1. Esophagus

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

3. Physiology:
Pump Tongue and pharynx
Reflex Soft palate
Hyoid bone
Epiglottis
Pressure gradient
Cricopharyngeous

4. Assesmant of esophageal function:
Structural
Functional

5. Structural:
Radiology
Endoscopy
Functional:
Stationary manometry
24 Hours pH monitoring

6. GERD:
Majority of esophageal pathology
Chronic problem
May require life-long treatment
Common symptoms
Atypical symptoms.

7. 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

8. Human antireflux mechanisms:
High pressure zone at GE junction
Specialized thickening
Collar sling and clasp fibres
Receptive relaxation

9. 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

10. 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 ).

11. 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

12. 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

13. 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)

14. 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

15. Scleroderma:
80% of patients have esophageal abnormalities
Result from vascular compromise due to collagen deposition
Smooth muscle atrophy
Diagnosis is by manometry

16. 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

17. Motility Disorders of the pharynx:
( transit dysphagia )
Resulted from discoordination of neuromuscular events
Congenital
Acquired ( involvement of the central or peripheral nervous system)

18. Zenkers Diverticulum:
Elderly
Dysphagia with spontaneous regurge ( bland )
Repeated Respiratory tract infections
Diagnosed by Barium swallow and endoscopy
Treated surgically by diverticulopexy or diverticulectomy

19. 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

20. Achalasia:
The most common :
A primary disorder of the LES
Esophageal dilatation ( bird peak and air fluid level )

21. Secondary Motility Disorders:
Scleroderma
Patients treated as infants for esophageal atresia
Treatment:
LES myotomy ( Heller operation )
Hydrostatic balloon dilatation
Botox

22. Diverticula of the body:
Location
Nature of concomitant pathology
Types:
1. Pulsion
2. Traction

23. 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

24. Clinical manifestations:
Dysphagia
Accidentally found
Squamous cell carcinoma spread to bronchial tree
Rarely , severe bleeding
Hoarseness
Systemic (distant metastasis )

25. Staging: CT
PET
Endoscopic ultrasound
Approach summary:
Diagnosed with endoscopic biopsy
Staged with CT
PET and EUS for patients with evidence of advanced disease

26. Tumour Location:
Cervical % almost all are squamous cell
Upper thoracic %
Middle 1/ % most commonly squamous,frequently
Associated with early L.N metastases
Lower esophagus and cardia 25% usually adenocarcinoma
Sarcoma is rare %

27. 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

28. Esophageal Perforation:
A true emergency
Most commonly follow a diagnostic or therapeutic procedure
Spontaneous ( Boerhaave syndrome ) %
Foreign body %
Trauma %
History of resisting vomiting
Subcutaneous emphysema
CXR
Contrast study
Spontaneous rupture usually to left pleural cavity
Management:
Key is early recognition
Early primary closure

29. Mallorry-Weis syndrome:
Acute upper GI bleeding following vomiting % 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

30. 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

31. Acquired Fistulas:
Malignancy
Trauma
Diverticuli