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Chapter 5 Workbook

LEARNER OBJECTIVES

At the completion of this chapter, the learner will be able to:

Section 1: Introduction
1.1 Define the esophagus and describe its primary function.

Section 2: Anatomy
2.1 Describe the anatomy of the normal esophagus and esophagogastric junction,
      including:
2.2 Motor innervation
2.3 Blood supply
2.4 Lymphatic drainage
2.5 Histology

Section 3: Physiology
3.1 Describe the process of deglutition.
3.2 Describe the function of the upper esophageal sphincter.
3.3 Discuss esophageal body peristalsis, including the difference in the control
      mechanisms between the upper striated-muscle esophagus and distal
      smooth-muscle esophagus.
3.4 Describe the function of the lower esophageal sphincter.

Section 4: Symptoms and Signs of Esophageal Diseases
4.1 Describe the symptoms of esophageal disease, including:

    4.1.1 Dysphagia
    4.1.2 Odynophagia
    4.1.3 Heartburn or pyrosis
    4.1.4 Regurgitation
    4.1.5 Nonheartburn chest pain
    4.1.6 Waterbrash
    4.1.7 Bleeding
    4.1.8 Respiratory/laryngeal symptoms

Section 5: Investigations Used in the Diagnosis of Esophageal Disease
5.0 Define the following investigations:
5.1 Barium x-ray
5.2 Endoscopy with mucosal biopsy and brush cytology
5.3 Bernstein (acid perfusion) test
5.4 Esophageal manometry
5.5 pH reflux studies
5.6 Radionuclide studies

Section 6: Anatomic Variants
6.1 Define esophageal atresia and tracheoesophageal fistula, including how
      they present.
6.2 Define hiatus hernia with regard to anatomic type (sliding versus paraesophageal).

Section 7: Gastroesophageal Reflux Disease (GERD)
7.1 Describe the anatomic and physiological factors predisposing to GERD.
7.2 Outline the clinical features of GERD.
7.3 Discuss the procedures used in diagnosing GERD.
7.4 Discuss the management of GERD, including medical and surgical treatment.
7.5 Define the complications of GERD, including peptic stricture, Barrett's
      esophagus, and respiratory complications.

Section 8: Nonreflux-Induced Esophagitis
8.1 Describe the major infectious causes of esophagitis, including how
      they present.

    8.1.1 Candida esophagitis
    8.1.2 Herpes simplex esophagitis
8.3 Discuss chemical-induced esophagitis, including:
    8.3.1 Caustic chemical ingestion
    8.3.2 Pill-induced esophagitis
8.4 Describe radiation-induced esophagitis.

Section 9: Disorders of the Oropharyngeal Phase of Deglutition
9.1 List the major causes of oropharyngeal deglutition.
9.2 Describe how oropharyngeal dysphagia can be differentiated from esophageal
      dysphagia based on history.
9.3 Describe the investigations required in assessing oropharyngeal dysphagia.
9.4 Discuss the complications of oropharyngeal dysphagia.

Section 10: Motor Disorders of the Esophagus and Lower Esophageal Sphincter
10.0 Describe the major primary and secondary motor disorders of the esophagus,
        including clinical symptoms.
10.1 "Nutcracker" esophagus
10.2 Diffuse esophageal spasm
10.3 Achalasia
10.4 Scleroderma esophagus

Section 11: The Esophagus as a Cause of Angina-Like Chest Pain
11.1 Discuss the management of angina-like chest pain of esophageal origin,
        including presenting symptoms, initial investigations, and treatment.

Section 12: Esophageal Neoplasms
12.0 Discuss the different types of tumors which can involve the esophagus,
        including:
12.1 Benign tumors (leiomyoma, squamous cell papillomas, fibrovascular polyps,
        granular cell tumors)
12.2 Malignant tumors

    12.2.1 Adenocarcinoma
    12.2.2 Squamous cell carcinoma

Section 13: Miscellaneous Disorders of the Esophagus
13.0 Describe the presenting symptomatology and typical x-ray findings of:
13.1 Webs and rings
13.2 Diverticula
13.3 Describe the clinical presentation and management of patients presenting with
        esophageal trauma.
13.4 Describe the clinical presentation and management of patients presenting with
        food-bolus obstruction or foreign bodies.
13.5 Demonstrate the ability to read a barium swallow in patients with sliding and
        paraesophageal hiatus hernia, esophageal cancer, Zenker's diverticulum,
        esophageal diverticulum, and achalasia.
13.6 Develop an approach for the diagnostic evaluation of a patient with dysphagia.

