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