Esophagus - anatomic and physiologic data,

research methods, diseases, clinic,

treatment
 The esophagus
• The esophagus is a fibromuscular tube,
approximately 25cm in length, that
transports food from the pharynx to
the stomach.
• It originates at the inferior border of
the cricoid cartilage (C6) and extends to
the cardiac orifice of the stomach (T11).
• The esophagus begins in the neck, at the
level of C6. Here, it is continuous
superiorly with the laryngeal part of
the pharynx (the laryngopharynx).
• It descends downward into the superior
mediastinum of the thorax, positioned
between the trachea and the vertebral
bodies of T1 to T4. It then enters the
abdomen via the esophageal hiatus (an
opening in the right crus of the
diaphragm) at T10.
• The abdominal portion of the esophagus
is approximately 1.25cm long – it
terminates by joining the cardiac orifice
of the stomach at level of T11.
Muscular layers
The esophagus consists of an internal circular layer and an external longitudinal layer
of muscle. Furthermore, the external longitudinal layer is composed of different
muscle types in each third of the esophagus:
• Superior third – voluntary striated muscle
• Middle third – voluntary striated and smooth muscle
• Inferior third – smooth muscle
Food is transported through the
esophagus by peristalsis –
a rhythmic contractions of the
muscles, which propagates
down the esophagus.
Hardening of these muscular layers
can interfere with peristalsis and cause
difficulty in swallowing (dysphagia).
 esophageal Sphincters
There are two sphincters present in the esophagus, known as the upper
and lower esophageal sphincters. They act to prevent the entry of air
and the reflux of gastric contents respectively.
Upper esophageal Sphincter
The upper sphincter is an anatomical,
striated muscle sphincter at the
junction between the pharynx and
esophagus. It is produced by the
cricopharyngeus muscle. Normally,
it is constricted to prevent the
entrance of air into the esophagus.
Lower esophageal Sphincter
The lower esophageal sphincter is a physiological sphincter located in the gastro-
esophageal junction. Which is situated to the left of the T11 vertebra, and is
marked by the change from esophageal to gastric mucosa.
• The sphincter is classified as a physiological (or functional) sphincter, as it does
not have any specific sphincteric muscle. Instead, the sphincter is formed from
four phenomena:
• The esophagus enters the stomach at an acute angle.
• The walls of the intra-abdominal section of the esophagus are compressed when
there is a positive intra-abdominal pressure.
• The folds of mucosa present aid in occluding the lumen at the gastro-esophageal
junction.
• During esophageal peristalsis, the sphincter is relaxed to allow food to enter the
stomach. Otherwise at rest, the function of this sphincter is to prevent the reflux
of acidic gastric contents into the esophagus.
 Vasculature
The thoracic part of the esophagus receives its
arterial supply from the branches of the thoracic
aorta and the inferior thyroid artery (a branch of
the thyrocervical trunk). Venous drainage into the
systemic circulation occurs via branches of the
azygous veins and the inferior thyroid vein.

The abdominal esophagus is supplied by the left

gastric artery (a branch of the coeliac trunk) and left
inferior phrenic artery. This part of the esophagus has
a mixed venous drainage via two routes:
• To the portal circulation via left gastric vein
• To the systemic circulation via the azygous vein.
These two routes form a porto-systemic
anastomosis, a connection between the portal and
systemic venous systems.
 Innervation
• The esophagus is innervated by
the esophageal plexus, which is formed by a
combination of the parasympathetic vagal
trunks and sympathetic fibers from
the cervical and thoracic sympathetic
trunks.
• Two different types of nerve fiber run in the
vagal trunks. The upper esophageal
sphincter and upper striated muscle is
supplied by fibers originating from
the nucleus ambigus. Fibers supplying the
lower esophageal sphincter and smooth
muscle of the lower esophagus arise from
the dorsal motor nucleus.
Lymphatics

