically oriented -can ->stricture or ADENOCARCINOMA -30-40-FOLD INCREASE W/ 2cm OF B.E. Short-Segment Barrett Mucosa-if only at jcn -can also->adenoCA, Esophagus Congenital Anomalies STENOSIS-fibrous thickening of wall -esp submucosa -atrophy of musc. propria -epith thin/ulcerating WEBS, RINGS-ledge-like protrusion -esp in WOMEN ᡠyo -Webs-upper esoph -Schatzki rings-lower esoph-squamous -undersurface-gastric columnar Scarring, XRT, Scleroderma->stenosis If web+Fe-def anemia+glossitis+cheilosis =Paterson-Brown-Kelly or Plummer-Vin ->post cricoid CA, Esophagus Tumors BENIGN - Mostly mesenchymal, w/in wall -esp sm. mm origin-leiomyomas (-)Sx (fibroma, lipomas, neurofib, heman too) -Fibrovascular polyps or Pedunculated lipomas -Squamous papilloma-HPV, single or mult -rarely, inflam polyp/inflam pseudotumor, Esophagus Tumors MALIGNANT - 6% of GI CA, more deaths -late discovery -equal SqCC and AC (worldwide-SqCC) SqCC- ᡪyo BLACK MEN -EtOH, TOBACCO, genes -also nutritional defs ->p53 mutation, also p16 -fungus, nitrosamine in Chinal -often HPV DNA in China (not US) -esophagitis->inc. cell turnover->dysplasia MORPH-in situ->overt -20, 50, 30% in upper, middle, lower 1. mostly EXOPHYTIC (60%) 2. some flat along wall (narrows lumen) 3. excavated-25%-ulceration, can->fistula or can erode Ao->BLEED -usually already big by Dx time-early invasion CLINICAL-insidious dysphagia, obstruction -adjust diet->wt loss -hemorrhage, sepsis, aspiration -high survival if caught early->SCREEN, Esophagus Esophageal Varices Tortuous, dilated vv. w/ inc. P (portal HTN) -90% of cirrhotic pts, esp EtOH cirr -hepatic schistosomiasis-2nd most common -protrusion into lumen->rupture->hematemesis -otherwise (-)Sx Tx-sclerotherapy (thrombotic agents), balloon -40% death in each episode, can recur, Esophagus Motor Dysfunction ACHALASIA-mostly primary -neural degeneration-myenteric ganglia -2ndary-Chagas' dz, polio, DM autonomic neuropathy, malig, amyloid, sarcoid 1.Aperistalsis 2.Partial, incomp relaxation or LES 3.Increased resting tone of LES ->dilitation above LES -can have mucosal changes, inflam CLINICAL-young adults -progressive dysphagia, regurg/aspiration -Candida esophagitis, diverticula, Esophagus Esophagitis INFECTIOUS, CHEMICAL -ITIS Inflam via: -mucosal irritants(EtOH, acids, bases) -mild to severe -hot liquids, SMOKING -CTX, superimposed infx, XRT -intimal prolif of vessels, flat pap -thin epith -HSV, CMV viremia, bacteremia -punched-out ulcers -HSV in margins, CMV in caps(base) -bac->necrosis, invade lam. prop. -fungal-CANDIDIASIS, mucor, asp too -teems w/ hyphae (like thrush) -uremia in renal failure, GVHD -also in pemphigoid, epidermolysis bullosa -desquamative derm conditions MORPH-diff, but same common final pathway -severe acute inflam->necrosis->ulceration