The Esophagus pdf - ولاء الفلوجي

Cardiovascular and Thoracic Surgery Dr.Wallaa AlFalluji

The Esophagus

is a long muscular tube approximately 40 cm from the incisor

teeth (25 cm from cricopharyngeus ) ,that extends from the
pharynx at the level of 6

. Cervical vertebra to the stomach

,which it joins opposite the body of 11

. thoracic vertebra.It is

arbitrary divided into Cervical ,Thoracic and Abdominal parts.

The esophagus has three distinct areas

of naturally occurring

anatomic narrowing :-1-The crico pharyngeal constriction
                                    2-Broncho aortic constriction .
                                    3-The diaphragmatic constriction .

Blood supply :-

Cervical esophagus

Inf.thyroid Ar.

Thoracic esophagus

esophageal branches (Aorta)and segmental

vessels (intercostal & phrenic) .

Venous drainage:-

Cervical esophagus

inferior thyroid &vertebral V.

Thoracic esophagus

azygous & hemi azygous

Abdominal esophagus

gastric veins

Lymphatic

regional lymph nodes ,The flow of the upper 2/3

is upward while the flow of the lower 1/3 is downward.

Nerve supply

the nerve supply to the normal esophagus is

cholinergic and causes contraction every where except for the
circular muscle of the cardia where its adrenergic and causes
relaxation .

Esophageal Hiatus :-

It is a sling of muscle fiber that arises

from the right crus in approximately 45% of the patients ,
however both right and left crus contribute to the hiatus

Physiology :-

It is a muscular tube that begins proximally with

upper esophageal sphincter (UES) and ends distally with lower
esophageal sphincter (LES) .Its function is to transport the
swallowed material from the pharynx down to the stomach

Cardiovascular and Thoracic Surgery Dr.Wallaa AlFalluji

Clinical manifestation of esophageal diseases

it include :-

Dysphagia (

difficulty in swallowing) ,

Odynophagia

(pain on swallowing) ,

Regurgitation & vomiting , Drooling of

saliva , Heart burn

(substernal burning sensation ) ,

Weight loss

& cachexia .

Investigations

1-Plain X-Ray chest :-

it show :-

a dilated esophagus

(especially in lateral view )

, in the lung (fluid level )

from the

spill over of the esophageal content ,

radio opaque foreign body

2-Barium swallow

It is very essential and may be diagnostic in

some esophageal diseases such as achalasia of the cardia .

3-Esophagoscopy :

It is the direct visualization of the interior of

, carried under GA

rigid esophagoscope

phagus by either

the eso

,carried under local anesthesia

flexible esophagoscope

or by the

Indications:-

evaluate symptoms of dysphagia &

diagnostic

odynophagia ..etc , To asses established esophageal pathology ,
To define or confirm radiological abnormalities ..etc ,It is of
great value in assessment of post operative problems as
anastomotic stricture ,tumor recurrence ,bleeding and recurrent
GER

Dilatation o

Removal of foreign bodies ,

Therapeutic :

stricture ,Placement of endoluminal prosthesis (stent )
,Sclerotherapy

, Lase

r photo coagulation for bleeding or tumor

de bulking

ceration of the lips or tongue ,

Minor Complications

Fracture or dislodgment of teeth

Pharyngeal laceration

% of

which occurs in

Perforation

Major Complications

patients after(F.B removal ,Dilatation of stricture or biopsy

Cardiovascular and Thoracic Surgery Dr.Wallaa AlFalluji

Management

4-Manometry :

It is the classical test to examine (LES) function.Hypertensive
Lower Esophageal Sphincter is seen in achalasia of the cardia
Loss of the tone is seen in pregnancy & alcholism

Disorders of esophageal motility

Functional disorders of the esophagus

Are those conditions that

interfere with the normal act of swallowing or produce
dysphagia without any associated intra – luminal, mural
organic obstruction or extrinsic compression.

Upper esophageal sphincter dysfunction :-

Crico pharyngeal

dysfunction (oro pharyngeal dysphagia ) :-

Symptoms complex

that result when there is a difficulty in propelling liquid or solid
food from the pharynx into the upper esophagus .

Causes :-

Neuro genic

CNS (MS) , vascular (CVA) ,tumors

,trauma

Myogenic

myasthenia gravis , inflammatory (poly

myositis)

Structural

divertuculum

Mechanical

intra or

extra luminal

Iatrogenic

surgical or irradiation ,

Gastro

esophageal reflux .

Motor disorders of the body of the esophagus

1-Achlasia of the cardia .
2-Diffuse esophageal spasm & related hyper motility disorders

Achalasia of the cardia

Is a disease entity of unknown etiology Characterized by
absence of peristalsis in the body of the esophagus, a high
resting pressure at the (LES) and failure of this sphincter to
relax in response to swallowing .

