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What are the three phases of swallowing?
- 1. Oral phase
- 2. Pharyngeal phase
- 3. Esophageal phase
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What are steps involved in the oral phase?
- 1. Ingestion
- 2. Mechanical formation of the bolus
- 3. Transport of the bolus to the pharyngeal inlet
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Where does the basic neural control for mastication reside?
Lower pons
Upper medulla
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What are the basic steps in pharyngeal phase of swallowing?
- 1. Seal nasopharynx
- 2. Propel bolus and raise hyoid and larynx
- 3. Seal pharyngeal inlet
- 4. Clear bolus, return larynx and hyoid to original position.
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What is the most common cause of death in patients with Parkinson's disease?
Aspiration pneumonia
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What are the normal sites of esophageal narrowing?
- Aortic arch
- Left mainstem bronchus
- Left atrium
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What structures prevent nasopharyngeal regurgitation?
Soft palate elevates to oppose Passavant's cushion
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What are the components of the pharynx?
- Nasopharynx
- Oropharynx
- Hypopharynx
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What anatomic lines define the oropharynx?
Soft palate to the hyoid bone
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What anatomic segments define the hypopharynx?
Hyoid bone to the cricopharyngeus
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What is Killian's triangle?
Space between inferior pharyngeal constrictor and cricopharyngeal muscle
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Where do Zenker's diverticula occur?
Posterior wall of pharynx
Killian's triangle
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What is primary peristalsis?
Bolus received
Stripping wave from top to bottom of esophagus
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What is secondary peristalsis?
Initiated by esophageal distention
Starts in mid esophagus, moves up and down to clear bolus
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What is tertiary peristalsis?
Nonproductive contractions associated with motility disorders
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What is the difference between penetration and aspiration?
Aspiration - barium passage below vocal cords
Penetration - entry of barium into vestibule but stays above vocal cords
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What are the characteristic radiographic signs of scleroderma in the esophagus?
Decreased peristalsis in lower 2/3 of esophagus
Incompetent LES
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Where do lateral pharyngeal diverticula tend to occur?
Tonsillar fossa and thyrohyoid membrane
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What types of patients get lateral pharyngeal diverticula?
Wind instrument players
Glass blowers
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What is the classic radiographic sign of achalasia?
Dilated proximal esophagus with smooth tapered esophagus
"Bird's Beak"
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What are the pathologic findings in an esophagus affected by achalasia?
Failure of LES to relax
Aperistalsis of distal 2/3 of esophagus
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What is the way to distinguish between achalasia and pseudoachalasia?
In achalasia, the LES will periodically will relax with continued drinking
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What is the differential diagnosis for a Ram's horn sign seen in upper GI?
Crohn's disease
Carcinoma
Syphilis
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In what structure does the esophagus terminate?
Esophageal vestibule
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Which structure marks the point between the tubular esophagus and the esophageal vestibule?
A ring
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What is the pathophysiology of pancreas divisum?
Failure of ventral and dorsal pancreatic buds to fuse
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Pancreas divisum - Failure of ventral and dorsal pancreatic buds to fuse
C -
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Middle hepatic - right and left lobes
Right hepatic vein - anterior and posterior segments (5 and 8 (anterior) and 6 and 7 (posterior))
Left hepatic vein - Medial and lateral segments(2 & 3 (lateral), 4 (medial)
Portal vein - Divides liver into upper and lower segments
Segments - clockwise rotation
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What part of the brainstem is responsible for swallowing?
Ventral and dorsal medulla
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What nucleus in the brainstem is responsible for integrating much of the sensory input regarding swallowing reflexes?
Nucleus tractus solitarius
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What nerve is primarily responsible for carrying sensory input to the nucleus tractus solitarius in swallowing?
Superior laryngeal nerve
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Where are the motor neurons located that are involved with the swallowing process?
Nucleus ambiguus
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How does the supraglottic swallow maneuver help prevent aspiration?
Patient holds breath prior to and during the swallow > closes vocal folds > coughs after swallow
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What are the types of gastric carcinoid tumors?
Type 1 - Associated with atrophic gastritis
Type 2 - Associated with Zollinger Ellison syndrome and MEN-1
Type 3 - Sporadic
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What is the differential diagnosis for dilated small bowel with normal folds?
