1. The Esophagus

2. Historical Aspects
The earliest esophageal procedures were limited to the cervical region (removal of foreign bodies-1863)
Modified ureteroscope used to diagnose carcinoma of the thoracic esophagus-1868
Esophagoscopy with distal light source developed around 1900
Flexible fiber-optic esophagoscopy-1964

3. Anatomy
A hollow muscular tube approximately 25 cm in length divided into four segments
Pharyngoesophageal, Cervical, Thoracic and Abdominal
The cervical esophagus is a midline structure positioned posterior and slightly to the left of the trachea
The thoracic esophagus passes into the posterior mediastinum continuing on the left side of the mainstem bronchus and eventually enters the abdomen through the crus in the diaphragm
The abdominal esophagus attaches to the cardia (or EG junction) of the stomach (is of variable length)

4. Anatomy (Continued)
The esophagus has three distinct areas of naturally occurring anatomic narrowing
Cervical constriction
Bronchoaortic constriction
Diaphragmatic constriction

5. Anatomy (Continued) A mucosal-lined muscular tube that lacks a serosa
It is surrounded by adventita
The adventita surrounds a coat of longitudinal muscle that overlies a inner layer of circular muscle
Between the two muscular layers is a thin intramuscular layer of fine blood vessels and ganglion cells
The upper (two-thirds) layer of muscle is striated and lower is not
The esophageal mucosa consists of squamous epithelium except for the distal 1-2 cm

6. Anatomy (Continued)
The esophagus has both sympathetic and parasympathetic innervation
The esophagus has an extensive lymphatic drainage that consists of two lymphatic plexuses
The esophagus has segmental blood supply and is nourished by a number of arteries

7. Physiology
Its basic function is to transport swallowed material from the pharynx into the stomach
Retrograde flow of gastric contents into the esophagus is prevented by the lower esophageal sphincter (LES)
Entry of air into the esophagus is prevented by the upper esophageal sphincter (UES)

9. Physiology (Continued)
Esophageal contractions-three types:
Primary peristalsis
Secondary peristalsis
Tertiary contractions
Esophageal peristaltic pressures range from mm Hg with a duration of contraction between 2-4 seconds
LES-no anatomic sphincter has ever been demonstrated (resting pressures are elevated in this area)

10. Disorders of Esophageal Motility
Are classified as functional disorders because they interfere with a normal act of swallowing or produce dysphagia without any associated organic obstruction or extrinsic compression
Information from esophageal manometry is extremely helpful
Some conditions are indistinguishable by x-rays (barium) but have specific manometric characteristics

11. Disorders of Esophageal Motility
As a basic rule the tests below constitute the basic evaluation of a patient with suspected disorders of esophageal motility:
Barium swallow
Esophagoscopy
Esophageal manometry
Esophageal pH reflux testing

12. Disorders of Esophageal Motility
Upper esophageal sphincter dysfunction
Various (old) terms have been used:
Achalasia
Spasm
Cricopharyngeal chalasia
The terms oropharyngeal dysphagia or cricopharyngeal dysfunction better described the symptoms that occur when there’s difficulty propelling liquid or solid food from the oropharynx into the upper esophagus

13. Causes of Oropharyngeal Dysphagia
Neurogenic
Myogenic
Structural causes
Mechanical causes
Iatrogenic causes
Gastroesophageal reflux

14. Clinical Presentation
The patient complains of cervical dysphagia which is localized between the thyroid cartilage and the suprasternal notch (the classical “lump in the throat”)
Expectoration of excessive saliva is common
Intermittent hoarseness can occur
Weight loss secondary to impaired caloric intake may occur

15. Diagnostic Tests and Treatment
Barium swallow may be normal especially in patients with intermittent symptoms
Esophageal function studies (manometric and acid reflux testing) should be performed whenever possible
In patients with severe symptoms and no reflux, surgical intervention may be necessary
Esophagomyotomy

16. Motor Disorders of the Body of the Esophagus
Esophageal motor disorders range from hypomotility (achalasia) to hypermotility (diffuse spasm)
Achalasia is defined as a failure or lack of relaxation
The name focuses on the distal sphincter however the condition involves the entire esophageal body
Diffused esophageal spasm is poorly understood and poorly treated

17. Achalasia The etiology is not known
The characteristic clinical, radiographic and manometric findings have occurred following a variety of situations:
Severe emotional stress
Major physical trauma
Chagas’ disease
Various animal model suggests a central or peripheral vagal nerve dysfunction resulting in the development of achalasia
The classic triad of presenting symptoms include dysphagia, regurgitation and weight loss