LEARNER WORKBOOK

EXERCISE 1
1.1 Briefly describe the esophagus, including its primary function.

EXERCISE 2
2.1 Describe the anatomy of the esophagus, including the UES and LES. 2.2.1 Motor innervation of the esophagus is via the __________________. 2.2.2 Describe motor innervation of the esophagus. 2.3.1 Arterial blood supply to the UES and cervical esophagus is via
         _________________. 2.3.2 Most of the thoracic esophagus is supplied by which arteries? 2.3.3 The LES and the most distal segment of the esophagus are supplied by which
         arteries? 2.3.4 Venous drainage is via ____________________. 2.4 Briefly describe lymphatic drainage as it relates to the esophagus. 2.5.1 The wall of the esophagus consists of ___ ________, ___ _______, and___
         ________. 2.5.2 Briefly describe the histology of the esophagus. EXERCISE 3
3.1 Briefly describe the process of deglutition. 3.2 What is the function of the upper esophageal sphincter? 3.3 What is the difference in the control mechanisms between the upper
      striated-muscle esophagus and distal smooth-muscle esophagus? 3.4 What is the function of the lower esophageal sphincter? EXERCISE 4
4.1 The most commonly used method of investigating the esophagus is a
       ______________. 4.2 Match the following investigations with the correct measurement.

    Investigation        Measurement
1. pH reflux studies
2. Esophageal manometry
3. Bernstein test
4. Barium x-ray
5. Radionuclide studies
6. Fiberoptic endoscopy
 _____
_____
_____
_____
_____
_____
 a. evaluates both structural lesions &
    motor disorders
b. identifies structural & neurologic
    abnormalities
c. records intraluminal pressures at
    multiple sites
d. assesses gastroesophageal reflux or
    esophageal transit
e. tests sensitivity of the esophagus to
    acid perfusion
f.  measures acid reflux events
g. visualizes the esophageal mucosa

EXERCISE 5
5.1 Briefly describe tracheoesophageal fistula with esophageal atresia. 5.2 Treatment of esophageal fistulas (with or without atresia) is by means of
      _________________. 5.3 Hiatus hernias can be divided into two types: _____________, _____________. 5.4 Describe each type of hiatus hernia. EXERCISE 6
6.1 Describe the anatomic and physiological factors predisposing to GERD. 6.2 The most important barrier to gastroesophageal reflux is the _______________. 6.3 List five clinical features of GERD. 6.4 What tests are used in diagnosing GERD? 6.5 Outline the medical therapies used in GERD. 6.6 Define the following complications of GERD: EXERCISE 7
7.1 The two most common forms of infectious esophagitis are _________________
      and _________________. 7.2 Briefly describe caustic chemical ingestion and its effects on the esophagus. 7.3 Briefly describe pill-induced esophagitis. EXERCISE 8
8.1 List two causes of oropharyngeal deglutition for each of the following categories:
    a. Central nervous system disease
    b. Peripheral nervous system disease
    c. Muscle disease
    d. Local disorders
    e. Idiopathic
8.2 Briefly discuss the treatment for oropharyngeal motor disorders. EXERCISE 9
9.1 Motor disorders of the esophagus can be classified as either primary or
      secondary. Briefly describe the following and identify if they are primary or
      secondary. EXERCISE 10
10.1 Describe the management of angina-like chest pain of esophageal origin,
        including:
    a. Presenting symptoms
    b. Initial investigations
    c. Treatment
EXERCISE 11
11.1 A large number of different tumors can involve the esophagus. Briefly describe
        the following benign tumors:
    a. Leiomyoma
    b. Squamous cell papillomas
    c. Fibrovascular polyps
    d. Granular cell tumors
11.2 Briefly describe the following malignant tumors:
    a. Adenocarcinoma
    b. Squamous cell carcinoma
EXERCISE 12
12.1 Webs are ________________________. 12.2 Schatzki's ring is ___________________. 12.3 Pharyngoesophageal diverticula are _________________________. 12.4 Briefly describe Zenker's diverticulum, including clinical presentation and
        medical management. 12.5 Briefly discuss the differences between midesophageal
        diverticula, epiphrenic diverticula, and intramural diverticulosis. 12.6 Describe the clinical presentation and management of patients presenting with:
 

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