- 1. Small bowel obstruction/Ileus
- 2. Scleroderma
- 3. Sprue
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What is the differential diagnosis for a segment of thick, straight folds?
- 1. Ischemia
- 2. Radiation
- 3. Hemorrhage
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What is the differential diagnosis for diffuse, thickened, straight folds?
- 1. Venous congestion
- 2. Hypoproteinemia
- 3. Cirrhosis
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What is the differential diagnosis for thickened, nodular folds in a segmental distribution?
Crohn's disease
Infection
Malignancy
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What are the top 3 benign neoplasms of the small bowel?
1. Leiomyoma
2. Adenoma
3. Lipoma
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What is the most common primary small bowel neoplasm?
Carcinoid tumor
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What is carcinoid syndrome?
Flushing (skin)
Diarrhea
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When does carcinoid syndrome occur?
Carcinoid produces serotonin
Normally serotonin is inactivated by liver
Carcinoid liver mets > carcinoid syndrome
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What types of polyps are found in patients with Peutz Jeghers?
Hamartomas
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In a patient with multiple hamartomas in the small bowel, what other clinical finding should you look for to look for syndromic disease?
Mucocutaneous pigmentation
(Peutz Jegher's syndrome)
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What is the clinical presentation associated with emphysematous cholecystitis?
Elderly patients
Diabetic
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What is the clinical setting in which graft versus host disease occurs?
After bone marrow transplant
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Graft versus host disease
Small/large bowel inflammation
"Ribbon" bowel
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How can the bowel be affected in neutropenic patients?
Typhilitis - inflammation of the cecum
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What is the pathophysiology of epiploic appendigitis?
Torsion/thrombosis of appendices epiploicae (fat containing pouches of peritoneum)
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What is the path of spread of peritoneal metastases starting from the pelvis?
Pouch of Douglas > Right paracolic gutter > Hepatorenal recess (Morrison's pouch) > Right subphrenic space > Prevented from going out to left side by phrenocolic ligament and falciform ligament
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What is the differential diagnosis for multiple round, submucosal filling defects in the rectum?
Colitis cystica profunda
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What changes can occur in the colon when a patient is healing from a bout of inflammatory bowel disease?
Post-inflammatory polyps can form
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Mucocele - dilated, fluid filled appendix with NO stranding or wall thickening
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What are benign causes of pneumatosis coli?
Steroid use
Collagen vascular disease
COPD
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What findings on CT place someone at risk for midgut volvulus?
Rotational anomaly of the gut
- - Jejunum in right upper quadrant
- - SMA to the right of the SMV
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What is the most common cause of Budd Chiari syndrome?
Hypercoagulable state (leading to thrombosis of hepatic veins/IVC)
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What is the etiology of a transient hepatic attenuation difference?
Occlusion of branch of portal vein > increased hepatic arterial supply to this region
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Gossypiboma - foreign body left behind during esophagus
Spongiform appearance with gas bubbles
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What do the ovarian veins drain into?
Left ovarian vein drains into left renal vein
Right ovarian vein drains into inferior vena cava
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What is the most common infection affecting the liver and spleen in immunocompromised patients?
Candida
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Jejunization of the ileum - Celiac sprue
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What is the difference between primary and secondary peristalsis?
Primary - initiated by swallowing
Secondary - initiated by distention/irritation along the esophagus
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Cricopharyngeal achalasia -
Failure of pharyngeal peristalsis to coordinate with relaxation of upper esophageal sphincter
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Achalasia - impaired relaxation of the lower esophageal sphincter
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How can one distinguish achalasia from scleroderma?
In both, the distal esophagus is dilated however in scleroderma, the lower esophageal sphincter is wide open however in achalasia, the lower esophageal sphincter fails to relax
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What is the difference between a web and a ring?
Ring - consists of mucosa, submucosa and muscle
Web - only consists of mucosa and submucosa (NO MUSCLE)
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Candida esophagitis
- - Shaggy esophagus
- - Multiple longitudinal/linear ulcers
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How to differentiate glycogenic acanthosis from candidiasis?
- Glycogenic acanthosis
- - Older patients
- - Ulcers are much more round instead of linear
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What is hepatic peliosis?
Multiple blood filled spaces within the liver
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