الجامعة السورية الخاصة كلية الطب البشري قسم الجراحة الدكتور عاصم قبطان

1. الجامعة السورية الخاصةكلية الطب البشريقسم الجراحةالدكتور عاصم قبطان The esophagus 1st Lecture M.A.Kubtan

2. هذه المحاضرة صوتية • للإستماع إلى المحاضرة ينصح بوضع سماعة الأن ليكون الصوت واضحاً . • يجب الضغط على الزر الأيسر للماوس فوق صورة مكبر الصوت لسماع الشرح الخاص بالسلايد المعروض على الشاشة . M.A.Kubtan

3. LEARNING OBJECTIVES To understand The anatomy and physiology of the esophagus • Their relationship to disease • The clinical features. • Investigations . • Treatment of benign and malignant disease with particular reference to the common adult disorders M.A.Kubtan

4. Surgical anatomy • The esophagus is a muscular tube. • Approximately 25 cm long . • Mainly occupying the posterior mediastinum . • Extending from the upper esophageal sphincter (the cricopharyngeus muscle) in the neck to the junction with the cardia of the stomach. M.A.Kubtan

5. Muscular Type • The upper esophagus, including the upper sphincter, is striated. • This is followed by a transitional zone of both striated and smooth muscle . • There is only smooth muscle in the lower half of the esophagus . M.A.Kubtan

6. Histological lining It is lined throughout with squamous epithelium. M.A.Kubtan

7. Nerve supply • The parasympathetic nerve supply is mediated by branches of the vagus nerve . • Has synaptic connections to the myenteric (Auerbach’s) plexus. • Meissner’s sub mucosal plexus is sparse in the esophagus. M.A.Kubtan

8. Esophageal sphincters • The upper sphincter consists of powerful striated muscle. • The lower sphincter is more subtle, and is created by the asymmetrical arrangement of muscle fibers in the distal esophageal wall just above the esophagogastric junction. M.A.Kubtan

9. Remember the distances 15, 25 and 40 cm for anatomical location during endoscopy M.A.Kubtan

10. Physiological Function • 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. M.A.Kubtan

11. The pharyngeal phase of swallowing • Sequential contraction of the oropharyngeal musculature . • Closure of the nasal and respiratory passages . • Cessation of breathing . • 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 (LES) . M.A.Kubtan

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13. primary peristalsis • The coordinated esophageal wave that follows a conscious swallow is called primary peristalsis. • It is under vagal control . • Also there are specific neurotransmitters that control the LES. M.A.Kubtan

14. Upper Esophageal Sphincters Function • The upper esophageal sphincter is normally closed at rest • Serves as a protective mechanism against regurgitation of esophageal contents into the respiratory passages. • It serves to stop air entering the esophagus other than the small amount that enters during swallowing. M.A.Kubtan

15. LES Function • The LES is a zone of relatively high pressure that prevents gastric contents from refluxing into the lower esophagus . • It opens in response to a primary peristaltic wave . • It relaxes to allow air to escape from the stomach and at the time of vomiting. M.A.Kubtan

16. Factors influence LES sphincter tone • Food . • Gastric distension . • Gastrointestinal hormones . • Drugs and smoking. M.A.Kubtan

17. Factors contributing to LES Function • The arrangement of muscle fibers, their differential responses to specific neurotransmitters. • The relationship to diaphragmatic contraction. • The normal LES is 3–4 cm long . • LES has a pressure of 10–25 mmHg. M.A.Kubtan

18. Esophageal Symptoms • Dysphagia . • Odynophagia . • Regurgitation and reflux . • Chest pain . M.A.Kubtan

19. Dysphagia • Described as difficulty with swallowing. • Food fails to enter the esophagus . • Food stays in the mouth . • Food enters the airway causing coughing or spluttering. M.A.Kubtan

20. Dysphagia in Voluntary Phase • Oral or pharyngeal . • Food fails to enter the esophagus . • Stays in the mouth or enters the airway causing coughing or spluttering. • Causes are chronic neurological or muscular diseases or inflammatory or traumatic origin. M.A.Kubtan

21. dysphagia occurs in the involuntary phase characterized by : • A sensation of food sticking. • Is often informative of the likely diagnosis. M.A.Kubtan

22. Mode of Dysphagia • Acute . • Chronic . • Can affect solids . • Can affect fluids . • Can affect solids & fluids . • Can be intermittent . • Can be progressive. M.A.Kubtan

23. Odynophagia • pain on swallowing. • Patients with reflux esophagitis often feel retrosternal discomfort . • Is a feature of infective esophagitis and may be particularly severe in chemical injury. M.A.Kubtan

24. Regurgitation and reflux • Regurgitation should strictly refer to the return of esophageal contents from above a functional or mechanical obstruction. • Reflux is the passive return of gastro duodenal contents to the mouth as part of the symptomatology of gastro esophageal reflux disease (GERD). M.A.Kubtan

25. Symptoms & Signs accompany regurgitation and/or reflux. • Loss of weight . • Anemia . • Cachexia . • Change of voice . • Cough or dyspnoea . M.A.Kubtan

26. Chest pain Similar in character to angina pectoris . M.A.Kubtan

27. Investigations • Radiography . • Endoscopy . • Endosonography . • Esophageal manometry . • 24-hour pH recording . M.A.Kubtan

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29. Therapeutic procedures • Dilatation of strictures . • Thermal recanalisation . M.A.Kubtan

30. Correlation of 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 gastro-esophageal reflux disease . • Chest pain Difficult to distinguish from cardiac pain M.A.Kubtan

31. FOREIGN BODIES IN THE ESOPHAGUS • The most common impacted material is food. • Usually occurs above a significant pathological lesion . • Plain radiographs are often useful for foreign bodies . • Modern denture materials are not always radiopaque . • Diagnosis made by endoscopy . M.A.Kubtan

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