• The lymphatic drainage of

the esophagus is divided into
thirds:
• Superior third – deep
cervical lymph nodes.
• Middle third – superior and
posterior mediastinal nodes.
• Lower third – left gastric and
celiac nodes.
Physiology
The main function of the esophagus is to transfer food from the mouth
to the stomach in a coordinated fashion. The initial movement from the
mouth is voluntary. The pharyngeal phase of swallowing involves
sequential contraction of the oropharyngeal musculature, closure of
the nasal and respiratory passages, cessation of breathing and opening
of the upper esophageal sphincter. Beyond this level, swallowing is
involuntary. The body of the esophagus propels the bolus through a
relaxed lower esophageal sphincter (LOS) into the stomach, taking air
with it. This coordinated esophageal wave that follows a conscious
swallow is called primary peristalsis. It is under vagal control, although
there are specific neurotransmitters that control the LOS.
The upper esophageal sphincter is normally closed at rest and serves as
a protective mechanism against regurgitation of esophageal contents
into the respiratory passages. It also serves to stop air entering the
esophagus other than the small amount that enters during swallowing.
The LOS is a zone of relatively high pressure that prevents gastric
contents from refluxing into the lower esophagus. In addition to opening
in response to a primary peristaltic wave, the sphincter also relaxes to
allow air to escape from the stomach and at the time of vomiting. A
variety of factors influence sphincter tone, notably food, gastric
distension, gastrointestinal hormones, drugs and smoking
• Dysphagia is used to describe difficulty with
swallowing.
• Odynophagia refers to pain on swallowing.
• Regurgitation and reflux often used
synonymously. It is helpful to differentiate
between them, although it is not always
possible. Regurgitation should strictly refer
to the return of esophageal contents from
above a functional or mechanical
obstruction. Reflux is the passive return of
gastroduodenal contents to the mouth as
part of the symptomatology of
gastroesophageal reflux disease (GORD).
Chest pain
Chest pain similar in character to angina pectoris may arise from an
esophageal cause, especially gastro-oesophageal reflux and motility
disorders. Exercise-induced chest pain can be due to reflux;
Symptoms of esophageal disease:
■ Difficulty in swallowing described as food or fluid sticking
(esophageal dysphagia) must rule out malignancy
■ Pain on swallowing (odynophagia) suggests inflammation and
ulceration
■ Regurgitation or reflux (heartburn) common in gastroesophageal
reflux disease
■ Chest pain is difficult to distinguish from cardiac pain
 Investigations
Radiography:
Contrast radiography has been somewhat
overshadowed by endoscopy but remains a
useful investigation for demonstrating
narrowing, space-occupying lesions, anatomical
distortion or abnormal motility. An adequate
barium swallow should be tailored to the
problem under investigation. It may be helpful
to give a solid bolus (bread or marshmallow) if a
motility disorder is suspected.
CT scann.
Cross-sectional imaging by computed
tomography (CT) scanning is an essential
investigation in the assessment of neoplasms of
the esophagus and can be used in place of a
contrast swallow to demonstrate perforation.
 Endoscopy
Endoscopy is necessary for the investigation of most esophageal conditions.
It is required to view the inside of the esophagus and the esophagogastric
junction, to obtain a biopsy or cytology specimen, for the removal of foreign
bodies and to dilate strictures. There are two types of instrument available,
the rigid oesophagoscope and the flexible video endoscope, but the rigid
instrument is now virtually obsolete. Novel techniques that rely on
fluorescence and narrow band imaging to enhance visual contrast are
becoming increasingly used for the identification of mucosal abnormalities
that are not easily seen with white light, for instance in patients with
Barrett’s esophagus undergoing endoscopic surveillance. As a matter of
routine, the stomach and duodenum are examined as well as the
esophagus. If a stricture is encountered, it may be helpful to dilate it to
allow a complete inspection of the upper gastrointestinal tract.
Endosonography
Endoscopic ultrasonography relies on a high-frequency (5–30 MHz)
transducer located at the tip of the endoscope to provide highly
detailed images of the layers of the esophageal wall and mediastinal
structures close to the esophagus. Radial echoendoscopes have a
rotating transducer that creates a circular image with the endoscope in
the center, and this type of scanner is widely used to create diagnostic
transverse sectional images at right angles to the long axis of the
esophagus. Linear echoendoscopes produce a sectoral image in the line
of the endoscope and are used to biopsy submucosal esophageal
lesions or mediastinal masses such as lymph nodes.
esophageal manometry
Manometry is widely used to diagnose
esophageal motility disorders.
Recordings are usually made by passing a
multilumen catheter with three to eight
recording orifices at different levels down
the esophagus and into the stomach.
High-resolution manometry uses a
multiple (up to 30) microtransducer
catheter with the results displayed as
spaciotemporal plots; this system is likely
to supplant conventional manometry.
Twenty-four hour pH and combined pH-
impedance recording
Prolonged measurement of pH is
now accepted as the most
accurate method for the
diagnosis of gastro-esophageal
reflux. It is particularly useful in
patients with atypical reflux
symptoms, those without
endoscopic esophagitis and when
patients respond poorly to
intensive medical therapy.
Diseases of the Esophagus

