Anatomy 09/05/2018

Bianca Bertoletti - Teresa Roatta

04_ESOPHAGUS

The “oesophagus” (British English) or “esophagus” (American English), is a muscular tubular

organ, which descends through the mediastinum and crosses the thorax, extending
from C6 to T11 and connecting the pharynx – from the cricoid cartilage – to the stomach –
at the cardiac orifice – thus allowing the passage of food (as it is part o the Digestive
System).
It is not straight, but it presents anterior and lateral curvatures and four main constrictions. In
facts, it follows the anteroposterior curve of the vertical column. It inclines to the left at the
root of the neck and by T7, and it narrows behind the cricoid cartilage of the larynx
(cricopharynx sphincter), by the aortic arch, by the left principal bronchus, and at the
esophageal, hiatus where it passes through the diaphragm.

It is topographically divided into

three main sections: the cervical
esophagus, the thoracic
esophagus, and the abdominal
esophagus.

1. CERVICAL ESOPHAGUS
From the pharyngoesophageal
notch up to the suprasternal notch.
It runs behind the trachea,
anteriorly to the vertebral column,
and laterally to the posterior part of
the thyroid.

2. THORACIC ESOPHAGUS
From the suprasternal notch up
to the diaphragmatic hiatus. It
slightly sits to the left of the
cervical esophagus and posteriorly
to the trachea, the tracheal
bifurcation, the left main bronchus,
and the pericardium. It passes
behind the right aortic arch (T4) but
lies anteriorly to the aorta from T8
to the diaphragmatic hiatus.

Note the very strict relation of the esophagus with the heart. This is important when it comes
to exploring the posterior and right part of the heart, which are hidden from the
electrocardiography because of the great number of muscles and bones of the area i.e.
spinal cord and ribs alternating with intercostal muscles. Therefore, the esophagus can be
used to obtain a sonography examination of the heart, which is very much complementary to
the electrocardiography, preferable if having to analyze the anterior and left portion of the
heart.

3. ABDOMINAL ESOPHAGUS
From the diaphragmatic hiatus up to the stomach’s cardiac orifice (cardioesophageal
junction) – overall only 1-2 cm long. It runs posteriorly to the left lobe of the liver. The
abdominal esophagus and the diaphragm (which is crossed by the vagus nerve at the same
opening) are kept together by the phrenoesophageal ligament (example of a connective
ligament), made up by two circumferential layers of elastin-rich connective tissue containing
some smooth muscle fibers. Beneath the diaphragm two tendons (crurae) extend obliquely
reaching the vertebral column and, other than keeping the esophagus attached to it, play a
role in maintaining its shape since the anterior wall of the organ is longer than the posterior
because of its curvature.

review of ligaments:
a. CONNECTIVE —> keep the position of an organ
b. PERITONEAL —> keep a moving organ

The esophagus is also connected, as well as the first part of the duodenum, to the liver by a
peritoneal serous ligament, called ​lesser omentum (​ more specifically, the ​esophageal
hepatic ligament​). The esophageal hepatic ligament together with the hepatogastric ligament
form the smooth part of the lesser omentum.

VASCULARISATION
Apart from a few exceptions i.e. when there are some complexities and portal systems,
vascularisation will not be required for this exam! It will be covered later on since it is crucial
for surgeries.

Arteries: the cervical esophagus is

supplied by the inferior thyroid artery,
whereas the thoracic esophagus is
supplied by the bronchial and esophageal
branches of the aorta.
Veins: the cervical esophagus is supplied
by the inferior thyroid vein, whereas the
thoracic esophagus is supplied by the
azygos vein, hemiazygos intercostal and
bronchial vein.

LYMPHATIC SYSTEM
The esophagus' lymphatic system is
extensive and continuous along its length
and two main regions (upper and lower) can be distinguished. The thoracic esophagus
drains into the posterior mediastinal nodes, whereas the abdominal esophagus into the left
gastric lymph nodes.

