DISORDERS OF THE DISORDERS OF THE ESOPHAGUSESOPHAGUS

ANATOMY OF THE ESOPHAGUSANATOMY OF THE ESOPHAGUS

• Hollow muscular tube guarded by Hollow muscular tube guarded by upper and lower sphinctersupper and lower sphincters

• Extends from the lower border of the Extends from the lower border of the cricoid (C6) to the stomachcricoid (C6) to the stomach

• The length- 25 to 30 cm.The length- 25 to 30 cm.

• Viewed endoscopically- 15 cm. from Viewed endoscopically- 15 cm. from the teeth till 40 cm. at cardio-the teeth till 40 cm. at cardio-esophageal junctionesophageal junction

The middle of the esophagus- The middle of the esophagus- open tubular view, pink open tubular view, pink coloration. Sweeping wave like coloration. Sweeping wave like contractions are what move contractions are what move foodfood

ANATOMY OF THE ESOPHAGUSANATOMY OF THE ESOPHAGUS

• Posterior mediastinumPosterior mediastinum

• Diaphragmatic hiatus in front of the aortaDiaphragmatic hiatus in front of the aorta

• Cervical esophagus best approached in Cervical esophagus best approached in the left side of the neckthe left side of the neck

• Middle thoracic esophagus- approached Middle thoracic esophagus- approached by right thoracotomyby right thoracotomy

• Distal esophagus-approached by left Distal esophagus-approached by left thoracotomythoracotomy

ANATOMY OF THE ESOPHAGUSANATOMY OF THE ESOPHAGUS

• Cardia = gastr-esoph. junction, the Cardia = gastr-esoph. junction, the junctional zone between pale junctional zone between pale squamous esophageal mucosa and squamous esophageal mucosa and pink gastric mucosa, Z linepink gastric mucosa, Z line

• Up to 3 cm. of gastric mucosa type Up to 3 cm. of gastric mucosa type extending up the esophagus is extending up the esophagus is accepted as normalaccepted as normal

• More than that indicates Barret’s More than that indicates Barret’s esophagusesophagus

ASSESSMENT OF ESOPHAGEAL ASSESSMENT OF ESOPHAGEAL DISEASEDISEASE

• Careful historyCareful history

• Physical examinationPhysical examination

• Appropriate investigationsAppropriate investigations

SYMPTOMS OF ESOPHAGEAL SYMPTOMS OF ESOPHAGEAL DISEASEDISEASE

• Dysphagia- difficulty in swallowingDysphagia- difficulty in swallowing

• May be due to- organic disease (benign May be due to- organic disease (benign strictures or esophageal carcinoma) strictures or esophageal carcinoma)

- esophagal motility disorders - esophagal motility disorders (achalasia or diffuse esophageal spasm)(achalasia or diffuse esophageal spasm)

• Dysphagia for solids implies severe Dysphagia for solids implies severe disease, organic or functionaldisease, organic or functional

• Dysphagia for liquids- motility disordersDysphagia for liquids- motility disorders

SYMPTOMS OF ESOPHAGEAL SYMPTOMS OF ESOPHAGEAL DISEASEDISEASE

• Regurgitation- effortless return of the Regurgitation- effortless return of the gastric content into the mouthgastric content into the mouth

• Postural regurgitation is a common Postural regurgitation is a common symptom in reflux diseasesymptom in reflux disease

• Precipitated by meals and increased Precipitated by meals and increased in intraabdo.pressurein intraabdo.pressure

• Overflow regurgitation into the Overflow regurgitation into the pharynx-trachea- aspiration pharynx-trachea- aspiration pneumonitispneumonitis

SYMPTOMS OF ESOPHAGEAL SYMPTOMS OF ESOPHAGEAL DISEASEDISEASE

• Odynophagia- painful swallowing- organic Odynophagia- painful swallowing- organic disease- esophagitisdisease- esophagitis

• Esophageal pain- two sorts: heartburn and Esophageal pain- two sorts: heartburn and angina-like tightening painangina-like tightening pain

• Heartburn is due to reflux of gastric juice to Heartburn is due to reflux of gastric juice to the esophagus- esophagitisthe esophagus- esophagitis

