Esophagus Anatomy,

Physiology, and Diseases

Alan Chu
March 13, 2013
Anatomy
 18 – 26cm from UES to LES
 Esophageal wall layers
 Mucosa, submucosa, muscularis propia, adventitia
 Proximal 33% skeletal muscle, middle 35-40%
mixed, distal 50-60% smooth muscle
 Smooth muscle innervated by CN X.
 Auerbach plexus: peristalsis
 Meissner’s plexus: afferent input
 Oropharyngeal dysphagia
 Difficulty
initiating swallow followed by
choking/coughing
 Esophageal dysphagia
 Anatomaic vs neuromuscular defect
 Solid vs solid+liquid dysphagia
 Dysphagia best assessed by MBSS
 Demonstrates presence of oropharyngeal
dysfunction and aspiration
 Standard upper endoscope 9mm,
transnasal endoscope 4mm
 Z line = GE junction
 In barrett’s squamocolumnar junction more
proximal than GEJ
Esophageal Motility disorder
 Acalasia
 InsufficientLES relaxation
 Dilated distal 2/3 esophagus with bird’s beak
appearance at LES on esophagram
 Upper endoscopy to r/o pseudoachalasia 2/2 to
GEJ tumor
 Tx: balloon dilation to disrupt circular muscle
fibers at LES; Heller’s myotomy via laproscopic
approach; Botox/CCB/nitrates
Esophageal Motility Disorder
 Diffuse Esophageal Spasm
 Simultaneous and repetitive contraction in esophagus
body with normal LES
 Cockscrew esophagus on esophagram
 Tx:nitrates/CCB
 Nutcraker esophagus
 High-amplitude peristalsis
 Ineffective esophageal motility
 High incidence in patients with GERD
Strictures
 Dysphagia when <15mm
 Tx: dilators (Bougies, Savary dilator,
balloon dilator)
 Risk of perforation 0.5%, higher in XRT
induced strictures
 Goal >15mm
Rings or Webs
 Ring
 Circumferential, muscle or mucosa, at distal
esophagus
 Schatzki’s ring
 Eosinophilic Esophagitis (>15 eosinophils/hpf in
mucosa)
 Web
 Partof lumen, mucosal, proximal esophagus
 Plummer Vinson
GERD
 Chronic symptoms 2/2 abnormal reflux of
gastric contents
 Heartburn, acid regurgitation, dysphagia,
odynophagia, belching
 Tx: lifestyle modification, H2 blockers
(60%), PPI (90%), surgery
 Atypical extraesophgeal symptoms:
asthma, chest pain, cough, laryngitis,
dental erosion
Barrett’s esophagus
 Pale pink squamous mucosa replaced with
salmon pink columnar mucosa
 LSBE vs SSBE (<3cm)

 Risk of esophageal adenoCA 0.5% per

year
Neoplasia
 AdenoCA
 Distalesophagus or GEJ
 Barrett’s

 SCC
 Mid-esopahgus and proximal esophagus
 Tobacco, EtOH use in AA
Diverticula
 Zenker’s diverticulum
 Midesophageal diveticula
 Epiphrenic diverticula
 Intramural pseudodiverticulosis
Transnasal Esophagoscopy

Alan Chu
March 13, 2013
 Transnasal esophagoscope
 3.1 – 5.1mm
 Performed without sedation
 Shorter procedure time
 66% cost of transoral esophagoscope
 Conventional Transoral esophagoscope
 10 - 12mm
 Performed withsedation
 Longer procedure time
 Transnasal esophagoscope
 Smaller biopsy size
 Conventional Transoral esophagoscope
Indications
 Head and Neck SCC
 Replaces panendoscopy
 Barrett’s esophagus
 Surveillence of Barrett’s esophagus
 Stricture dilation
 Balloon dilation
 Tracheoesophageal puncture
Technique
 Topical anesthetic and decongestant
 Pt’s head flexed and swallows as scope
approaches cricoid level
 Z-line (squamocolumnar junction)
visualized
 Retroflex view of gastric cardia