Esophagus

• Anatomy: • From cricoid cartilage to diaphragm • 25 Cms. • 4 portions: • Cervical 5 cms. • Thoracic 25 cms. • Abdominal 2 cms. • Blood supply • Lymphatic spread Upper 2/3 Cephalad • Lower 1/3 Caudad

• Physiology:

• Pump Tongue and pharynx

• Reflex Soft palate

• Hyoid bone

• Epiglottis

• Pressure gradient

• Cricopharyngeous

•

• Assesmant of esophageal function:

• Structural

• Functional

• Structural:

• Radiology

• Endoscopy

• Functional:

• Stationary manometry

• 24 Hours pH monitoring

• GERD:

• Majority of esophageal pathology

• Chronic problem

• May require life-long treatment

• Common symptoms

• Atypical symptoms.

• Definitions:

• Heartburn: substernal burning-type discomfort beginning in the epigastrium and radiating upwards.

• (Aggravating and relieving factors)

• Regurgitation: The effortless return of acid or bitter gastric contents into the chest , pharynx or mouth.

• Dysphagia: difficulty in swallowing.

• Etiology could be oropharyngeal or esophageal

• If accompanied by pain ( Odynophagia)

• Chest pain:

• enterwining of visceroneural pathways

•

• Human antireflux mechanisms:

• High pressure zone at GE junction

• Specialized thickening

• Collar sling and clasp fibres

• Receptive relaxation

• Association with HH:

• Repeated gastric distension

• GEJ ( upside down funnel-shaped )

• Progressive opening of the angel of His )

• Stretching of phrenico esophageal ligament

• Enlargement of hiatal opening

• Axial herniation

• Factors (GERD ):

• GERD originates in the stomach

• Over eating

• Delayed gastric emptying

• Unrolling of LES

• Repeated exposure (Squamous epithelium )

• Inflammation

• Development of columnar epithelium

• For relief Increased swallowing of saliva resulting in aerophagia, bloating and belching

• A vicious cycle Increased gastric distension further exposure to injury.

• Metaplasia

• Fibrotic mucosal ring ( Schatzki ).

• Barretts esophagus (BE ):

• 10-20% of GERD

• Defined as the presence of columnar mucosa extending at least 3 cms into the esophagus

• Complcated by:

• Ulceration

• Stricture

• Dysplasia-cancer sequence

• Respiratory complications

• Treated by:

• PPIs

• Anti reflux procedures

• GERD Approach Summary:

• High doses of PPIs

• If symptoms return …….Endoscopy

• Surgery

• Advice on:

• Change of life style

• Dietary measures

• Medications

• 25-50% persistent or progressive disease

• Anti reflux Surgery:

• The principle is to safely create a new anti reflux valve at GEJ while preserving the patient ability to swallow normally and to belch to relieve the gaseous distension.

• ( Nissen fundoplication)

• Hiatus Hernias (HH ):

• Types:

• Sliding

• Para esophageal (PEH) Rolling type 11

• Combined type 111

• Sliding is 7 times more than PEH

• PEH are more in women

• Manifestations

• Diagnosis:

• Erect CXR

• Barium study

• Fiberoptic esophagoscopy

• Treatment:

• Surgery

• Significant incidence of catastrophic life-threatening copplications

• Scleroderma:

• 80% of patients have esophageal abnormalities

• Result from vascular compromise due to collagen deposition

• Smooth muscle atrophy

• Diagnosis is by manometry

• Motility Disorders:

• Manifested by dysphagia

• Pain, chokes or vomits with eating

• Require liquids with eating

• The last to finish

• Forced to interrupt or avoid a social meal

• Admission to hospital with food impaction

• Motility Disorders of the pharynx:

• ( transit dysphagia )

• Resulted from discoordination of neuromuscular events

• Congenital

• Acquired ( involvement of the central or peripheral nervous system)

• Zenkers Diverticulum:

• Elderly

• Dysphagia with spontaneous regurge ( bland )

• Repeated Respiratory tract infections

• Diagnosed by Barium swallow and endoscopy

• Treated surgically by diverticulopexy or diverticulectomy

• Motility disorders of the esophagus: • Abnormalities: • Propulsive pump action • Relaxation of LES • Primary, or • Generalised: • Neural • Muscular • Collagen deposit • For categories: • 1. Achalasia • 2. DES • 3. Nutcracker esophagus • 4. HH LES

• Achalasia:

• The most common 1 : 100 000

• A primary disorder of the LES

• Esophageal dilatation ( bird peak and air fluid level )

• Secondary Motility Disorders:

• Scleroderma

• Patients treated as infants for esophageal atresia

• Treatment:

• LES myotomy ( Heller operation )

• Hydrostatic balloon dilatation

• Botox

• Diverticula of the body:

• Location

• Nature of concomitant pathology

• Types:

• 1. Pulsion

• 2. Traction

• Carcinoma of the esophagus: • Majority are squamous cell • Predisposing factors: • Nitroso compounds • Zinc and molybdenum deficiency • Smoking • Alcohol • Long standing achalasia • Human papilloma virus • Adenocarcinoma: • More than 50% in the west • Occur at younger ages • Metaplastic columnar epithelium

• Clinical manifestations:

• Dysphagia

• Accidentally found

• Squamous cell carcinoma spread to bronchial tree

• Rarely , severe bleeding

• Hoarseness

• Systemic (distant metastasis )

• Staging:

• CT

• PET

• Endoscopic ultrasound

• Approach summary:

• Diagnosed with endoscopic biopsy

• Staged with CT

• PET and EUS for patients with evidence of advanced disease

• Tumour Location:

• Cervical 8% almost all are squamous cell

• Upper thoracic 3%

• Middle 1/3 32% most commonly squamous,frequently

• Associated with early L.N metastases

• Lower esophagus and cardia 25% usually adenocarcinoma

• Sarcoma is rare 0.5 -1.5%

• Benign Tumours:

• Relatively uncommon

• Intramural:

• 1. solids

• 2. Cysts:

• a. Congenital

• Respiratory type

• Gastric type

• Transitional Enteric

• Bronchogenic

• b. Acquired (retention cysts )

• Intraluminal:

• Polypoid

• pedunculated

• Esophageal Perforation:

• A true emergency

• Most commonly follow a diagnostic or therapeutic procedure

• Spontaneous ( Boerhaave syndrome ) 15%

• Foreign body 14%

• Trauma 10%

• History of resisting vomiting

• Subcutaneous emphysema

• CXR

• Contrast study

• Spontaneous rupture usually to left pleural cavity

• Management:

• Key is early recognition

• Early primary closure

• Mallorry-Weis syndrome:

• Acute upper GI bleeding following vomiting 15% of UGI bleeding

• Result from acute increase in intra abdominal pressure against a closed glottis in a patient with HH

• Diagnosed by upper GI endoscopy

• Majority stop bleeding spontaneously

• Treatment:

• Blood replacement

• Gastric decompression

• Anti emetics

• Endoscopy Epinephrine injection

• Surgery

• Caustic Injuries:

• Children ………accidental

• Adults …………suicides

• Two types:

• 1. Alkalis

• 2. Acids

• Acids cause coagulative necrosis therefore limited penetration

• Alkalis dissolve tissues therefore penetrate deeply

• Treatment should be immediate:

• Alkalis ½ strength vinegar

• Lemon or orange juice

• Acids Milk

• Egg white

• Antacids

• Sodium bicarbonates should not be given

• Emetics are contraindicated

• For strictures,

• Repeated dilatations

• Surgery

• Acquired Fistulas:

• Malignancy

• Trauma

• Diverticuli