Diseases of esophagus: esophagitis, gastroesophageal reflux disease, achalasia, diverticula, hiatal hernia. Esophageal tumors - benign & malignant
Esophagitis
- This is inflammation of the esophagus, below we list common forms of esophagitis
- Lacerations
- Most common form of laceration is Mallory-Weiss tears, often associated with severe retching and vomiting that may be a result of excessive alcohol.
- Prior to vomiting there is usually muscular relaxation, it is thought this fails during prolonged vomiting which causes the esophageal wall to stretch and tear
- In Mallory-Weiss syndrome tears are generally superficial, in the more severe Boerhaave syndrome however, there are transmural esophageal tears which are a catastrophic event
- Chemical and infectious esophagitis
- The stratified squamous mucosa of the epithelium may be damage by irritants such as alcohol, acids, alkalis, hot fluids and heavy smoking.
- Generally such esophagitis only causes pain, particularly pain with swallowing (odynophagia)
- Morphologic changes see accumulation of neutrophils, hyperemia and ulceration
- Infectious forms generally only occur in immunocompromised individuals
- Reflux esophagitis
- Stratified squamous epithelium is sensitive to acid, where we have reflux of gastric contents into lower esophagus (GERD) we get the most frequent cause of esophagitis.
- Pathogenesis is based around conditions that decrease cardiac sphincter or increase abdominal pressure including alcohol and tobacco use, obesity and CNS depressants.
- Reflux causes basal zone hyperplasia with hyperemia and eosinophils in the mucosa
- Clinical features are that of heartburn, dysphagia and occasionally sour-tasting gastric contents
- Most notable complication is Barrett Esophagus, where metaplasia occurs, converting squamous epithelium to columnar epithelium with goblet cells and significantly increasing the risk of adenocarcinoma (30-100x increase).
H&E, Barrett oesophagus: native stratified squamous epithelium (left) is replaced by columnar epithelium with goblet cells (round clear mucin vacuoles, centre) – intestinal metaplasia; gastric-type mucinous cells on the right.
Image: “Histopathology of Barrett's esophagus, original” by Mikael Häggström, M.D. Author info - Reusing images - Conflicts of interest: None Mikael Häggström, M.D. Consent note, CC0, via Wikimedia Commons.
Achalasia
Achalasia is an esophageal motility disorder where the smooth muscle fails to relax (literally, a- + -chalasia = no relaxation), causing lower esophageal sphincter to remain closed. Clinical picture presents with dysphagia, reflux, and sometimes chest pain.
Remember: achalasia is a triad of aperistalsis, incomplete relaxation of the LES and increased LES tone. A barium swallow shows a dilated oesophagus narrowing to a smooth 'bird's beak'. Long-standing achalasia raises the risk of squamous cell carcinoma.