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The Esophagus

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Title: The Esophagus


1
The Esophagus
  • Vic Vernenkar, D.O
  • Department of Surgery
  • St. Barnabas Hospital

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)

8
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9
Physiology (Continued)
  • Esophageal contractions-three types
  • Primary peristalsis
  • Secondary peristalsis
  • Tertiary contractions
  • Esophageal peristaltic pressures range from
    20-100 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 theres 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
    15-25 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

20
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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

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28
Testing
  • Esophagoscopy
  • 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 30-50 (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

36
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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

38
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39
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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
  • 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
    Boerhaaves 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
  • 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 (
  • Classified in two groups
  • Mucosal
  • Extramucosal (intramural)
  • More useful classification
  • 60 of benign neoplasms are leiomyomas
  • 20 are cysts
  • 5 are polyps
  • Others (

50
Leiomyomas
  • Most common benign tumor of the esophagus
  • Intramural
  • Occur between 20-50 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

51
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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 31
  • 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
  • Lugols 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

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62
Perforation of the Esophagus
63
Causes of Perforation
  • Iatrogenic
  • 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 scans 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

67
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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
71
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72
Diagnosis
  • Esophagoscopy
  • 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
  • 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

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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
  • 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
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