Cardiovascular and Thoracic Surgery Dr.Wallaa AlFalluji

Etiology :-

attributes to a neuromuscular dysfunction affecting

both the narrowed and the dilated segments of the esophagus

occurs at any age. The highest incidence

Clinical features

is(25-60) Mostly equal sex incidence or > in female ,The
duration of symptoms (Days to years) ,The onset ,sudden or
insidious .sudden( emotional stress ) ,The symptoms include :-
dysphagia ,Regurgitation ,Pain ,Weight loss &Cachexia

Heart burn

,Emotional Disturbance ,Respiratory symptoms ,

air bubble. Visible

Absence of gastric

CXR :

Diagnosis

Esophagus, Fluid level .

2-Barium Swallow

: Dilated Esophagus ,food residue ,Little

barium passed to the stomach ,Morphological forms : Cork-
Screw,Cucumber ,Tortuous & Sigmoid, Bird s beak appearance

3-Esophagoscopy

:To confirm the diagnosis ,exclude other path

4-Manometry:

Absence of peristalsis(body), high LES pressure

Differential diagnosis:

Diffuse esophageal spasm OR Systemic

sclerosis OR Organic obstruction( stricture , tumors)

Treatment :

1-Medical treatment - adalat , isordil 2-Dilatation

(bougienage) pneumatic or hydrostatic 3-Surgery --

---

Heller’s cardio myotomy

…. Recently -- Laparoscopic cardio

myotomy

Complications of achalasia:-

1- Those related to retention &

stasis ( Retention esophagitis ) 2-Air way obstruction &
repeated chest infection 3-Pre malignant (squamous cell
carcinoma )

Perforation of the esophagus

either by

instrumentation

Esophageal perforation following

1
the rigid esophagoscope or by bougienage

Cardiovascular and Thoracic Surgery Dr.Wallaa AlFalluji

perforation , Foreign bodies ingestion or blunt and

Traumatic

2
penetrating trauma

haave’ s syndrome ) due to the

( Boer

Spontaneous rupture

3
strain of emesis with or without predisposing disease .

of the normal anatomical constriction are the most

sites

The

of the

2/3

upper

common sites of perforation .The
esophagus will perforate into the rt. Pleural cavity while the

will perforate into the lt. Pleural cavity .

1/3

lower

Pain ,Fever ,Dysphagia ,Cervical pain

Clinical manifestations

or crepitation , Dyspnea , Pneumothorax and in severe
cases dyspnea and cyanosis .

:Mediastinal emphysema . Pleural effusion

ray

Chest X

alize the site of perforation

can loc

Barium study

),IVF , Nasogasric feeding,

NBM = NPO

(

Medical

;

Treatment

Surgical to close the perforation.

Stricture of the Esophagus

the ingestion of solid or

resulting from

Caustic Strictures

liquid caustics most frequently seen in children who have
accidentally swallowed the material or in adult who have
ingested the material for suicidal purposes .

like &

included alkaline caustics, acids or acid

The chemicals

household bleaches .Strong alkalis (Na&KOH)

Ranges from(minimal to shock ) . Dyspnea may

Symptoms

occur .

ation of the etiological agent ,

Identific

Management

Administration of the neutralizing agent , Assessment of the
extent of the injury , Early Esophagoscopy  ! to determine
whether there is esophageal injury or not , Cortico steroid
decreases the degree of stricture  , Antibiotics  together with
steroid for (3-6 week )  , Barium –swallow two weeks later to
see if there is stricture or not , Dilatation ( Bougenage) may be
needed after(3-4 weeks) and many patients need regular
dilatation , May need  Esophageal replacement .

Esophageal stricture is a premalignant.

Cardiovascular and Thoracic Surgery Dr.Wallaa AlFalluji

stricture

Esophageal

Reflux Esophagitis and Strictur

secondary to the reflux of acid or alkaline secretions into the
esophagus caused by esophagogastric incompetence as a result
of hypotensive (LES ) . it is a continuous process of destruction
and healing that may stop at any stage or may progress to
fibrosis ,stricture with the resulting dysphagia.

Low stricture

to reflux are of three types

Stricture secondary

occur at the

esophagogastric junction

2- High stricture

occur at higher level ,associated with

barrett

esophagus;

it is an acquired condition in which the squamous

epithelium has been eroded by the damaging effects of GE
reflux and has subsequently been replaced by columnar
junctional epithelium, it is a rare ,but it is PRE MALIGNANT
and the malignancy is adenocarcinoma .

3- long stricture

rarest type ,occur in

postpartum vomiting

Resection

Surgery

Dilatation

Bougienage

Treatment

CARCINOMA ESOPHAGUS

Carcinoma of the esophagus is a disease of men between
age (50-70) .Two risk factors:- smoking and high
consumption of alcohol.

Achalasia , Barret esophagus &

Predisposing lesions :

Corrosive stricture

most common

95%

Squamous cell carcinoma >

Pathology

(body) , Primary adenocarcinoma < 1-7% most common of
them is adenocarcinoma arise in Barrett’s esophagus
,Mucoepidermoid &Adenocystic carcinoma.

Spread :

Direct extension

OR Lymphatic to cervical

,mediastinal and sub diaphragmatic OR Blood metastases liver
,lung &bone

Cardiovascular and Thoracic Surgery Dr.Wallaa AlFalluji

Clinical manifestations :

Dysphagia ,to solid later to liquid

,Weight loss ,Aspiration pneumonia .Pressure symptoms .