18. Achalasia (Continued)
Retrosternal pain on swallowing (odynophagia) is not characteristic
Effortless regurgitation after eating especially upon bending forward is usually not associated with a sour taste of undigested food-in contrast to acid regurgitation
Often results in recurrent respiratory symptoms due to aspiration pneumonitis
Is a premalignant esophageal lesion with carcinoma developing as a late complication in patients who have this condition an average of years

19. Radiographic Appearance of Achalasia
Varies with the extent of the disease
Mild dilatation and early stages progressing to massive dilatation and tortuosity and later stages
Peristalsis is disordered in early stages and lacking in later stages
The radiographic hallmark is the distal bird beak taper of the (EG) junction

21. Testing
Manometric criteria of achalasia are failure of the LES to relax with swallowing and a lack of progressive peristalsis throughout the length of the esophagus
Esophagoscopy is indicated an achalasia to rule out severe retention esophagitis, carcinoma or tumor of the cardia (stomach) that mimics achalasia

22. Treatment Incurable Palliative measures Nonsurgical Surgical
Both are directed toward relieving the obstruction caused by the nonrelaxing LES

23. Nonsurgical Treatment
Early stages
Sublingual nitroglycerin
Long-acting nitrates
Calcium channel blockers
Passage of Mercury weighted bougies

24. Surgical Treatment
Forceful dilatation (balloon)
Esophagomyotomy

25. Diffuse Esophageal Spasm (DES)
Is poorly understood hypermotility disorder
Results from repetitive high amplitude esophageal contractions
The etiology is unknown
These patients typically are anxious and complain of chest pain inconsistent to eating, exertion and position
The character of pain may mimic that of angina
Symptoms are greatest during periods of emotional stress
Patients may experience slow emptying of the esophagus and obstructive symptoms are uncommon

26. Radiographic Findings
Frustratingly variable
Classic “corkscrew”
Beaklike taper
Increase in esophageal wall thickness

28. Testing Esophagoscopy Esophageal manometry Diagnostic when present
Distal esophageal obstructing lesions may produce proximal esophageal contractions that are confused with DES
Esophageal manometry
Diagnostic when present
Classic criteria are:
Simultaneous, multiphasic, repetitive, high amplitude contractions that occur after a swallow

29. Treatment
Due to the lack of understanding of this condition the treatment is less than satisfactory
Antispasmodics are occasionally helpful
Response to sublingual nitroglycerin is variable

30. Scleroderma
Esophageal motor disturbances occur in several of the collagen vascular diseases
Dermatomyositis
Polymyositis
Lupus erythematosus
Scleroderma (extremely common)
Etiology is unknown
Characterized by induration of skin, fibrous replacement of smooth muscle of internal organs and progressive loss of visceral and cutaneous function
Disruption of esophageal peristalsis is common

31. Testing
Esophageal manometry and intraesophageal pH readings are the most sensitive means of detection

32. Treatment Standard antireflux medicine includes H-2 blockers
Cimetidine
Ranitidine
In patients with intractable symptoms gastroesophageal reflux surgery should be considered

33. Diverticula of the Esophagus

34. Esophageal Diverticula
Almost all are acquired and occur predominantly in adulthood
Are classified according to their:
Site of occurrence
Pharyngoesophageal
Parabronchial
Epiphrenic
Wall thickness
True
False
Mechanism of formation
Pulsion
Traction

35. Pharyngoesophageal Diverticula (Zenker)
The most common esophageal diverticulum
Occurs between the ages of (believed to be acquired)
Arises within the inferior pharyngeal constrictor, between the oblique fibers of the thyropharyngeus muscle and the cricopharyngeus muscle
Is a pulsion diverticulum
Complaints are of cervical dysplasia, effortless regurgitation of food or pills sometimes consumed hours earlier
Sometimes a gurgling sensation in the neck after swallowing is felt

37. Diagnosis and Treatment
Barium swallow establishes the diagnosis
Surgery is indicated in symptomatic patients regardless of the size
It is the degree of cricopharyngeal muscle dysfunction and not the size of the diverticulum that determines the relative severity of cervical dysphagia

40. Midesophageal (Traction) Diverticula
Are typically associated with mediastinal granulomatous disease (TB, histoplasmosis)
They are usually small with a blunt tapered tip that points upward
These are usually an incidental finding on barium swallow
They rarely cause symptoms or require treatment
Need to be differentiated from pulsion diverticula which can also occur in this location (associated with neuromotor esophageal dysfunction)

