The Esophagus

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The Esophagus

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

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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

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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)

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Anatomy (Continued)

• The esophagus has three distinct areas of
  naturally occurring anatomic narrowing
• Cervical constriction
• Bronchoaortic constriction
• Diaphragmatic constriction

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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

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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

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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)

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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)

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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

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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

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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

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Causes of Oropharyngeal Dysphagia

• Neurogenic
• Myogenic
• Structural causes
• Mechanical causes
• Iatrogenic causes
• Gastroesophageal reflux

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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

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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

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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

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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

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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

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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

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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

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Treatment

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

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Nonsurgical Treatment

• Early stages
• Sublingual nitroglycerin
• Long-acting nitrates
• Calcium channel blockers
• Passage of Mercury weighted bougies

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Surgical Treatment

• Forceful dilatation (balloon)
• Esophagomyotomy

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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

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Radiographic Findings

• Frustratingly variable
• Classic corkscrew
• Beaklike taper
• Increase in esophageal wall thickness

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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

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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

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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

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Testing

• Esophageal manometry and intraesophageal pH
  readings are the most sensitive means of detection

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Treatment

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

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Diverticula of the Esophagus
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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

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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

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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

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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)

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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

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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

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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

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Esophagoscopy
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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

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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

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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

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Tumors of the Esophagus
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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 (

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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

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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

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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

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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

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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

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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

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Diagnosis

• Esophageal biopsy
• Brushings for cytologic evaluation
• Barium swallow
• Lugols solution

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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

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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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Perforation of the Esophagus
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Causes of Perforation

• Iatrogenic
• Endoscopy
• Dilators
• Esophageal intubation
• Variceal sclerosis
• Intraopoerative
• Mediastinoscopy
• Thyroid surgery

• Spontaneous
• Postemetic
• Radiation therapy
• Traumatic
• Blunt and penetrating
• Caustic
• Carcinomas

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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

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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

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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

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Hiatal Hernia and Gastroesophageal Reflux
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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

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Signs and Symptoms of Gastroesophageal Reflux
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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)

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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

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Medical Treatment
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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

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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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Corrosive Strictures of the Esophagus
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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

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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

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Treatment Options

• Mechanical
• Intraluminal Silastic stents
• Pharmacological
• Corticosteroids to modify the inflammatory
  response
• Antibiotics to control secondary infection

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Strictures

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

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Treatment Options for Strictures

• Esophageal dilatation by the passage of bougies
• Surgical reconstruction

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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)

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The End