The esophagus 2 nd Lecture M.A.Kubtan1

 للإستماع إلى المحاضرة ينصح بوضع سماعة الأذن ليكون الصوت واضحاً.  يجب الضغط على الزر الأيسر للماوس فوق صورة مكبر الصوت لسماع الشرح الخاص بالسلايد المعروض على الشاشة. M.A.Kubtan2

 Perforation of the esophagus is usually iatrogenic (instrumental perforations at therapeutic endoscopy) it can be managed conservatively ( not all the time ).  Barotrauma’ (spontaneous perforation). is often a life-threatening condition that regularly requires surgical intervention. M.A.Kubtan3

 Potentially lethal complication due to mediastinitis and septic shock.  Numerous causes, but may be iatrogenic.  Surgical emphysema is virtuall pathognomonic.  Treatment is urgent; it may be conservative or surgical, but requires specialised care. M.A.Kubtan4

Boerhaave syndrome :  This occurs classically when a person vomits against a closed glottis.  The pressure in the esophagus increases rapidly, and the esophagus bursts at its weakest point in the lower third sending a stream of material into the mediastinum and often the pleural cavity.  Boerhaave syndrome is the most serious type of perforation. This causes rapid chemical irritation in the mediastinum and pleura followed by infection if untreated. M.A.Kubtan5

6 Barotrauma has also been described in relation to other pressure events when the patient strains against a closed glottis (e.g.defaecation, labour, weight-lifting).

 The clinical history is usually of severe pain in the chest or upper abdomen following a meal or a bout of drinking.  Associated shortness of breath is common.  There may be a surprising amount of rigidity on examination of the upper abdomen, even in the absence of any peritoneal contamination.  The diagnosis can usually be suspected from the history and associated clinical features. M.A.Kubtan7

 A chest X-ray is often confirmatory with air in the mediastinum, pleura or peritoneum.  Pleural effusion occurs rapidly.  A contrast swallow or CT is nearly always required to guide management M.A.Kubtan8

9 severe subcutaneous emphysema 33 years old woman secondary to prolonged labor during normal vaginal delivery

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M.A.Kubtan11 A contrast swallow

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 Aero digestive fistula is most common and usually encountered in primary malignant disease of the esophagus or bronchus.  Erosion into an adjacent structure with fistula formation is more common.  Free perforation of ulcers or tumors of the esophagus into the pleural space is rare.  Coughing on eating and signs of aspiration pneumonitis may allow the problem to be recognized. M.A.Kubtan13

 Covering the communication with a self-expanding metal stent is the usual solution.  Erosion into a major vascular structure is invariably fatal. M.A.Kubtan14

 Foreign bodies : The esophagus may be perforated during removal of a foreign body.  Occasionally, an object that has been left in the esophagus for several days will erode through the wall.  Instrumental perforation : Instrumentation is by far the most common cause of perforation.  Perforation can occur in the pharynx or esophagus, usually at sites of pathology or when the endoscope is passed blindly.  Perforation may follow biopsy of a malignant tumor. M.A.Kubtan15

 The esophagus may be perforated by guide wires, graduated dilators or balloons, or during the placement of self-expanding stents.  The risk is considerably higher in patients with malignancy. M.A.Kubtan16

 Forceful vomiting may produce a mucosal tear at the cardia rather than a full perforation.  In Mallory–Weiss syndrome, vigorous vomiting produces a vertical split in the gastric mucosa.  Tear immediately below the squamocolumnar junction at the cardia in 90% of cases.  In only 10% is the tear in the esophagus. M.A.Kubtan17

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 Perforation of the esophagus usually leads to mediastinitis.  The aim of treatment is to limit mediastinal contamination and prevent or deal with infection.  The event causing the perforation (spontaneous vs. instrumental).  Underlying pathology (benign or malignant).  The status of the esophagus before the perforation (fasted and empty vs. obstructed with a stagnant residue). M.A.Kubtan19

 attempted suicide.  Accidental ingestion occurs in children and when corrosives are stored in bottles labeled as beverages.  All can cause severe damage to the mouth, pharynx, larynx, esophagus and stomach.  In general, alkalis are relatively odorless and tasteless, making them more likely to be ingested in large volume. M.A.Kubtan20

Significant stricture formation occurs in about 50% of patients with extensive mucosal damage. M.A.Kubtan21

M.A.Kubtan22 Multiple stricture of the body of esophagus

Most congenital malformations develop during embryonic life between the third and eighth weeks of gestation. M.A.Kubtan23

A blind proximal pouch with a distal tracheo- esophageal fistula is the most common type. Affected infants typically present  Soon after birth with frothy saliva.  cyanotic episodes, exacerbated by any attempt to feed.  The preceding pregnancy may have been complicated by maternal polyhydramnios. M.A.Kubtan24

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 Is confirmed by failure to pass a 10 Fr oro-gastric tube into the stomach.  The tube is visible within an upper esophageal pouch on the chest radiograph.  The presence of abdominal gas signifies the tracheo- esophageal fistula.  Associated anomalies are common and include cardiac, renal and skeletal defects. M.A.Kubtan26

 Surgical repair : The esophageal ends are anastomosed.  Division and repair of tracheo – esophageal tract. M.A.Kubtan27

 Infants with pure esophageal atresia and no tracheo- esophageal fistula. Usually best managed by a temporary gastrostomy.  Delayed primary repair.  Except for very-low-birth weight babies and those with major congenital heart disease, most infants with repaired esophageal atresia have a good prognosis. M.A.Kubtan28

 Anastomotic leak.  Stricture.  Recurrent fistula formation.  Gastro- esophageal reflux. M.A.Kubtan29