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د.سمير الصفار

4/10/2015

The Esophagus

Introduction



Anatomy



Physiology



Clinical features



Investigations



Diseases of esophagus

Surgical anatomy



The esophagus is a muscular tube approximately 25 cm long.



The musculature of the upper 5%, including the upper esophageal sphincter,
is striated; the middle 40% has mixed striated and smooth muscle, the distal
55% is entirely smooth muscle.



The parasympathetic nerve supply is mediated by the vagus.



There are an upper and lower esophageal sphincters.

Physiology



The main function of the oesophagus is to transfer food from the mouth to
the stomach.



The initial movement of food from the mouth is voluntary.



The upper esophageal sphincter is normally closed at rest and serves as :

1. A protective mechanism against regurgitation of esophageal contents into

the respiratory passages.

2. Also it serves to stop air entering the esophagus.



The lower esophageal sphincter(LOS) is a physiological sphincter, about 3-4
cm in length and has a pressure of 10-25 mmHg.



The tone of it is influenced by many things including food, gastric distension,
smoking, and GI hormones.



Its main function is to prevent gastric and duodenal contents from refluxing
into the lower esophagus.

Clinical features:

Symptoms

Dysphagia:

Is the term used to describe difficulty, but not necessarily pain, on swallowing.

The type of dysphagia is important; it may be dysphagia for solids or fluids,
intermittent or progressive.

Odynophagia

It refers to pain on swallowing.

Regurgitation and reflux

Regurgitation strictly refer to the return of esophageal contents from above
an obstruction in the esophagus.
Reflux is the passive return of gastroduodenal contents to the mouth.

Chest pain

Chest pain similar in character to angina pectoris may arise from an esophageal cause.

Other symptoms of esophageal disorders include; loss of wt, anemia, cachaxia,

change of voice, and cough.

Investigations

A- Radiography
1- Plain X ray; may show opaque foreign bodies.
2- Contrast radiography (Barium swallow) is a useful investigation for

demonstrating narrowing, space-occupying lesions, anatomical distortion or
abnormal motility.

B- Endoscopy



Is the investigation of first choice for most oesophagial disorders.



It is either for diagnostic or for therapeutic purposes.



Diagnosis is by visual inspection of the inside of oseophagus and also by
taking a biopsy or cytology specimen.



For therapy, can be used for;

Removal of FB
Dilatation of strictures
Oseophagial varices

There are two types;

1- Rigid oesophagoscopy; which is now virtually obsolete.

Disadvantages:

Needs general anesthesia, difficult to introduce, and carry high risk of
perforation

2- Fibre-optic endoscopy



It has virtually supplanted the rigid instrument.



It is done under local anesthesia on an out-patient basis, easy to enter, and
carry low risk of perforation.

C- Oesophageal manomerty



Is widely used to diagnose esophageal motility disorders.



Recordings are usually made either by;
1- Multilumen catheter 2- Catheters with solid-state transducer

D- 24-hour PH recording
Prolonged measurement of esophageal pH is now accepted as the most accurate
method for the diagnosis of gastro esophageal reflux.

Diseases of the esophagus

Congenital abnormalities



Atresia and tracheo-oesophageal fistula



Oesophageal stenosis



Dysphagia lusoria

Foreign bodies in the oesophagus



A lot of things may become arrested in the oesophagus such as coins, pins,
dentures. The commonest impacted material is food.



Plain radiographs are the most useful examination.



Endoscopy is good tool for the dx specially of non-opaque FB.

Treatment:

Flexible endoscopy is now the method of choice and the majority

of objects

can be extracted with suitable grasping forceps, a snare or a basket.
An impacted food bolus will often break up and pass on if the patient is given
fizzy drinks and confined to fluids for a short time

Perforation of the oesophagus

Perforation of the oesophagus is a serious condition that requires prompt diagnosis
and treatment

Causes:

Barotrauma _ Boerhaave’s syndrome



So-called “spontaneous” perforation of the oesophagus is usually due to severe
barotrauma when a person vomits against a closed glottis.



Usually at the lower third



The clinical history is of severe pain in the chest or upper abdomen following a
meal or a bout of drinking.

B) Pathological perforation



Perforation of ulcers, such as a Barrett’s ulcer or tumours.