• Achalasia
• Barrett's Esophagus
• Esophageal Cancer
• Gastroesophageal Reflux Disease (GERD)
• Peptic Stricture
• Webs, Rings and Diverticula
Achalasia
Achalasia is a motor
disorder characterized
by a complete loss of
contraction and
relaxation of muscles
used to move contents
down the esophagus. It
is due to loss of the
ganglion cells in the
myenteric (Auerbach’s)
plexus.
Pathophysiology.
Achalasia is an esophageal disease of unknown etiology, although it
may be secondary to ganglionic dysfunction, which causes:
(1) High resting LES pressure
(2) Failure of the LES to relax during swallowing
(3) Absence of coordinated peristalsis in the body of the esophagus
b. The body of the esophagus becomes dilated, and the muscle
hypertrophies in an attempt to force material through the dysfunctional
LES. A similar symptom complex can be caused by Chagas disease,
which is caused by the organism Trypanosoma cruzi.
c. Carcinoma of the esophagus is 10 times more common in patients
with achalasia than in the general population.
Symptoms of achalasia include dysphagia, followed
by regurgitation and weight loss. Frequently,
respiratory symptoms caused by aspiration are
present.
Diagnosis
a. Radiographic studies reveal a dilated esophagus
with a bird's beaklike extension into the lower
narrowed segment at the LES.
b. Esophageal manometry reveals the high resting
LES pressure, failure of relaxation during
swallowing, higher than normal resting pressure in
the body of the esophagus, and absence of
peristalsis.
c. Esophagoscopy is required to rule out neoplasia
and to document the extent of esophagitis.
Treatment for achalasia is palliative because LES function can never be
restored to normal.
a. Nonsurgical treatment consists of forced pneumatic dilatation of the
spastic lower esophageal sphincter, which is just above the
gastroesophageal junction.
b. b. Surgical treatment is esophagomyotomy by the modified Heller
procedure, via laparotomy! laparoscopy, or occasionally left
thoracotomy. Care is taken not to disturb the vagus nerve attachments
to the esophagus to prevent reflux. The myotomy is confined to the
lower portion of the esophagus, usually 6-8 cm in length.
(I) Surgical results with the Heller procedure are generally better than with
pneumatic dilatation for relief of dysphagia.
Barrett's Esophagus
• Barrett’s esophagus is a metaplastic change in the lining mucosa of
the esophagus in response to chronic gastroesophageal reflux
 GASTRO-ESOPHAGEAL REFLUX DISEASE