• Angina-like tightening pain-esophageal Angina-like tightening pain-esophageal anterior chest pain, simulates angina anterior chest pain, simulates angina pectoris- reflux esophagitis, motility disorderspectoris- reflux esophagitis, motility disorders

Atypical Presentation ofAtypical Presentation of Esophageal DiseaseEsophageal Disease

• Anemia due to chronic blood loss- erosive Anemia due to chronic blood loss- erosive esophagitisesophagitis

• Acute upper GI bleeding- Mallory-Weiss Acute upper GI bleeding- Mallory-Weiss sdr.,peptic ulcer in a hiatus herniasdr.,peptic ulcer in a hiatus hernia

• Severe sepsis, respiratory distress- Severe sepsis, respiratory distress- perforation of the esophagusperforation of the esophagus

• Angina-like pain- reflux diseaseAngina-like pain- reflux disease• Pulmonary symptoms- aspiration Pulmonary symptoms- aspiration

pneumonitis- reflux diseasepneumonitis- reflux disease

ESOPHAGEAL DISEASEESOPHAGEAL DISEASEPHYSICAL SIGNSPHYSICAL SIGNS

• Inaccesible to physical examinationInaccesible to physical examination

• Evidence of weight lossEvidence of weight loss

• Palor due anemiaPalor due anemia

• Neck swellingNeck swelling

• Chest signsChest signs

• HepatomegalyHepatomegaly

ESOPHAGEAL DISEASEESOPHAGEAL DISEASEINVESTIGATIONSINVESTIGATIONS

• CXR, Barium swallow, CT scanCXR, Barium swallow, CT scan• USS, external, endoscopicUSS, external, endoscopic• Radioisotope studies- labelled bollusRadioisotope studies- labelled bollus• Endoscopy with biopsy, cytologyEndoscopy with biopsy, cytology• ManometryManometry• Ph 24-hours monitoringPh 24-hours monitoring• Tests to exclude cardiac disease- Tests to exclude cardiac disease-

ecg, coronary angiography ecg, coronary angiography

ESOPHAGEAL DISEASEESOPHAGEAL DISEASEINVESTIGATIONSINVESTIGATIONS

• CXR may reveal:CXR may reveal:

- aspiration pneumonitis,- aspiration pneumonitis,

- mediastinal widening,- mediastinal widening,

- fluid/gas level,- fluid/gas level,

- mediastinal emphysema,- mediastinal emphysema,

- pleural effusion- pleural effusion

ESOPHAGEAL DISEASEESOPHAGEAL DISEASEINVESTIGATIONSINVESTIGATIONS

• Barium swallow- indicationsBarium swallow- indications– Esophageal motility disordersEsophageal motility disorders– Esophageal carcinoma and benign strictureEsophageal carcinoma and benign stricture– Gastro-esophageal reflux +/- hiatus herniaGastro-esophageal reflux +/- hiatus hernia– Suspected esophageal perforation Suspected esophageal perforation – Leaking esophageal anastomosis Leaking esophageal anastomosis

ESOPHAGEAL DISEASEESOPHAGEAL DISEASEINVESTIGATIONSINVESTIGATIONS

• CT scan- preop.assessment of CT scan- preop.assessment of esophageal malignancyesophageal malignancy

- extent of mural invasion,- extent of mural invasion,

- involvement of adjacent - involvement of adjacent structures,structures,

- mediastinal lymph nodes- mediastinal lymph nodes

ESOPHAGEAL DISEASEESOPHAGEAL DISEASEINVESTIGATIONSINVESTIGATIONS

• Radioisotope studies- assess g-e Radioisotope studies- assess g-e incompetence:incompetence:

- in pts. with reflux symptoms- in pts. with reflux symptoms

- esophageal transit of liquid and - esophageal transit of liquid and solid boluses in pts. with motility solid boluses in pts. with motility disordersdisorders

ESOPHAGEAL DISORDERESOPHAGEAL DISORDERINVESTIGATIONSINVESTIGATIONS

• Endoscopy- essential in all pts.with Endoscopy- essential in all pts.with dysphagiadysphagia– visual information- severity of visual information- severity of

esophagitisesophagitis– esophageal cancer- biopsy, cytologyesophageal cancer- biopsy, cytology– gastro-esophageal refluxgastro-esophageal reflux

ESOPHAGEAL DISEASEESOPHAGEAL DISEASEINVESTIGATIONSINVESTIGATIONS

• Physiological testsPhysiological tests– manometry- the pressure profile- manometry- the pressure profile-

motility disordersmotility disorders– 24h.pH monitoring- pathological reflux is 24h.pH monitoring- pathological reflux is

considered when the time in the acid considered when the time in the acid zone Ph<4 is more than 5 min.zone Ph<4 is more than 5 min.