Barium –swallow :

irregular ragged mucosal pattern with

annular luminal narrowing .

Esophagoscopy :

to see the tumor , to take biopsy(tissue

diagnosis) ,and esophageal wash for cytology .

CT with oral contrast

Treatment :

Chemo-therapy:

little value 2-

Radio-therapy :

useful but it may cause post radiation stricture ,radiation
pneumonitis . 3-

Surgery:

a- palliative

b- Resection - partial gastrectomy ,partial esophagectomy
&gastro esophageal anastomosis (Ivor lewis operation ) through
lapratomy & thoracotomy .

Gastro Oesophageal Reflux Disease (GORD)

Heartburn:-

Mild , intermittent reflux of gastric content into the

esophagus without tissue injury .Common among adult .

GORD

Esophagitis with varying degree of erythema ,

edema & friability of the distal esophageal mucosa .

Aetiology :-

Lower esophageal sphincter (LES ) incompetence ,

Gastric outlet obstruction , 50% of patients have an associated
hiatal hernia , Defective esophageal function (Scleroderma )

Mechanism of Anti –Reflux

……..

1-High resting pressure in the distal esophagus (10-20 mm Hg).
2- the right crus of the diaphragm around the esophago -gastric

junction .

3-The phreno esophageal membrane .
4-The presence of the intra abdominal segment of the esophagus
5-The oblique angle of insertion of the esophagus into the
stomach (angle of His ) .
6-The small diameter of the esophagus entering abruptly into the
large diameter (stomach) Law of Laplace .

Cardiovascular and Thoracic Surgery Dr.Wallaa AlFalluji

Clinical features :-

Epigastric or retro sternal pain , after meal or

at night , Pain similar to angina , Reflux of food or gastric
content , occurs with bending , Odyno phagia , Pulmonary
aspiration , nocturnal cough

Diagnosis :-

History and physical examination

Barium swallow

,Oesophago gastro dudenoscopy (OGD ) & biopsy ,
Ambulatory 24 hours PH monitoring

Esophageal manometry

Treatment:-

1- Medical :-

Weight reduction , Change diet (light

frequent meal ) , Stop smoking , Elevate the head of the bed  (4-
5 inches )  , Anti acid , Metoclopromide increase LES pressure
& gastric emptying , H2 receptor blockers , Ranitidine (Zantac ),
Proton pump inhibitor   omeprazole.

2- Surgical:-

Indications

:- Failure of medical treatment , Presence of complications
(stricture , respiratory symptoms)  ,Patient preference . Surgery
:-Laparoscopic Nissen ‘s fundoplication  , Lapratomy
Nissen ‘s fundoplication , Thoracotomy   Belsy’s mark 1V
repair

Esophageal hiatal hernia

It is the herniation of the

stomach through the esophageal hiatus of the diaphragm.

Hiatal

Hernia are of two types ;

1-Type 1 axial (sliding H.H.)

common ,  usually insignificant ,in which there is hiatus opening
dilatation and  or stretching of phrenoesophageal membrane ,
so  that a portion of the fundus will slide upward into the hiatus
.No true sac. In some patients a large pouch can occur producing
abnormal degree of GE reflux .  (significant) ..

on but more

less comm

)

esophageal (rolling

The Para

significant ,there is a defect of phreno –esophageal mm. So this
allows protrusion of the peritonium through the fascia (true
hernial sac ) .this will lead to progressive enlargement of the

Cardiovascular and Thoracic Surgery Dr.Wallaa AlFalluji

hernia .the entire stomach may herniated. May lead to gastric
volvulus, strangulation and intrathoracic gastric distention.

In which herniation of the cardia well above

Combined H.H

the diaphragm in addition to paraesophageal hernia .

colon , small

other organs herniated (

Multiorgan H.H.

intestine) .

Heart burn &Regurgitation

Clinical presentation ;

aggravated by posture Commonly after meal , Dysphagia ,
Aspiration into the chest can occur often awaken the patient
can lead to lung abscess .

eal type (II)

hag

paraesop

cipal indication

the prin

Treatment :

H.H. & no indication for repair of type(I) unless severe
reflux.

Medical:-

should started once reflux diagnosed

Surgical :-

Nissen ‘s fundoplication (lapratomy or

laparascopic) , Beksy’s mrak IV repair (Thoracotomy )

Esophageal divertuculae

Are epithelial -lined mucosal

pouches that protrude from the esophageal lumen. Classified
into :-Pharyngo esophageal , Parabronchial (midesophageal) ,
Epiphrenic (Supra diaphragmatic)

Sideropenic Dysphagia

(Plummer-Vinson or Patterson-

Kelly syndrome )

Cervical dysphagia in patients with iron

deffiency Anemia ,Usually women over the age of (40) years , It
is pre malignant condition,Treatment dilatation &correction of
anemia

Schatzki s Ring

(Distal esophageal web)

Commonly seen in

patient with a sliding H.H.,appearing as annular strictures
projecting into the lumen.

Mallory-Weiss Syndrome

A history of emesis followed

by either melena or hematemesis ,May occur in pregnancy
,alcoholism, bowel obstruction