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. 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

3. 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

4. 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

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

6. 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

7. 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

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

9. 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

10. 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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12. 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

13. 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

14. 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

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

16. 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

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

18. 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

19. 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

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

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

22. 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

23. 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

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

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

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

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

29. 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

30. 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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36. الجامعة السورية الخاصةكلية الطب البشريقسم الجراحةالدكتور عاصم قبطان The esophagus 2nd Lecture M.A.Kubtan

37. PERFORATION • Perforation of the esophagus is usually iatrogenic (instrumental perforations at therapeutic endoscopy) it can be managed conservatively ( not all the time ). • Barotrauma’ (spontaneous perforation). is often a life-threatening condition that regularly requires surgical intervention . M.A.Kubtan

38. Perforation of the esophagus • Potentially lethal complication due to mediastinitis and septic shock . • Numerous causes, but may be iatrogenic . • Surgical emphysema is virtuallpathognomonic . • Treatment is urgent; it may be conservative or surgical, but requires specialised care . M.A.Kubtan

39. 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 . • Boerhaave syndrome is the most serious type of perforation . This causes rapid chemical irritation in the mediastinum and pleura followed by infection if untreated. M.A.Kubtan

40. M.A.Kubtan Barotrauma has also been described in relation to other pressure events when the patient strains against a closed glottis (e.g.defaecation, labour, weight-lifting).

41. Diagnosis of spontaneous perforation • The clinical history is usually of severe pain in the chest or upper abdomen following a meal or a bout of drinking. • Associated shortness of breath is common. • There may be a surprising amount of rigidity on examination of the upper abdomen, even in the absence of any peritoneal contamination. • The diagnosis can usually be suspected from the history and associated clinical features. M.A.Kubtan

42. Continue • A chest X-ray is often confirmatory with air in the mediastinum, pleura or peritoneum. • Pleural effusion occurs rapidly . • A contrast swallow or CT is nearly always required to guide management M.A.Kubtan

43. severe subcutaneous emphysema 33 years old woman secondary to prolonged labor during normal vaginal delivery M.A.Kubtan

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45. A contrast swallow M.A.Kubtan

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47. Pathological perforation • Aero digestive fistula is most common and usually encountered in primary malignant disease of the esophagus or bronchus. • Erosion into an adjacent structure with fistula formation is more common. • Free perforation of ulcers or tumors of the esophagus into the pleural space is rare . • Coughing on eating and signs of aspiration pneumonitis may allow the problem to be recognized . M.A.Kubtan

48. Continue • Covering the communication with a self-expanding metal stent is the usual solution. • Erosion into a major vascular structure is invariably fatal. M.A.Kubtan

49. Penetrating injury • Foreign bodies : The esophagus may be perforated during removal of a foreign body . • Occasionally, an object that has been left in the esophagus for several days will erode through the wall. • Instrumental perforation : Instrumentation is by far the most common cause of perforation. • Perforation can occur in the pharynx or esophagus, usually at sites of pathology or when the endoscope is passed blindly. • Perforation may follow biopsy of a malignant tumor. M.A.Kubtan

50. Continue • The esophagus may be perforated by guide wires, graduated dilators or balloons, or during the placement of self-expanding stents. • The risk is considerably higher in patients with malignancy. M.A.Kubtan