ESOPHAGEAL MOTILITY ESOPHAGEAL MOTILITY DISORDERSDISORDERS

• Cricopharyngeal dysfunctionCricopharyngeal dysfunction

• AchalasiaAchalasia

• Diffuse esophgeal spasmDiffuse esophgeal spasm

CRICOPHARYNGEAL CRICOPHARYNGEAL DISFUNCTIONDISFUNCTION

• Failure of the UES to relax properlyFailure of the UES to relax properly

• Pharyngoesofageal diverticulum- Zenker’s Pharyngoesofageal diverticulum- Zenker’s

• False diverticulum- mucosa herniates False diverticulum- mucosa herniates posteriorly between the fb.of CPH.muscleposteriorly between the fb.of CPH.muscle

• Frequently associated with hiatus hernia Frequently associated with hiatus hernia and GER.and GER.

• Symptoms: dysphagia, mass in the neck, Symptoms: dysphagia, mass in the neck, tracheal compressiontracheal compression

CRICOPHARYNGEAL CRICOPHARYNGEAL DYSFUNCTIONDYSFUNCTION

• Diagnosis: Diagnosis: – historyhistory– physical examinationphysical examination– barium swollowbarium swollow– endoscopyendoscopy

CRICOPHARYNGEAL CRICOPHARYNGEAL DYSFUNCTIONDYSFUNCTION

• Treatment:Treatment:– Cricopharyngeal myotomyCricopharyngeal myotomy– Excision of the diverticulum+myotomyExcision of the diverticulum+myotomy

Formation of pharyngoesophageal (Zenker's) diverticulum. Formation of pharyngoesophageal (Zenker's) diverticulum. Left- herniation of the pharyngeal mucosa and submucosa Left- herniation of the pharyngeal mucosa and submucosa occurs at the point of transition (arrow) between the oblique occurs at the point of transition (arrow) between the oblique fibers of the thyropharyngeus muscle and more horizontal fibers of the thyropharyngeus muscle and more horizontal fibers of the cricopharyngeus muscle (Killian's triangle). fibers of the cricopharyngeus muscle (Killian's triangle). Center and right— as the diverticulum enlarges, it dissects Center and right— as the diverticulum enlarges, it dissects toward the left side and downward in the superior toward the left side and downward in the superior mediastinum in the prevertebral space. mediastinum in the prevertebral space.

Barium swallow- Zenker’s Barium swallow- Zenker’s diverticulumdiverticulum

ACHALASIAACHALASIA

• Unknown etiologyUnknown etiology

• Abnormal peristalsis in the body of the Abnormal peristalsis in the body of the esophagus, resulting in:esophagus, resulting in:– high resting LES pressurehigh resting LES pressure– failure of the LES to relax during swollowingfailure of the LES to relax during swollowing

The body of the esophagus becomes dilatedThe body of the esophagus becomes dilated

Carcinoma of the esophagus is 10 times Carcinoma of the esophagus is 10 times commoner in pts. with achalasiacommoner in pts. with achalasia

ACHALASIAACHALASIA

• Symptoms:Symptoms:– Difficulty in swollowing fluidsDifficulty in swollowing fluids– Respiratory symptomsRespiratory symptoms– VomitingVomiting– Retrosternal painRetrosternal pain– Weight loss Weight loss

ACHALASIAACHALASIA

• Diagnosis:-contrast studies- smooth Diagnosis:-contrast studies- smooth tapering narrowing of lower esoph. tapering narrowing of lower esoph. end with dilated, tortuous lower end with dilated, tortuous lower esophagus, uncoordinated or absent esophagus, uncoordinated or absent peristalsisperistalsis

• Esophageal manometryEsophageal manometry

• Esophagoscopy Esophagoscopy

ACHALASIAACHALASIA

• Treatment:Treatment:– Non surgical treatment- pneumatic Non surgical treatment- pneumatic

dilatation of the LESdilatation of the LES– Surgical- esophagomyotomy (Heller’s op.) Surgical- esophagomyotomy (Heller’s op.)