Gastroesophageal reflux disease (GERD) is

a chronic digestive disorder where liquid
content from the stomach backs up into
the esophagus, with the most common
symptom being heartburn.
The classical triad of symptoms is
retrosternal burning pain (heartburn),
epigastric pain (sometimes radiating
through to the back) and regurgitation.
 PERFORATION
Perforation of the esophagus is usually iatrogenic
(at therapeutic endoscopy) or due to
‘barotrauma’ (spontaneous perforation-
Boerhaave syndrome) This occurs classically
when a person vomits against a closed glottis.
The pressure in the esophagus increases rapidly,
and the esophagus bursts at its weakest point in
the lower third, sending a stream of material into
the mediastinum and often the pleural cavity as
well.
The diagnosis can usually be suspected from the
history and associated clinical features. A chest x-
ray is often confirmatory with air in the
mediastinum, pleura or peritoneum. Pleural
effusion occurs rapidly either as a result of free
communication with the pleural space or as a
reaction to adjacent inflammation in the
mediastinum. A contrast swallow or CT is nearly
always required to guide management
Treatment of esophageal perforations
Perforation of the esophagus
usually leads to mediastinitis. The
loose areolar tissues of the
posterior mediastinum allow a
rapid spread of gastrointestinal
contents. The aim of treatment is
to limit mediastinal contamination
and prevent or deal with infection.
non-operative treatment aims to
limit the effects of mediastinitis
and provide an environment in
which healing can take place.
The decision between operative and non-operative management rests on
four factors. These are:
1. the site of the perforation (cervical versus thoracoabdominal
esophagus);
2. the event causing the perforation (spontaneous versus instrumental);
3. underlying pathology (benign or malignant);
4 the status of the esophagus before the perforation (fasted and empty
versus obstructed with a stagnant residue). It follows that most
perforations that can be managed nonoperatively occur in the context of
small instrumental perforations of a clean esophagus without obstruction.
 MALLORY–WEISS SYNDROME
Forceful vomiting may produce a mucosal
tear at the cardia rather than a full
perforation. The mechanism of injury is
different. In Boerhaave’s syndrome, vomiting
occurs against a closed glottis, and pressure
builds up in the esophagus. In Mallory– Weiss
syndrome, vigorous vomiting produces a
vertical split in the gastric mucosa,
immediately below the squamocolumnar
junction at the cardia in 90 percent of cases.
In only 10 percent is the tear in the
esophagus. The condition presents with
hematemesis.
NEOPLASMS OF THE OESOPHAGUS

Benign tumors
Benign tumors of the esophagus are relatively rare. True papillomas,
adenomas and hyperplastic polyps do occur, but the majority of
‘benign’ tumors are not epithelial in origin and arise from other layers
of the esophageal wall (gastrointestinal stromal tumor (GIST), lipoma,
granular cell tumor). Most benign esophageal tumors are small and
asymptomatic, and even a large benign tumor may cause only mild
symptoms. The most important point in their management is usually to
carry out an adequate number of biopsies to prove beyond reason.
 Malignant tumors
• Non-epithelial primary malignancies are also rare, as is malignant
melanoma. Secondary malignancies rarely involve the esophagus with
the exception of bronchogenic carcinoma by direct invasion of either
the primary and/or contiguous lymph nodes.
• Cancer of the esophagus is the sixth most common cancer in the
world. In general, it is a disease of mid to late adulthood, with a poor
survival rate. Only 5–10 per cent of those diagnosed will survive for
five years.
The exact cause is
unknown. Associated
factors are tobacco use,
excessive alcohol
ingestion, nitrosamines,
poor dental hygiene, and
hot beverages. Certain
pre-existing conditions
also increase the
likelihood of developing
esophageal cancer,
including achalasia and
Barrett's esophagus.
Pathology:
Type
(1) Squamous cell carcinoma is the most common form.
(2) Adenocarcinoma, the next commonest, is the type that occurs in
patients with Barrett's esophagus.
(3) Rare tumors of the esophagus include mucoepidermoid carcinoma
and adenoid cystic carcinoma.
Tumor spread.
Esophageal malignancies metastasize through both the lymphatic system
and the bloodstream, with metastases occurring in liver, bone, and brain.
Diagnosis
a. A history of dysphagia and weight loss is almost always present.
b. Contrast study of the esophagus demonstrates the location and extent of
the tumor.
c. Computed tomography ( CT) scan of the chest and abdomen is done to
evaluate local lymphatic spread, and a thorough search is made for distant
metastases.
d. Esophagoscopy is essential for tissue diagnosis and determination of the
extent of the tumor.
e. EUS is done to assess the depth of the invasion and staging.
f. Bronchoscopy is performed in patients with proximal esophageal lesions to
assess the possibility of invasion of the tracheobronchial tree.
 Treatment
a. Overall, surgical therapy is associated with
less than a 5% mortality rate. Several
procedures are described for resection of
the esophagus. Transhiatal
esophagectomy through a laparotomy and
cervical incisions. A complete thoracic
esophagectomy is performed bluntly with
reconstruction of gastrointestinal
continuity with the stomach or, rarely, the
colon.
b. Ivor Lewis esophagectomy through a right
thoracotomy and laparotomy.
Reconstruction is also accomplished with
the stomach or, rarely, the colon.
Radiotherapy and chemotherapy are currently being investigated as
adjuncts to surgery or as primary treatment modalities.
(1) Neoadjuvant chemotherapy in combination with X-Ray Therapy (XRT)
given before surgical resection appears to shrink the tumor mass.
Several studies have shown an impact on long-term survival.
Combination chemotherapy with cisplatin have shown up to a 50%
response rate. However, a significant long-term survival has not been
demonstrated.
(2) Radiotherapy alone for carcinoma of the esophagus results in a 5-year
survival of less than 10%.
(3) In patients who have advanced disease with either invasion of the
tracheobronchial tree or advanced metastases, palliative effects may
be obtained by utilizing endoscopically placed metallic stents to allow
swallowing of saliva and soft foods.
MOTILITY DISORDERS AND DIVERTICULA