41. Epiphrenic (Supradiaphragmatic) Diverticula
Generally occur within the distal 10cm of the thoracic esophagus
These are pulsion diverticula that arise due to esophageal motor dysfunction or mechanical distal obstruction
Many patients are asymptomatic when diagnosed
When symptomatic their symptoms are difficult to differentiate from: hiatal hernia, DES, achalasia, reflux esophagitis and carcinoma
Dysphagia and regurgitation are common symptoms

42. Diagnosis and Treatment
Diagnosis is easily made with barium swallow
Esophageal function studies should also be performed to rule out any motor disturbances
Lesions < 3 cm often require no treatment
Extreme symptomatic patients sometimes require surgical repair

43. Miscellaneous Condition of the Esophagus
Mallory-Weiss syndrome
During the act of forceful emesis against a closed glottis increased intra-abdominal pressure can cause a tear in the mucosa (Mallory-Weiss tear) of the esophagus at the esophagogastric junction
A transmural esophageal tear is called Boerhaave’s syndrome
A history of emesis followed by melena or hematemesis is suggestive for a Mallory-Weiss tear

44. Esophagoscopy

45. Indications and Contraindications
Indications include:
Dysphagia
Reflux
Hematemesis
Atypical chest pain
Many other conditions
Contraindications:
To assess reflux symptoms that respond to medical management
A uncomplicated sliding hiatal hernia

46. General Considerations
The esophagoscopy should be performed after barium swallow
Bacteremia during upper GI endoscopy has been well documented therefore prophylactic antibiotic treatment should be administered
Patient should be in NPO for 6-8 hours

47. Complications The minor ones: Major complication
Lacerations of the lips or tongue
Dislodgment or fracture of teeth and possible aspiration
Major complication
Esophageal perforation
Cervical esophagus (40%)
Mid esophagus (25%)
Distal esophagus (35%)
Morbidity and mortality from perforation is directly related to the time interval between the occurrence of injury, diagnosis and repair

48. Tumors of the Esophagus

49. Benign Esophageal Tumors and Cysts
Benign tumors are rare (< 1 %)
Classified in two groups
Mucosal
Extramucosal (intramural)
More useful classification:
60% of benign neoplasms are leiomyomas
20% are cysts
5% are polyps
Others (< 2 percent)

50. Leiomyomas Most common benign tumor of the esophagus Intramural
Occur between years of age with no gender preponderance
80% occur in the middle and lower third of the esophagus, they are rare in the cervical region
Obstruction and regurgitation may occur in large lesions
Bleeding is a more common symptom of the malignant form of the tumor: leiomyosarcoma

52. Esophageal Cysts Arise as diverticula of the embryonic foregut
¾ of this cyst present in childhood
Over 60% are located along the right side of the esophagus
Are often associated with vertebral anomalies (ex: spina bifida)
60% present in the first year of life with either respiratory or esophageal symptoms
Cyst found in the upper third of the esophagus present in infancy while lower third lesions present later in childhood

53. Pedunculated Intraluminal Tumors (Polyps)
Benign polyps are rare
Usually occur in older men and may cause intermittent dysphagia
Are sometimes easily missed with barium swallow and esophagoscopy

54. Malignant Tumors of the Esophagus
Usually are in advanced stages at the time of diagnosis (involving the muscular wall and extending into adjacent tissues)
Alcohol consumption and cigarette smoking seem to be the most consistent risk factors
Esophageal squamous cell carcinoma (95% of all esophageal cancers) is a disease of men (5: 1)
Squamous cell esophageal cancer occurs least frequently in the cervical esophagus and
Squamous cell esophageal cancer occurs most often in the upper and midthoracic segments

55. Malignant Tumors of the Esophagus
Adenocarcinoma constitute approximate 8% of primary esophageal cancers
The frequency of adenocarcinoma is increasing dramatically in the U.S. at a rate surpassing any other cancer
Most often occur in the distal third of the esophagus in the 6th decade of life.
Male to female ratio is 3:1
Patients with Barretts metaplasia are 40 times more likely to develop adenocarcinoma
These tumors are aggressive as well

56. Clinical Presentation
Dysphagia is the presenting complaint in 80-90% of patients with esophageal carcinoma
Early symptoms are sometimes nonspecific retrosternal discomfort or indigestion
As the tumor enlarges, dysphagia becomes more progressive.
Later symptoms include weight loss, odynophagia, chest pain and hematemesis

57. Diagnosis Esophageal biopsy Brushings for cytologic evaluation
Barium swallow
Lugol’s solution

58. Staging of Tumors
Endoscopic ultrasound-to define the depth of invasion and presence of paraesophageal lymph nodes
Chest x-ray ± abnormal findings
CT scan (most widely used and now standard radiographic means of staging)
Bronchoscopy for tumors which are proximal to the trachea