•Myotomy is confined to the lower portion of Myotomy is confined to the lower portion of the esophagus, 7-10 cm. and upper gastric the esophagus, 7-10 cm. and upper gastric musclemuscle

•Esophagomyotomy can be combined with an Esophagomyotomy can be combined with an antireflux procedureantireflux procedure

TREATMENTTREATMENT

• As the degenerative neural lesion of this As the degenerative neural lesion of this disease cannot be corrected, treatment is disease cannot be corrected, treatment is directed at palliation of symptoms and directed at palliation of symptoms and prevention of complications. prevention of complications.

• Effective peristalsis is rarely restored by Effective peristalsis is rarely restored by successful treatment, but improved successful treatment, but improved oesophageal emptying and a decrease in oesophageal emptying and a decrease in oesophageal diameter are generally oesophageal diameter are generally expected. expected.

Pharmacotherapy :Pharmacotherapy :

• Smooth muscle relaxants alleviate symptoms and Smooth muscle relaxants alleviate symptoms and improve oesophageal emptying in up to 70% of improve oesophageal emptying in up to 70% of patients. patients.

• Nitrites, such as sublingual Nitrites, such as sublingual isosorbide dinitriteisosorbide dinitrite, , and and calcium channel blockerscalcium channel blockers, such as diltiazem, , such as diltiazem, nifedipine and verapamil, have this effect. nifedipine and verapamil, have this effect.

• This treatment option is suitable for patients with This treatment option is suitable for patients with medical conditions that interfere with pneumatic medical conditions that interfere with pneumatic dilatation or myotomy. dilatation or myotomy.

Botulinum Toxin: Botulinum Toxin:

• Botulinum toxin type A Botulinum toxin type A is derived from the is derived from the controlled fermentation of Clostridium controlled fermentation of Clostridium botulinum. botulinum.

• The toxin binds to presynaptic cholinergic The toxin binds to presynaptic cholinergic neuronal receptors, interferes with neuronal receptors, interferes with acetylcholine release. acetylcholine release.

• Botulinum toxin decreases LOS basal tone and Botulinum toxin decreases LOS basal tone and improves symptoms in patients with achalasia.improves symptoms in patients with achalasia.

• Beneficial response occurs in 90% of patients, Beneficial response occurs in 90% of patients, but symptoms reappear within a year in many but symptoms reappear within a year in many initial responders.initial responders.

DilatationDilatation: : • Forceful dilatation of the gastroesophageal sphincter to a Forceful dilatation of the gastroesophageal sphincter to a

diameter of 3 cm is necessary to tear the circular muscle diameter of 3 cm is necessary to tear the circular muscle and to ensure a lasting reduction in LOS pressure. and to ensure a lasting reduction in LOS pressure.

• Pneumatic dilators are conventionally used today. Pneumatic dilators are conventionally used today.

• Water-soluble contrast material is used to detect distal Water-soluble contrast material is used to detect distal oesophageal leaks. oesophageal leaks.

• Surgical consultation is undertaken if perforation is Surgical consultation is undertaken if perforation is evident. evident.

• Small perforations are managed conservatively with Small perforations are managed conservatively with broad-spectrum antibiotics.broad-spectrum antibiotics.

• Clinical deterioration e.g. shock, sepsis, haemorrhage or Clinical deterioration e.g. shock, sepsis, haemorrhage or a finding of free-flowing barium into the mediastinum, a finding of free-flowing barium into the mediastinum, requires immediate thoracotomy and repair. requires immediate thoracotomy and repair.