Penetrating injury



Foreign bodies



Instrumental perforation

Diagnosis



Beware and beware of perforation



Chest pain



Subcutaneous emphysema in the neck



Emphysema around the pericardium can be detected on auscultation as a
mediastinal crunch



Chest XR may show gas in the mediastinum



Contrast swallow using barium suspension

Treatment



Prompt dx and treatment is essential for the best results



There are two options:

 Operative

 Non-operative

Management options in perforation of the oesophagus:

Factors that favour

Nonoperative

Operative

Small septic load

Large septic load

Minimal CV upset

Septic shock

Perforation confined to

Pleura breached

Mediastinum
Endoscopic perforation

Boerhaave syndrome

Perforation of cervical

Perforation of abdominal

Oesophagus

oesophagus

Nonoperative management



Analgesia



Nil by mouth



Antibiotics



General supportive care…IV fluids



When stable…enteral or paenteral nutrition



Nasogastric tube is not recommended

Operative management



It involves thoracotomy and repair of the perforation



This is best done within a few hours of perforation

Corrosive injury

Sodium hydroxide

Sulphuric acid

Drug induced injury
Antibiotic tab
Potassium tab

Gastro-oesophageal reflux disease

Pathophysiology

Competence of the gastro-oesophageal junction is dependent into:

Physiology of LOS;

Basal tone, length, intra-abdominal length

Anatomy of the cardia

Diaphragmatic hiatus-Sliding hiatus hernia

Gastro-oesophageal reflux



Physiological reflux After meals
Physiological reflux occurs during transient lower oesophageal sphincter
relaxations (TLOSRs)



Pathological reflux

Gastro-oesophageal reflux disease



Is by far the commonest condition affecting the upper GI tract.



Its incidence increased during the last years;



*Improvement of socioeconomic conditions  ↓ H.pylori  ↓ DU



Obesity

GORD

Reflux oesophagitis

is a complication of GORD that occur in a minority of sufferers

Clinical features



Retrosternal burning pain( heartburn)



Epigastric pain



These are usually provoked by food, particularly fatty food.



Unpleasant acidic taste



In advanced cases there is a history of pain and reflux when lying flat or on
stooping.



Odynophagia



Less typical symptoms;

Angina-like chest pain
Pulmonary or laryngeal symptoms



Dysphagia

Diagnosis of GORD

In the majority of cases the dx is assumed rather than proven and treatment
is empirical

1- Endoscopy;

To exclude: serious pathology

    Reflux oesophagitis
    Peptic stricture
    Barrett’s oesophagus

2- Oesophageal manometery
3- 24-hours oesophageal pH recording

Is the gold standard for the dx of GORD

Barium swallow and meal;

Gives the best appreciation of G-O anatomy but it is not important for the dx of GORD

Differential Dx

Achalasia and GORD are easily confused

Management of uncomplicated GORD

Non-operative management

Medical management



Simple medications; like
Antacids, H2 receptor antagonists



Simple measures; like
Advice about wt. loss, smoking, excessive consumption of alcohol, tea or
coffee, and a modest degree of head up tilt of the bed



Proton pump inhibitors;
Omeprozole, Lansoprazole and pantoprazole are by far the most effective
drug treatment for GORD

Operative managemen

Surgery

Indications:

1.  In uncomplicated GORD-
2.  Failure of medical therapy..PPI
3.  Patient choice

Disadvantages of surgery:



Mortality (0.1-0.5%)



Failed operation (5-10%)



3-Side effects; dysphagia, gas bloat(5-10%)

What operation

There are many antireflux operations for GORD;
1.

Total fundoplication …Nissen 360

Disadvantage of Nissen:

Over competent cardia….Dysphagia, gas bloat syndrome

Partial fundoplication …Belsy 240

Disadvantage; high recurrence rate….Hill operation

Other antireflux procedures



Angelchik prosthesis

Silastic prosthetic collar



Partial gastrectomy with Roux-en Y reconstruction

What operative approach

Abdominal
Thoracic
Minimal access surgery…Laparoscopic approach

Laparoscopic Fundoplication

Complications of GORD :

1.Reflux oesophagitis : is a complication of GORD that occur in a minority of sufferers .

2. Stricture : reflux induced stricture,,Usually affect middle aged and elderly.

D.Dx from malignant stricture.

Treatment:

a)  Dilatation
b)  Long-term PPI
c)  In younger and fit patients May consider Antireflux surgery.

3. Oesophageal shortening : Reflux oesophagitis…longitudenal contraction…secondary
hiatus hernia.

The main problem is during antireflux operation

Collis gastroplasty which produce neo-oesophagus around which a fundoplication can be
done (Collis-Nissen operation)

4. Barrett’s oesophagus : (columnar-lined lower oesophagus)

is a metaplastic change in the lining mucosa of the oesophagus in response to chronic
gastro-oesophageal reflux .

