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Esophageal disorders: Pathology review

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Questions

USMLE® Step 1 style questions USMLE

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A 65-year-old woman comes to the clinic due to difficulty swallowing and retrosternal pain. For the past 2 days, she has had pain with swallowing which has progressively worsened to the point of avoiding all food and drinks. She has not had similar symptoms in the past. Medical history is significant for coronary artery disease, hyperlipidemia, seasonal allergies, and osteoarthritis. The patient has smoked 1 pack of cigarettes per day for 30 years. Medications include aspirin, metoprolol, loratadine, lovastatin, and piroxicam as needed. Temperature is 37.0°C (98.6°F), pulse is 80/min, and blood pressure is 125/85 mmHg. The oral mucosa is clear without erythema or exudate. Cardiac auscultation reveals no murmurs, and ECG shows normal sinus rhythm without ischemic changes. The rest of the physical examination is normal. Endoscopy is obtained and shows multiple round ulcers in the proximal esophagus with relatively normal surrounding tissue. Which of the following is the most likely diagnosis?  

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Yifan Xiao, MD

A 33-year-old named Ravi came to the clinic because he has difficulty swallowing food and water over the last 3 months. Physical examination shows significant weight loss, of 7-kg or 15-lb, since his last visit 4 months ago. Esophageal manometry shows incomplete lower esophageal sphincter relaxation in response to swallowing, while barium swallow reveals a dilated esophagus with an area of distal stenosis. At the same time, a 62-year-old man named Frank comes to the clinic because of bad breath, regurgitation of food overnight, and trouble swallowing food. He has had these symptoms for several months. He denies fever, chills, nausea, vomiting, or weight loss. Physical examination shows a mass on the side of the neck. v

Now, both Ravi and Frank have some form of the esophageal disorder. Esophageal disorders can be subdivided into: inflammatory esophageal disorders, or esophagitis, which are characterized by an inflammation of the esophageal lining along with dysphagia, and odynophagia; functional esophageal disorders, which affect the muscles and nerves that control the motility of the esophagus and cause intermittent dysphagia for solids and liquids; and mechanical esophageal disorders, which are characterized by the blockage of the passageway and they typically cause progressive dysphagia for solids.

Inflammatory esophageal disorders, also known as esophagitis, are characterized by an inflammation of the esophageal lining and based on the cause, they are also subdivided into several types.

First, there’s reflux esophagitis, which is associated with the reflux of gastric acid from the stomach back into the esophagus. Alternatively, pill-induced esophagitis, where a medication injures the esophagus thereby causing inflammation and possible upper GI bleeding. It is associated with medications such as nonsteroidal anti-inflammatory drugs or NSAIDs, bisphosphonates, tetracyclines, iron, and potassium chloride. In caustic esophagitis, caustic agents, such as strong acids like vinegar or strong bases like detergents, cause esophageal lesions.

Sources

  1. "Harrison's Principles of Internal Medicine, Twentieth Edition (Vol.1 & Vol.2)" McGraw-Hill Education / Medical (2018)
  2. "Robbins Basic Pathology" Elsevier (2017)
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  4. "Endoscopic assessment of oesophagitis: clinical and functional correlates and further validation of the Los Angeles classification" Gut (1999)
  5. "How I Approach Dysphagia" Current Gastroenterology Reports (2019)
  6. "Iron deficiency anemia and Plummer–Vinson syndrome: current insights" Journal of Blood Medicine (2017)
  7. "Morphometric and anthropometric analysis of Killian's triangle" The Laryngoscope (2010)