DilatationDilatation

• At least 60% of patients have a good responseAt least 60% of patients have a good response

• The response rate varies with patient age, The response rate varies with patient age, (younger patients do not do as well as older (younger patients do not do as well as older patients), and duration of symptoms, (those with patients), and duration of symptoms, (those with a shorter history do not respond as well) a shorter history do not respond as well)

• Morbidity is mostly related to oesophageal Morbidity is mostly related to oesophageal perforation, a complication in approximately 5% perforation, a complication in approximately 5% of patients, but surgical repair is required in less of patients, but surgical repair is required in less than half of these cases.than half of these cases.

Surgery:Surgery:

• The Heller procedure was described in The Heller procedure was described in 1913 and now a modification of this 1913 and now a modification of this procedure is used most commonly in the procedure is used most commonly in the surgical management of achalasiasurgical management of achalasia

• An anterior myotomy is performed by An anterior myotomy is performed by dividing the circular muscle of the dividing the circular muscle of the oesophagus down to the level of the oesophagus down to the level of the mucosa. mucosa.

Minimally invasive surgical Minimally invasive surgical proceduresprocedures• A preferable alternative to open myotomy, allowing the A preferable alternative to open myotomy, allowing the

Heller myotomy to be performed thoracoscopically and Heller myotomy to be performed thoracoscopically and laparoscopicallylaparoscopically

• Shorter hospitalisation, less pain and early resumption of Shorter hospitalisation, less pain and early resumption of activity are the benefits of the minimally invasive approach, activity are the benefits of the minimally invasive approach, which remains as effective as the open techniques in the which remains as effective as the open techniques in the relief of dysphagia.relief of dysphagia.

• Complications of minimally invasive surgery include: Complications of minimally invasive surgery include: anterior gastric perforation, mucosal perforation at the anterior gastric perforation, mucosal perforation at the gastroesophageal (GO) junction and, most significantly, GORgastroesophageal (GO) junction and, most significantly, GOR

Comparisons between Comparisons between therapiestherapies

• Pneumatic dilatation, pharmacotherapy and Pneumatic dilatation, pharmacotherapy and botulinum toxin injection are easy to use, botulinum toxin injection are easy to use, usually well-tolerated and relatively cheap usually well-tolerated and relatively cheap treatment options in achalasia. treatment options in achalasia.

• Surgery generally gives longer-lasting results as Surgery generally gives longer-lasting results as well as more complete relief of symptoms. well as more complete relief of symptoms.

• Non-operative therapy is recommended initially. Non-operative therapy is recommended initially. Patients are only referred for surgery if they Patients are only referred for surgery if they remain symptomatic after 3 attempts at remain symptomatic after 3 attempts at pneumatic dilatation. pneumatic dilatation.

a: Initial esophagram of patient with early achalasia and no a: Initial esophagram of patient with early achalasia and no esophageal dilation. esophageal dilation. b: Patient after 2 years of nonoperative treatment. Note b: Patient after 2 years of nonoperative treatment. Note significant esophageal dilation and air-fluid level compared to significant esophageal dilation and air-fluid level compared to pretreatment.pretreatment. c: End-stage achalasia with sigmoid or megaesophagus. c: End-stage achalasia with sigmoid or megaesophagus.

After satisfactory cardioesophageal myotomy, a After satisfactory cardioesophageal myotomy, a Toupet fundoplication is done- the posterior fundus Toupet fundoplication is done- the posterior fundus of the stomach is brought around the esophagus of the stomach is brought around the esophagus and secured to the right crus and the right cut edge and secured to the right crus and the right cut edge of the myotomy. In a similar (in fact mirror image) of the myotomy. In a similar (in fact mirror image) fashion the anterior fundus is sutured to the left fashion the anterior fundus is sutured to the left crus and left edge of the myotomy. crus and left edge of the myotomy.

