Esophagus

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Esophagus

• Chapter 12

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ESOPHAGUSObjectives

• Anatomy and Physiology
• GERD and Hiatal Hernia
• Esophageal Dysmotility
• Esophageal Diverticula
• Benign Esophageal Neoplasms
• Malignant Neoplasms
• Esophageal Trauma

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ANATOMY

• 3 Segments
• Cervical esophagus
• Thoracic esophagus
• Abdominal esophagus
• Anatomic Relationships
• Trachea
• Aorta
• Vagus nerve

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ANATOMY

• Wall
• Mucosa
• stratified squamous epithelium
• goblet cells
• 2 muscular layers
• Inner circular
• Outer longitudinal
• upper 1/3 is skeletal lower 2/3 is smooth muscle

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ANATOMY

• Upper esophageal sphincter (UES)
• Cricopharyngeus muscle
• Lower esophageal sphincter (LES)
• Zone of high pressure 3-5 cm long
• Intrinsic muscular tone
• Diaphragmatic crura
• phrenoesophageal ligament
• intrabdominal pressure

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PHYSIOLOGY

• Food enters the back of the oropahrynx
• Coordinated peristaltic wave
• Primary
• Secondary
• Relaxation of the LES

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GERD

• Gastroesophageal Reflux Disease
• Reflux of acid and bile into the esophagus
• Abnormal clearance from the esophagus
• Resulting erosion and ulceration of mucosal wall
• Scarring and stricture formation

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GERD Pathophysiology

• Abnormal clearance of acid
• peristaltic wave
• Saliva
• Abnormal relaxation of the LES.
• Low resting pressures
• shortened abdominal segment

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GERD Pathophysiology

• Abnormalities in the gastric reservoir
• delayed gastric emptying
• gastric dilation
• increased intragastric or abdominal pressure
• gastric hypersecretion

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GERDPathophysiology

• Hiatal Hernia
• Type I Sliding hernia- movement of
  gastroesophageal junction
• shortens abdominal segment
• surgery required if sx and unresponsive to
  medical mgmt

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GERDPathophysiology

• Type II Paraesophageal hernia- no movement of GE
  junction
• usually no reflux
• surgery is required.

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GERDEtiology

• Decreased resting LES pressure
• alcohol
• cigarette
• chocolate
• caffeine
• medsnitrates, calcium channel blockers, MSO4
  derivatives

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GERDEtiology

• Increased abdominal pressures
• pregnancy
• obesity

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GERDClinical presentation

• Burning epigastric or substernal pain
• Intensity of pain is often positional
• Dysphagia
• H/O chronic aspiration bronchitis or pneumonitis
• Often relieved by antacids

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GERDDiagnostic Tests

• Esophagoscopy and biopsy
• Barium Swallow
• Manometry
• pH Monitoring- 24 Hr
• Hemocult

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GERDTreatment

• Medical
• change habits
• Avoid eating within several hours of sleeping
• Sleep with head of bed elevated
• Weight loss
• Meds antacids, H2 Blockers, Proton pump
  inhibitors(lt6 months)

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GERDTreatment

• Surgical
• Nissen Fundoplication
• Toupet
• Belsey Mark IV
• Collis Gastroplexy
• Hill Repair
• Laparoscopy

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ESOPHAGEAL MOTILITY DISORDERS

• Achalasia
• Diffuse esophageal spasm
• Nutcracker esophagus
• Hypertensive LES

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ESOPHAGEAL MOTILITY DISORDERSAchalasia

• Failure To Relax
• Pathophysiology
• Neuronal degeneration in the myenteric plexus of
  the esophageal wall
• Causes aperistalsis and proximal dilatation
• Presentation
• Dysphagia
• Weight loss
• Regurgitation of undigested food

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ESOPHAGEAL MOTILITY DISORDERSAchalasia

• Diagnosis
• Cineradiography-Barium swallow
• Birds Beak appearance
• Manometric studies
• Treatment
• Medical
• Balloon Dilatation
• Surgical
• Myotomy
• Partial wrap

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ESOPHAGEAL DIVERTICULA

• Def outpouching of the wall
• Zenkers Diverticula
• occur between thyropharyngeus and cricopharyngeus
  muscles
• sx with regurgitated food
• Treatment Diverticulectomy and myotomy
• Epiphrenic Diverticula- Distal 1/3
• As result of other abnormalities-achalasia,
  strictures, tight fundoplications

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Esophageal Neoplasm

• Benign neoplasms- rare
• Leiomyomas
• Malignant Neoplasms
• Squamous cell Carcinoma- 85
• Adenocarcinoma- 10
• Malignant Melanoma- 1

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Malignant Tumors of the EsophagusEpidemiology

• Geographic areas
• Diet
• Alcohol- daily consumption gt 9gm ETOH
• Smoking- gt20 cigarettes/day
• Achalasia
• Barretts esophagus-
• 10 develop adenocarcinoma
• malignant transformation

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Malignant Tumors of the EsophagusPresentation

• Insidious onset
• Dysphagia is most common
• Odynophagia is second most common
• Hoarseness
• Recurrent aspiration

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Malignant Tumors of the Esophagus

• Pathophysiology
• invades locally
• adjacent lymph nodes
• Diagnosis
• Upper GI series
• Endoscopy and biopsy
• CT scan for staging

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Malignant Tumors of the Esophagus

• Treatment
• en bloc resection
• Right thorocotomy- upper and middle esophagus
• Left thorocoabdominal- distal esophagus
• Ivor-Lewis- Right thorocotomy and midline
  laparotomy- middle and distal
• Transhiatal with cervical incision

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Malignant Tumors of the Esophagus

• Esophageal replacement with stomach, colon or
  jejunum
• Pyloromyotomy
• Radiation and Chemotherapy
• Palliation
• Prognosis
• Overall 5 year survival is 5-10

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Esophageal Trauma

• Borhaaves Syndrome
• Presentation
• severe chest and abdominal pain
• nausea and vomiting
• Diagnosis
• history
• CXR
• Treatment
• Immediate surgical intervention
• Repair and drainage- Time dependent