Risk of Barrett’s oesophagus :

- Barrett’s ulcer
- Dysplasia…Carcinoma

Diagnosis of Barrett’s :

OGD with biopsy

Dull red of the metaplastic columnar epithelium contrasts sharply with the pale glossy
normal squamous lining.

Treatment of Barrett’s oesophagus :

The primary aim is to prevent Barrett's oesophagus from turning into oesophageal cancer.

 Of the underlying GORD

 Ablation of abnormal mucosa by :

 Laser

 Photodynamic therapy

 Argon beam plasma coagulation

 Follow up: yearly OGD

Barrett’s ulcer :

- Is an ulcer in the columnar-lined portion of a Barrett’s oesophagus.
- Barrett’s ulcers may be deep and prone to bleeding or, rarely, perforation.

Paraoesophageal (rolling) hiatus hernia :

-  Is a true hernia that is prone to complications
-  True(pure) paraoesophageal hernia
-  Mixed paraoesophageal hernia
-  Sometimes the whole of the stomach lies in the chest and may undergo volvulus with

perforation or gangrene.

Clinical features:

- Commonly occurs in the elderly, but it also may occur in young fit people

symptoms :

-  Dysphagia
-  Chest pain
-  Symptoms of GORD

Investigations :

-  Plain X-ray of the chest
-  Barium meal
-  Endoscopy

Treatment :

- Rolling hernias always require surgical repair as they are potentially dangerous.
- The principle of surgery is :



Reduction of the hernia



Gastropexy

- Some surgeons may perform a fundoplication

Neoplasms of the oesophagus :

- Benign tumours
- Malignant tumors :



Primary



Secondary

Benign tumours :

-  are rare
-  Leiomyoma is the commonest
-  Oesophageal polyps

Squamus cell polyp

Malignant tumours :

1. Sarcoma are rare

- Leiomyosarcoma
- Rhabdomyosarcoma

2. Malignant melanoma

-Is rare

- May be secondary

- Poor prognosis

3.  Carcinoma of the oesophagus
-  Is the sixth most common cancer in the world.
-  A disease of mid to late adulthood
-  Carry a poor prognosis, 5-year survival is only 5-10%

Pathology :

Histologic types:



Squamous cell carcinoma (95%)
- World-wide is the commonest tumour
- Affect the upper 2/3rd



Adenocarcinoma (4%)
- 70% from

Barrett esophagus

- Is the commonest in westernised countries accounts for 60-75% of all
oesophageal cancers.

- Affect the lower 1/3rd

Radiological types:



polypoid/fungating form (most common)
- sessile/pedunculated tumor with lobulated surface

-"applecore" lesion



ulcerating form



infiltrating form
      -gradual narrowing with smooth transition (DDx: benign  stricture)



varicoid form: superficial spreading carcinoma
-thickened nodular tortuous longitudinal folds (DDx:

varices

)



The poor prognosis of oesophageal cancer is proof of its ability to spread



This may be locoregional or systemic

Aetiology



Epidemiology
-South africa
-Northren Iran and china



The cause in endemic areas
-Fungal contamination of food….carcinogenic mycotoxin - -- -
Nutritional deficiences



In non-endemic areas
-Tobacco and alcohol are the major factors in the occurrence of squamous
cancer.

High risk factors for oesophageal carcinoma :

1.  Alcohol and smoking
2.  Long history of dyspepsia
3.  Barrett’s oesophagus
4.  Achalasia cardia
5.  Stricture “ Corrosive,radiation”
6.  Scleroderma
7.  Plummer-Vinson syndrome
8.  Hyperkeratosis(tylosis)

Clinical features :

1. Patients with early disease may present with rather nonspecific dyspeptic

symptoms or a vague feeling of “something that is not quite right” during
swallowing.

2. Features of advanced disease
3. Dysphagia, is the usual presenting feature

4. Loss of weight
5. Hoarsenece of voice

6. Haematemesis or melaena
7. Palpable cervical lymphadenopathy

Diagnosis :

 Endoscopy; is the most important diagnostic tool and its widespread use is the major

contributor to early diagnosis;

 when the disease at a relatively early stage

 when the chances of cure are greater.

 It should be emphasised that biopsies should be taken of all lesions no matter how

trivial they appear.

 Contrast radiology “Barium swallow” :

The tumour appears as a filling defect in the lumen of oesophagus.

 Not helpful for the diagnosis of early disease.

 Gives a good assessment of the length of the lesions.

Staging



Once a diagnosis of oesophageal carcinoma is made, staging of the disease is
necessary to establish the appropriate method of treatment.