DIFFUSE ESOPHAGEAL DIFFUSE ESOPHAGEAL SPASMSPASM• Strong nonperistaltic contractionsStrong nonperistaltic contractions

• Normal sphincter relaxationNormal sphincter relaxation

• May be associated with GERMay be associated with GER

• Symptoms: chest painSymptoms: chest pain

• Manometry-high amplitute repetitive Manometry-high amplitute repetitive contractionscontractions

• Constrast study: normal in ½, Constrast study: normal in ½, segmental spasm, diverticulasegmental spasm, diverticula

DIFFUSE ESOPHAGEAL DIFFUSE ESOPHAGEAL SPASMSPASM

• Treatment:Treatment:– Surgery- long esophagomyotomy, from Surgery- long esophagomyotomy, from

the arch of the aorta to just above the the arch of the aorta to just above the LES,-antireflux op in case of GERLES,-antireflux op in case of GER

– Medical treatment- calcium channel Medical treatment- calcium channel blockers and smooth muscle relaxantsblockers and smooth muscle relaxants

GASTRO-ESOPHAGEAL GASTRO-ESOPHAGEAL REFLUXREFLUX

• Secondary to LES dysfunctionSecondary to LES dysfunction

• LES dysfunction may be related to:LES dysfunction may be related to:– Decreased gastrin productionDecreased gastrin production– Operation on or near the esophageal Operation on or near the esophageal

hiatushiatus– Sliding hiatus herniaSliding hiatus hernia– SclerodermaScleroderma– Tabacco and alcoholTabacco and alcohol

GASTRO-ESOPHAGEAL GASTRO-ESOPHAGEAL REFLUXREFLUX

• Diagnosis:Diagnosis:

• Substernal pain, heartburn, Substernal pain, heartburn, regurgitationregurgitation

• Manometry-decreased LES pressureManometry-decreased LES pressure

• Esopgagoscopy-esophagitisEsopgagoscopy-esophagitis

• 24h pH monitoring24h pH monitoring

• CineradiographyCineradiography

GERD-when acid from the GERD-when acid from the stomach bathes the lower stomach bathes the lower esoph. A feeling of heartburn esoph. A feeling of heartburn occurs.This can cause some occurs.This can cause some mild inflammation. mild inflammation.

GERD- lower esoph. with a GERD- lower esoph. with a slight erosion surrounded by slight erosion surrounded by inflammed red tissue- inflammed red tissue- esophagitis gr.IIesophagitis gr.II

GERD- extensive deep GERD- extensive deep ulceration, severe case of ulceration, severe case of esophagitis (gr.III)esophagitis (gr.III)

GERD- severe case of GERD- severe case of extensive deep ulcerations in extensive deep ulcerations in the lower esophthe lower esoph

GASTRO-ESOPHAGEAL GASTRO-ESOPHAGEAL REFLUXREFLUX• TreatmentTreatment

– Medical: antiacids and metoclopramideMedical: antiacids and metoclopramide– Surgical: antireflux operations- Nissen Surgical: antireflux operations- Nissen

fundoplication- wrapping the lower esophagus fundoplication- wrapping the lower esophagus with gastric funduswith gastric fundus

Indications for surgery:Indications for surgery:

-sy.refractory to medical treatment-sy.refractory to medical treatment

-severe esophagitis, Barret’s esophagus -severe esophagitis, Barret’s esophagus (replacement with columnar epithelium in the (replacement with columnar epithelium in the lower esophagus secondry to esophagitis)lower esophagus secondry to esophagitis)

Barrett’s occurs after Barrett’s occurs after longstanding reflux of acid. longstanding reflux of acid. The stomach lining grows up The stomach lining grows up where does not belong. Red where does not belong. Red stomach tissue creeping upstomach tissue creeping up

Barrett’s- significant Barrett’s- significant progressionprogression

Barrett’s- extensive long Barrett’s- extensive long fingers and patches of fingers and patches of Barrett’s- prone to malignant Barrett’s- prone to malignant changeschanges

BARRETT’S ESOPHAGUSBARRETT’S ESOPHAGUS• Replacement of the lower esophagus with Replacement of the lower esophagus with

gastric-type mucosa, exceeding 3 cm. above gastric-type mucosa, exceeding 3 cm. above the squamo-columnar junction and gastric the squamo-columnar junction and gastric mucosa islands amongst the squamous mucosa islands amongst the squamous mucosamucosa

• Recognized as a metaplastic response to Recognized as a metaplastic response to reflux with increased exposure to gastric acidreflux with increased exposure to gastric acid

• 30-fold increased risk of developing an 30-fold increased risk of developing an adenocarcinomaadenocarcinoma

• Regular endoscopic surveillance until an early Regular endoscopic surveillance until an early adenocarcinoma is detectedadenocarcinoma is detected