Practice question answers esophageal pathology

Practice question answers

Esophageal pathology

Updated: 03/07/2021

© Jun Wang, MD, PhD

1. D. Dysphagia may be caused by abnormal esophageal motility or physical obstructions, including web and ring, as well as cancers. In this case, physical obstruction is ruled out by endoscopy and image studies. High-resolution manometry is used to monitor the pattern of esophageal motility. Chest pain without other presentations is less likely caused by coronary artery or mediastinal abnormality. Biopsy is used when there is suspicious lesions, or symptoms of reflux.

2. C. Diffuse uncoordinated muscular contraction involving entire esophagus is consistent with diffuse esophageal spasm. Achalasia is characterized by lack of progressive peristalsis and partial/incomplete relaxation of lower esophageal sphincter. Esophagitis, including candidiasis and esophageal web have changes can be identified by endoscope or image studies.

3. A. Achalasia is characterized by lack of progressive peristalsis and partial/incomplete relaxation of lower esophageal sphincter, as shown as stenosis at GE junction by image studies. Barrett esophagus is defined as intestinal metaplasia at GE junction, with gross erythematous mucosal changes. Diffuse esophageal spasm has diffuse uncoordinated muscular contraction involving entire esophagus, not limited to GE junction. Esophageal web is semi circumferential mucosal protrusion that can be identified by endoscopic examination. Esophagitis has recognizable mucosal inflammatory changes.

4. D. Achalasia is associated with muscularis propria hypertrophy. Distal esophagus scarring occurs after injury. Glandular proliferation may be seen in Barrett esophagus with dysplasia, or cancers. Mucosal protrusion can be seen in web and ring. Squamous cell proliferation can be seen in squamous cell carcinoma of esophagus. All these have recognizable mucosal abnormalities.

5. C. Concentric thickening of esophageal wall without malignant features is consistent with esophageal ring. Achalasia usually does not have mucosal thickening. Esophageal cancers have atypia. Esophageal web is semi circumferential mucosal protrusion. Keep in mind, iron deficiency anemia may occur in patients with esophageal ring as well.

6. C. An upper endoscopic exam in a patient with upper GI tract bleeding not only establish the diagnosis, but offer opportunity for therapeutic interventions. For this patient, the etiology might be various, and endoscopic finding of longitudinal fissure along GE junctions confirms the diagnosis of Mallory Weiss tear. Barrett esophagus is defined as intestinal metaplasia at GE junction, with gross erythematous mucosal changes. Candidiasis infection of esophagus, like oral infections, has white patches. Reflux esophagitis and ulcer has irregular erythematous changes and ulcers, but not longitudinal fissure. Varices are dilated submucosal vessels, usually caused by portal hypertension, with associated abnormal liver function test.

7. E. Varices are dilated submucosal vessels, usually caused by portal hypertension, with associated abnormal liver function test. Esophageal cancers usually have a discrete mass, with or without ulceration. Candidiasis infection of esophagus, like oral infections, has white patches. Esophageal web is semi circumferential mucosal protrusion. Mallory Weiss tear is longitudinal mucosal tear along GR junction.

8. D. Herpes infection has cytological changes of multinucleation, nuclear molding and chromatin margining. Esophageal cancers usually have a discrete mass, with or without ulceration. Candidiasis infection of esophagus, like oral infections, has white patches, and microscopically identifiable fungal hyphae. Eosinophilic esophagitis has marked eosinophilic infiltrate, but not nuclear changes seen in Herpes infection.

9. B. See discussion of question 8.

10. C. See discussion of question 8.

11. A. This is a case of eosinophilic esophagitis, characterized by marked eosinophilic infiltrate. It can be caused by allergic reaction or systemic eosinophilia. Monoclonal eosinophilic proliferation is a myeloid neoplasm and usually has other symptoms and lab findings. Parasitic infection is associated with eosinophilic infiltrate in other part of GI tract, or other organs, but parasitic infection is very rare in esophagus.

12. D. The white patch can be caused by various abnormalities, but reduction of pH coindicent with symptom is consistent with reflux esophagitis. Allergic reaction may cause eosinophilic esophagitis. Gastric and intestinal metaplasia is seen in Barrett esophagus. Esophageal cancers usually have a discrete mass, with or without ulceration. Candidiasis infection of esophagus, like oral infections, has white patches. None of these will reduce pH without gastric content reflux.

13. B. Barrett esophagus is defined as intestinal metaplasia at GE junction, with gross erythematous mucosal changes. Esophageal cancers have atypia. Candidiasis infection of esophagus, like oral infections, has white patches. Lymphocytic esophagitis has lymphocytic infiltrate in squamous epithelium, without intestinal metaplasia, unless with concurrent Barrett esophagus.

14. B. Barrett esophagus is a risk factor for esophageal adenocarcinoma.

15. A. Mass with irregular glands lined by atypical cells is most likely adenocarcinoma, especially in the background of Barrett esophagus. Candidiasis infection of esophagus, like oral infections, has white patches, but does not have invasive glands. Esophageal web is semi circumferential mucosal protrusion. Prostate adenocarcinoma usually does not have intestinal metaplasia. Squamous cell carcinoma usually presents with mass with or without ulceration, and microscopically it has irregular growth, invasion and cytological atypia.

16. A. The most important risk factor for esophageal adenocarcinoma is Barrett esophagus.

17. E. Squamous cell carcinoma usually presents with mass with or without ulceration, and microscopically it has irregular growth, invasion and cytological atypia, and intercellular bridges, as shown in the image. Also see discussion of question 15.

18. B. Risk factors of esophagus squamous cell carcinoma is quite similar to those for oral cavity squamous cell carcinoma, including cigarette smoking, betel nuts chewing, and caustic injuries, etc. The most important risk factor for esophageal adenocarcinoma is Barrett esophagus.

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