Fig.15.7AandB
Fig.15.7CandD ).Theoverlyingmucosacanbeintactorulceratedandnecrotic,particularlyifrupturehasoccurred.
Varices often are asymptomatic, but their rupture can lead to massive hematemesis and death. Variceal rupture therefore constitutes a medical emergency. Despite intervention, as many as half of the patients die from the first bleeding episode, either as a direct consequence of hemorrhage or due to hepatic coma triggered by the protein load that results from intraluminal bleeding as well as hypovolemic shock. Among those who survive, additional episodes of hemorrhage, each potentially fatal, occur in as many as 20% of cases.
EsophagealLacerations,MucosalInjury,andInfections
The most common esophageal lacerations are Mallory-Weiss tears, which are often induced by severe retching or vomiting. Normally, a reflex relaxation of the gastroesophageal musculature precedes the anti-peristaltic contractile wave associated with vomiting. This relaxation may fail during prolonged vomiting, with the result that refluxing gastric contents cause the esophageal wall to stretch and tear. Patients usually present with hematemesis.
The roughly linear lacerations of Mallory-Weiss syndrome are longitudinally oriented and usually cross the gastroesophageal junction (
Fig. 15.8A ). These superficial tears generally heal quickly without surgical intervention. By contrast, severe, transmural esophageal tears (Boerhaave syndrome) result in mediastinitis, are catastrophic, and require prompt surgical intervention.
The stratified squamous mucosa of the esophagus may be damaged by a variety of irritants including alcohol, corrosive acids or alkalis, excessively hot fluids, and heavy smoking. Medicinal pills, most commonly doxycycline and bisphosphonates, may adhere to the esophageal lining and dissolve in the esophagus rather than passing immediately into the stomach, resulting in pill-induced esophagitis. Esophagitis due to chemical injury generally causes only self-limited pain, particularly odynophagia (pain with swallowing). Hemorrhage, stricture, or perforation may occur in severe cases. Iatrogenic esophageal injury may be caused by cytotoxic chemotherapy, radiation therapy, or graft-versus-host disease. The morphologic changes are nonspecific, consisting of ulceration and acute inflammation. Irradiation causes blood vessel damage adding an element of ischemic injury.
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Fig. 15.7 Esophagealvarices.(A)Angiogramshowingseveraltortuousesophagealvarices.(B)Althoughtheangiogramisstriking,endoscopyismorecommonlyusedtoidentifyvarices.(C)Collapsedvaricesarepresentinthispostmortemspecimencorrespondingtotheangiogramin(A).Thepolypoidareasaresitesofvaricealhemorrhagethatwereligatedwithbands.(D)Dilatedvaricesbeneathintactsquamousmucosa.
Infectious esophagitis may occur in otherwise healthy individuals but is most frequent in those who are debilitated or immunosuppressed. In these patients, esophageal infection by herpes simplex viruses, cytomegalovirus (CMV), or fungal organisms is common. Among fungi, Candida is the most common pathogen, although mucormycosis and aspergillosis may also occur. The esophagus may also be involved in desquamative skin diseases such as bullous pemphigoid and epidermolysis bullosa and, rarely, Crohn disease.