A careful search for metastatic disease

-  Chest X-ray
-  Ultrasonography
-  CT scan of chest and abdomen
-  MRI
-  Endoscopic ultrasonography
-  Bronchoscopy
-  Laparoscopy

Staging system:

-  TNM classification system
-  T for tumour extent
-  N for lymph nodes assessment
-  M for distant metastases

General assessment:

- Assessment for fitness
- Nutritional assessment

Treatment of oesophageal cancers :

- The treatment depends on:

 the staging of the disease

 the general condition of the patient.

The treatment options available are:

 Surgerical excision

 Radiotherapy

 Chemotherapy

 Intubation

 Laser coagulation

 Combined modality treatment

The treatment is either Radical or Palliative :

A) Radical treatment:

-Indicated for potentially curable disease in fit patients

-Curative treatment involves;

Radical surgery

Radical radiotherapy

Radical Surgical Resection:

Is the treatment of choice for tumours of the lower two-thirds of the oesophagus provided:

1. The patient is fit for major surgery
2. Preoperative staging tests indicate that the tumour is resectable and there is no

metastatic disease.

The principle of surgical treatment:

-Resection of the tumour with safety margins.

-Restoration of the continuty, usually gastro-oesophageal anastomosis.

Radical Radiotherapy:

Radiotherapy may be a useful alternative to surgery especially in unfit patients.

- 5year survival 9-19%(average10%) while following surgical treatment 20-35% (20%)

Chemotherapy:

-  Improved after the introduction of newer drugs like cis-platinum.
-  Chemotherapy never cures the disease
-  Best results are seen in SCC

Multimodality treatment:

- Adjuvant radiotherapy either pre- or post- operative
- Radiochemotherapy

B) Palliative Treatment:

Simple procedures that will produce worthwhile relief of dysphagia with minimal
disturbance to the patient

1. Intubation:

-Traction tubes ( Celestin )
-Pulsion tubes ( Atkinson tube ,, Metal slent )

2. Endoscopic Laser:

-Used to core a channel through the tumour

3. Brachytherapy : intraluminal radiation

Carcinoma of the oesophagus :

-  Squamous cell usually affects the upper two-thirds
-  adenocarcinoma usually affects the lower third
-   Common aetiological factors are tobacco and alcohol

(squamous cell) and GORD (adenocarcinoma)

-   The incidence of adenocarcinoma is increasing
-   Lymph node involvement is a bad prognostic factor
-   Dysphagia is the most common presenting symptom, but

is a late feature

- Accurate pretreatment staging is essential in patients
- thought to be fit to undergo ’curative’ treatment

Oesophageal Motility disorders :

1. Achalasia

Pathology: Loss of the inhibitory ganglion cells in Auerbach’s plexus.

Aetiology

-  Unknown
-  Neurotropic viruses, Varicella zoster
-  Trypanosoma Cruzi cause Chagas disease

- Incomplete or absent relaxation of the lower oesophageal sphincter and absent peristalsis
in the body of oesophagus.

- It results in :

1. Retension of food in oesophagus
2. Dilatation….Megaoesophagus

Clinical features :

-  Is commonest in middle life
-  Typically presents with dysphagia
-  Long standing cases…overspill into the trachea at night Retrosternal discomfort

Diagnosis :

1.  Endoscopy
2.  Contrast radiology:
-  Dilated oesophagus
-  Tapering stricture…bird’s beak
-  Absent gas bubble

3. Oesophagial Manometry

Treatment :

1. Forceful dilatation

Disadvantages:

-Perforation

-Reflex

-Repeated sessions

2. Heller’s cardiomyotomy

a. Open Laparotomy

b. Laparoscopic

3. Botulinum toxin

4. Drugs : Calcium channel antagonists

Other oesophageal motility disorders :

-  Cricopharyngeal achalasia
-  Diffuse oesophageal spasm
-  Nutcracker oesophagus
-   Eosinophilic oesophagitis

Oesophageal diverticula :

- Pulsion diverticula
- Traction diverticula

Zenker’s diverticulum (Pharyngeal pouch)

it protrudes posteriorly above the cricopharyngeal sphincter through the natural weak
point (the dehiscence of Killian) between the oblique and horizontal (cricopharyngeus)
fibres of the inferior pharyngeal constrictor



Symptoms:

-  Pharyngeal dysphagia
-  Halitosis
-  Oesophagial Dysphagia



Diagnosis:

- Endoscopy
- Barium swallow



Treatment:

- Endoscopic: stapler creating diverticulo-oesophagostomy
- Open surgery:

  Pouch excision
  Pouch suspension
  Myotomy