INNERVATION
Details on innervation are not required for this exam! Just know the general concept​.
The same division (upper and lower esophagus) applies for the nerves’ supply. The two are
differentially innervated: the former is supplied by somatic motor neurons (which are usually
under voluntary control) – precisely by branches of the lower/recurrent laryngeal nerve* that
in turns branches from the vagus nerve, the latter is supplied by autonomic (involuntary)
nerves – precisely by the esophageal plexus, which is part of the orthosympathetic plexus.
Despite being partially innervated by somatic motor neurons, the overall control of the
esophagus is involuntary. This peculiarity is due to the ambiguity of the first nucleus of
somatic nerves (called in fact nucleus ambiguous) that sits in the medulla of the brainstem,
which works as if they were autonomic.

*the main function of the lower/recurrent laryngeal nerve is to innervate the somatic vocal
muscles, this is the most precise muscle innervation in our body (think of the complexity of
the phonation) thus it is the most difficult to recover after a damage, even more than the
movement of the hands.
Fun fact: the esophagus is still under the control of the brain and it can be learnt (e.g.
through yoga) to voluntarily dominate it.

HISTOLOGY
The esophagus’ walls present five /four* concentric layers, which do not enclose a proper
lumen: the mucosa is multi-layered and because of its grooves and ridges (that disappear
when bolus or liquids are passing through) it collapses when the organ is empty.
1. MUCOSA
The epithelium of the mucosa is
non-keratinised, stratified and
squamous, and it is continuous with
the one of the pharynx. Papillae
(connective tissue) divide epithelium
from the lamina propria. The
epithelium changes at the
gastroesophageal junction ("Z line" or
squamocolumnar junction) becoming
columnar because of the change in
environment – acidic.
The mucosa provides the first mean
of protection against mechanical
injury during ingestion thanks to
the thickness due to its multi-layer.
2. MUSCULARIS MUCOSA
This layer, composed mainly of longitudinal smooth muscle, is found between the mucosa
and the submucosa, it is particularly developed in the esophagus (thus usually very clear in
the histological slides, but it can be found elsewhere as well with other compositions e.g. in
the intestines), and it constitutes the second self-protection of the esophagus: despite not
being capable of moving the whole organ – like the muscularis externa – it allows moments
of the mucosa so that unwanted things enter the esophagus can be expelled.

3. SUBMUCOSA
The submucosa contains blood vessels, the submucosal nerve plexus – in the
gastrointestinal tract starting from the esophagus there are two plexuses, one in the
submucosa (Meissner) and the other in the muscle layer (Auerbach’s plexus) – the
esophageal glands which secrete mucus that protects the esophagus and serous cells,
which secrete lysozymes.

4. MUSCULARIS EXTERNA
The muscularis externa is formed by circular and outer longitudinal muscle fibers (the
longitudinal layer is generally much thicker than the circular one) and innervated by the
Auerbach’s plexus. The muscular layer is important for swallowing and differs among the
three different esophagus portions, according to their functions: the superior part is made up
primarily of striated muscle fibers, the middle one of mixed muscle fibres (skeletal and
smooth), the distal portion of smooth muscle fibers exclusively.

5. ADVENTITIA/SEROSA
The external layer is formed by irregular, dense connective tissue containing many elastic
fibers. It continues up until the thoracic part of the esophagus and is substituted into the
abdominal part by a serosa because the organ converts from retroperitoneal to
intraperitoneal.

DEVELOPMENT
The esophagus derives from the endoderm, such as the whole GI tract. The sphincters
(particularly the lower esophageal sphincter – see next paragraph) are not yet mature at
birth, resulting in frequent regurgitations during the neonatal period.