A motility disorder can be readily understood when a patient has

dysphagia in the absence of a stricture, and a barium impregnated food
bolus is seen to stick in the esophagus. If this can be correlated with a
specific abnormality on esophageal manometry, accepting that this is
the cause of the patient’s symptoms may be straightforward.
Unfortunately, this is often not the case. Pain, with or without a
swallowing problem, is frequently the dominant symptom, and patients
often undergo extensive hospital investigation before the esophagus is
considered as a source of symptoms.
Pharyngeal and esophageal diverticula
Most esophageal diverticula are pulsion diverticula that develop at a site of
weakness as a result of chronic pressure against an obstruction. Symptoms are
mostly caused by the underlying disorder unless the diverticulum is particularly
large. Traction diverticula are much less common. They are mostly a consequence
of chronic granulomatous disease affecting the tracheobronchial lymph nodes due
to tuberculosis, atypical mycobacteria or histoplasmosis. Fibrotic healing of the
lymph nodes exerts traction on the esophageal wall and produces a focal
outpouching that is usually small and has a conical shape. There may be associated
broncholithiasis, and additional complications may occur, such as aerodigestive
fistulation and bleeding
Zenker’s diverticulum (pharyngeal pouch)
Is not really an esophageal diverticulum as it protrudes posteriorly above the
cricopharyngeal sphincter through the natural weak point (the dehiscence of
Killian) between the oblique and horizontal (cricopharyngeus) fibers of the
inferior pharyngeal constrictor. The exact mechanism that leads to its
formation is unknown, but it involves loss of the coordination between
pharyngeal contraction and opening of the upper sphincter. When the
diverticulum is small, symptoms largely reflect this incoordination with
predominantly pharyngeal dysphagia. As the pouch enlarges, it tends to fill
with food on eating, and the fundus descends into the mediastinum.
Treatment can be undertaken endoscopically with a linear cutting stapler to
divide the septum between the diverticulum and the upper esophagus,
producing a diverticulo-esophagostomy, or can be done by open surgery.
Schatzki’s ring
Schatzki’s ring is a circular ring in the distal esophagus usually at the
squamocolumnar junction. The cause is obscure, but there is a strong
association with reflux disease. The core of the ring consists of variable
amounts of fibrous tissue and cellular infiltrate. Most rings are
incidental findings. Some are associated with dysphagia and respond to
dilatation in conjunction with medical antireflux therapy.