The correct answer is C. The biopsy is consistent with esophageal adenocarcinoma, which is tightly associated with reflux esophagitis. In response to chronic irritation from gastric acid, normal squamous epithelium of the esophagus is replaced by a gastric or intestinal-type epithelium that is more resistant to stomach acid. This process of gastric/intestinal metaplasia is also known as Barret esophagus.
Esophageal adenocarcinoma:
- Typically arises in the lower or middle third of the esophagus.
- Symptoms include dysphagia (progressing from solids to liquids), weight loss, constitutional symptoms, and reflux.
- Esophageal carcinoma can easily spread beyond the esophageal wall (only 3 mm thick) and into critical adjacent chest structures or submucosal lymphatics.
- The prognosis for adenocarcinoma is poor unless caught very early, thus Barrett esophagus must be monitored very carefully.
Esophageal rings (choice A) are rims of fibrovascular tissue found in the lower esophagus.
Esophageal webs (choice B) are mucosal ledges in the upper esophagus. When esophageal webs are associated with iron deficiency (Plummer-Vinson syndrome), it is recommended that monitoring for squamous cell carcinoma of the esophagus be routinely performed. It is not yet clear whether this association is related to trapping of carcinogen containing food by the web or to an intrinsic part of the disease physiology in Plummer-Vinson syndrome.
Scleroderma (choice D) can cause fibrosis and impaired motility of the esophagus. It can predispose affected patients to reflux, but does not directly lead to the development of esophageal adenocarcinoma.
In sliding hiatal hernias (choice E), part of the stomach protrudes above the diaphragm. Hiatal hernias can predispose to reflux due to reduced lower esophageal sphincter tone, and therefore adenocarcinoma. Reflux esophagitis is a more direct cause, and therefore a better answer.
This is a multi-step question.
What is the question asking?
You are being asked which of the following risk factors is directly associated with the diagnosis in this patient.
What is the first step?
You must first establish the diagnosis.
- This is a 60-year-old male who presented with progressive solid and liquid dysphagia.
- Endoscopy is performed and shows a distal esophageal mass which appears to be composed of abnormal invasive glandular tissue on microscopy.
The mass is most likely esophageal carcinoma based on the biopsy results.
What is the next step?
Now, it is important to distinguish between the two primary types of esophageal carcinoma: adenocarcinoma and squamous cell carcinoma.
- The lower esophagus is associated primarily with adenocarcinoma caused by intestinal metaplasia (Barret esophagus) as a response to gastric acid exposure.
- Squamous cell carcinoma typically occurs higher up in the esophagus and is associated with tobacco, alcohol, caustic injury, radiation, and other trauma.
Chronic reflux esophagitis (choice C) is the single most important risk factor for Barrett esophagus and adenocarcinoma.
Can other answers be eliminated?
The other answer choices can be eliminated because they do not directly increase the risk for adenocarcinoma:
- Scleroderma (choice D) and sliding hiatal hernia (choice E) both can increase the risk for reflux esophagitis, but they do not independently increase the risk for adenocarcinoma.
- Esophageal rings (choice A) are not directly associated with the development of adenocarcinoma.
- Esophageal webs (choice B) are more closely associated with squamous cell carcinoma, not adenocarcinoma.
What is the single best answer and why?
Reflux esophagitis (choice C) is the single best answer because it is directly associated with an increased risk for adenocarcinoma. Barrett esophagus is a premalignant lesion that develops as a result of chronic reflux esophagitis and is the single most important risk factor for adenocarcinoma.
MedEssentials (4th Ed.): pp. 355
First Aid (2019): pp. 372.1, 372.1
First Aid (2018): pp. 372.1, 372.1
First Aid (2017): pp. 361.1, 361.1
Pathoma (2018-2019): pp. 102.2, 102.3, 102.4, 102.1 Image
Pathoma (2014-2017): pp. 102.2, 102.3, 102.4, 102 Image