PHYSIOLOGY
SPHINCTERIC MECHANISM
The esophagus at rest is closed at top and bottom by two functional muscular sphincters.
These are not anatomical parts since they do not present a particular thickening or
difference in constitution compared to the rest of the organ.
• Upper Esophageal Sphincter (UES)
It triggered by the swallowing reflex, therefore it is NOT under voluntary control,
despite being constituted of skeletal muscle (cricopharyngeal part of the inferior
pharyngeal constrictor) – as previously said.
• Lower Esophageal Sphincter (LES) or Gastroesophageal/Cardiac Sphincter:
It is composed of smooth muscles always under tonic contraction unless something is
passing through (bolus or vomiting).
DEGLUTITION (SWALLOWING)
Food is introduced into the mouth, where it becomes bolus after mechanical and chemical
breakdowns. During deglutition, the UES relaxes allowing the bolus from the pharynx into
the esophagus, while the epiglottis moves backward, covering the larynx and preventing the
bolus from entering the trachea. At this stage, gravity is the main driving force in
physiological conditions, but peristaltic contractions take place as well to help push the food
down the esophagus and are divided into primary peristaltic wave and secondary peristaltic
wave. The former lasts about 8-9 s, beginning when the bolus enters the esophagus, the
latter occurs in the event that the bolus gets stuck or moves slower than the primary
peristaltic wave (e.g. if the esophagus is poorly lubricated): stretch receptors in the
esophageal lining are stimulated and a local reflex response causes the secondary
peristaltic wave around the bolus that lasts until it reaches the stomach, following the LES
relaxation. The process of peristalsis is controlled by medulla oblongata (brainstem).

PATHOLOGY

• VOMITING
A forceful expulsion of the contents of the GI system out through the mouth. A rapid
muscular contraction of the diaphragm and abdomen increases the intra-abdominal pressure
while anti-peristaltic movements (much more important in the esophagus than the peristaltic
ones) push the food upwards against gravity, relaxation of both sphincters is observed.
Vomiting can be triggered by a variety of stimuli (GI tract irritation, infections, drugs, tactile
stimulation of the back of the throat, brain damage), but the reasons behind it can be
grouped into two categories:
1. Physiological control i.e. “good vomiting” – usually accompanied by nausea. It can follow
ingestion; e.g. poisoned food, food to which we are allergic, or simply food that we do not
like is eliminated from the stomach because no absorption has yet taken place. Once
nutrients reach the duodenum and the intestines absorption begins and there is no further
way to remove them. It can follow smelling. Same mechanism as ingesting, but it can
happen even if nothing has been in-taken.
2. Neurological control i.e. “bad vomiting” – nausea or sickness feeling is ABSENT
Vomiting without other symptoms commonly is the first sign of MENINGITIS! Following a
serious brain damage, the brainstem, where peristalsis is controlled, can be compressed
(e.g. by the meninges) and vomiting is activated without any form of external or internal
additional information.

• DYSPHAGIA
Dysphagia literally means a difficulty in swallowing and is mainly due to a dysmotility. It can
be associated with odynophagia (painful swallowing), but the two are not necessarily
correlated, therefore it is often undiagnosed. When so, it can lead to aspiration of food that
can reach the trachea and lungs with subsequent aspiration pneumonia, or malnutrition and
dehydration.

• GASTROESOPHAGEAL REFLUX DISORDER (GERD)

Gastroesophageal reflux is the condition in which the acidic contents of the stomach go back
up into the esophagus, causing potential damages, mainly because of LES un-proper
relaxation or dysfunction. LES is in fact normally contracted to create a high-pressure
zone (HPZ) on the last 2-4 cm of the esophagus. Symptoms usually include a taste of
acid in the mouth, bad breath, wearing away of the teeth, vomiting, heartburn, chest pain,
breathing problems. GERD is commonly treated with the use of anti-acidic drugs: the gastric
juice is so aggressive that the sensory fibers of the esophagus (despite its multi-layer)
immediately sense it causing a strong pain sensation. The stomach instead, even though it
only has a single layer, is protected by an alkaline mucus that acts as a buffer. The mucus is
secreted by every single cell so that a basic environment is exclusively provided near to the
organ’s wall (without affecting the actual content of the stomach) and is restricted to the
areas where it is needed. Moreover, modulating and controlling pH guarantees the
conversion of pepsin into pepsinogen (pepsinogen is the inactive precursor produced by the
gastric glands, which is activated into pepsin if introduced in an acidic environment). It
appears evident how anti-acidic drugs would furnish the same double protection (buffering
the gastric juice’s low pH and inactivating pepsin) to the esophagus lining.
Diet and/or behavioral changes are sufficient to treat GERD in the instance that it is simply
caused by alimentary or attitudinal problems (e.g. eating and going to sleep right away might
cause/increase the problem).
In extreme and very rare cases surgery is required.
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useful online slides
https://www.slideshare.net/ravindradaggupati/anatomy-of-esophagus-by-dr-ravindra-daggup
ati