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