59. TMN Classification for Staging
The esophagus is first divided into four segments
Cervical
Upper thoracic
Middle thoracic
Lower
“T” defines the depth of invasion
“N” defines regional lymph node involvement
“M” defines the presence or absence of distant metastasis
The TNM categories are grouped into stages which have been shown to reflect the prognosis of tumors

62. Perforation of the Esophagus

63. Causes of Perforation Iatrogenic Intraopoerative Spontaneous
Endoscopy
Dilators
Esophageal intubation
Variceal sclerosis
Intraopoerative
Mediastinoscopy
Thyroid surgery
Spontaneous
Postemetic
Radiation therapy
Traumatic
Blunt and penetrating
Caustic
Carcinomas

64. Clinical Presentation
Symptoms and signs vary with the cause and location of the perforation
Pain is the most consistent symptom (70-90%)
Blood tainted emesis is present and 30% of these patients
The pain pattern is often misdiagnose as a dissecting aortic aneurysm, spontaneous pneumothorax or myocardial infarction
Tachycardia and tachypnea is common
Hypotension and shock can occur

65. Diagnosis Chest x-ray (plain film)
When obtained early may appear normal
Mediastinal emphysema may appear in one hour
Pleural effusions may take several hours
Definitive diagnosis-contrast studies
CT scan’s for atypical presentations
Esophagoscopy is rarely used for diagnosis of perforation

66. Treatment Three factors affect management of esophageal perforation
Etiology
Location
The delay between rupture and treatment
Surgical treatment remains the mainstay of management in esophageal perforations

68. Hiatal Hernia and Gastroesophageal Reflux

69. Factors Affecting Reflux
Gastric juices
Gastric acid and bile
Gastric emptying
Abnormal emptying patterns (prolonged fundal distention)
Previous gastroesophageal operations
Social habits and medication
Fatty foods, chocolate and peppermint reduces LES tone
Smoking causes a significant decrease in LES resting pressures
All medication affecting smooth muscle contraction have been shown to affect LES pressures

70. Signs and Symptoms of Gastroesophageal Reflux

72. Diagnosis Esophagoscopy Esophageal biopsies Motilitiy studies
To note mucosal changes
Esophageal biopsies
To note changes at the cellular level
Motilitiy studies
Low LES pressures are associated with reflux
pH monitoring
The most precise measure for the presence of acid in the esophageal lumen (24 hour monitoring)

73. Final Staging
The results from the four studies above are scored and patients are put into one of four categories
The treatment regimen depends on the stage of the disease

74. Medical Treatment

75. Surgical Treatment
Indications for surgical treatment are somewhat controversial
Stage 0 and Stage 1 disease should never be an indication for surgery
Stage 2 disease should always undergo a well supervised period of medical management for at least six months to a year
Stage 3 disease should also undergo medical therapy first
In stage2 and in Stage 3 disease surgical options should be entertained after failed medical management

76. Surgical Treatment Nissen fundoplication Their aim is to:
Total or partial
Their aim is to:
Restore normal anatomy (intra-abdominal segment of esophagus)
Re-creating an appropriate high-pressure sound at the esophagogastric junction
Maintaining this repair in the normal anatomic position

78. Corrosive Strictures of the Esophagus

79. Etiolgy
The most common chemicals implicated in corrosive burns of the esophagus include:
Alkaline caustics
Household drain cleaners
Dishwashing detergent
Washing soda
Ammonia
Disk shaped alkaline batteries
Acid or acid like corrosives
Automobile battery acids
A variety of commercial cleaners
Household bleach

80. Important Elements in Successful Management of a Corrosive Burn
Immediate verification of the corrosive agent
Accurate assessment of the depth and extent of injury (esophagoscopy)
Superficial injuries
Erythema
Edema or blistering
Deep injuries
ulceration
Subsequent treatment is individualized on the basis of these findings
In the presence of injury the esophageal status should be assessed at repeated intervals of 3 weeks, 3 months and between 6 months to a year

81. Treatment Options Mechanical Pharmacological
Intraluminal Silastic stents
Pharmacological
Corticosteroids to modify the inflammatory response
Antibiotics to control secondary infection

82. Strictures Most frequent complication of caustic burns
Usually develops between three and eight weeks after initial injury
Multiple areas of stricture can occur

83. Treatment Options for Strictures
Esophageal dilatation by the passage of bougies
Surgical reconstruction

84. Special Note
There is an increased incidence in patients who have previously suffered corrosive esophageal burns to develop esophageal carcinoma later in life (1000 fold increase)

85. The End