Esophagus: Anatomy, Disorders, and Management

1. Kingdom of BahrainArabian Gulf UniversityCollege of Medicine and Medical Sciences GI System – Review Problem (3) – Esophagus Ali Jassim Alhashli, BSc www.alhashli.com

2. Anatomy • It is a muscular tube of 25 cm length which begins at the level of lower border of C6. • It is divided into 3 parts: • Superior third: striated muscle only. • Middle third: striated + smooth muscles. • Inferior third: smooth muscle only. • There are 3 main areas of narrowing (which can be detected by barium swallow): • At the level of cricopharyngeus muscle. • Where the left mainstem bronchus and aortic arch cross. • At the hiatus of diaphragm (at the level of T10). Remember the vertebral levels at which the following traverse the diaphragm: • T8 = Inferior Vena Cava (IVC). • T10 = esophagus. • T12 = aorta. • There are 2 sphincters of the esophagus: • Upper Esophageal Sphincter (UES = formed by cricopharyngeus muscle): it prevents the passage of excess air into the stomach during breathing. • Lower Esophageal Sphincter (LES = physiological sphincter): it prevents the reflux of gastric contents into the esophagus. • Histology: non-keratinized stratified squamous epithelium.

3. Definition: it is the failure of lower portion of esophagus to relax during swallowing which can be caused by 3 mechanisms: • Complete absence of peristalsis in esophageal body. • Impaired relaxation of LES after swallowing. • Increased resting tone of LES. This in turn will result in elevation of intraluminal esophageal pressure and esophageal dilation. • Signs and symptoms: • Dysphagia (for both solids and liquids). • Regurgitation of food. • Severe halitosis. • Diagnosis: • Barium swallow: distal bird’s beak sign. • Esophageal motility study: increased LES tone. • Treatment: • Medical management: • Drugs which relax LES: nitrates or Botox injections. • Endoscopic dilation: has a lower success rate and a higher complication rate. • Surgical management: esophagomyotomy ± fundoplication (treatment of choice). • Complications: • Squamous cell carcinoma of esophagus. • Aspiration pneumonia. Achalasia

4. Tracheo-esophageal Fistula • Tracheoesophageal (TE) fistula: • Definition: incomplete separation of esophagus and trachea. • Signs and symptoms: • Respiratory distress and chocking following the first feed. • Postprandial regurgitation. • Excess drooling and salivation. • There are 5 types of TE fistula: • Type-A: pure esophageal atresia. • Type-B: esophageal atresia with proximal TE fistula. • Type-C (most common): esophageal atresia with distal TE fistula. • Type-D: esophageal atresia with proximal and distal TE fistula. • Type-E: no esophageal atresia with TE fistula. • Diagnosis: • Inability to pass feeding tube. • CXR: tube coiled in upper esophagus. • AXR: presence of air in the stomach. If air is not present, this might indicate the presence of esophageal atresia without TE fistula. • Notice that TE fistula is associated with: • Polyhydramnios. • Pre-term birth. • Small for gestational age. • Treatment: • Decompression of the blind esophageal pouch with constant suction. • Prophylactic antibiotics (to prevent complications of aspiration). • Search for other anomalies (especially cardiac and renal). • Surgical repair: • Ligation of fistula and insertion of gastrostomy tube. • Anastomosis of the two ends of esophagus (jejunal or colonic grafts are used).

5. Tracheo-esophageal Fistula

6. Plummer-Vinson Syndrome (PVS): • Epidemiology: middle-aged females. • Clinical presentation: • Iron-deficiency anemia. • Glossitis. • Esophageal web: which is a thin extension from esophageal mucosa made from squamous cells and occurs mostly in hypopharnyx producing dysphagia mostly to solids. • Diagnosis: barrium swallow. • Treatment: • Treat iron-deficiency anemia with ferrous sulfate. • Treat esophageal web with dilation procedures. • Esophagitis: • Definition: infection/inflammation of the esophagus. • Etiology: • Candidalalbicans in patients with: • HIV and CD4 count > 200 cells/mm3. • Diabetics. • Ingestions of medications or caustic substances. • Clinical manifestations: progressive odynophagia especially when swallowing food (why?) → due to mechanical rub of food against the inflamed esophagus. • Diagnosis: • In HIV patients, assume it is Candida and start treatment with systemic anti-fungal (fluconazole). Regression of symptoms confirm your diagnosis. • Otherwise, do upper GI endoscopy with biopsy to determine the cause. • If esophagitis is caused by a medication or caustic substance → this will be determined from history. Plummer-Vinson Syndrome and Esophagitis

7. Diseases of The Esophagus Plummer-Vinson syndrome Esophagitis caused by Candida albicans

8. Zenkerdiverticulum: • Definition: it is outpouching of posterior pharyngeal constrictor muscles at the back of the pharynx (simply: outpouching of posterior pharynx). • Clinical manifestations: • Dysphagia: inability to initiate swallowing because it is a proximal problem. • Halitosis (bad breath). • Patient waking up at night with undigested, regurgitated food on his pillow which has been eaten several day ago  • Diagnosis: barrium swallow. Notice that endoscopy is contraindicated due to the high risk of perforation. • Treatment: surgical resection. • Mallory-Weiss syndrome: • Etiology: non-transmural (not involving the whole wall) tears in lower esophagus due to repeated retching and vomiting (especially in alcoholics). • Clinical manifestations: • PAINLESS upper GI bleeding. • Melena (black stool) when amount of blood is < 100ml. • Hematemesis: if there is continuous vomiting. • Diagnosis: upper GI endoscopy. • Treatment: • Most cases resolve spontaneously. • If there is severe bleeding: inject the area with epinephrine or perform cauterization. ZenkerDiverticulum and Mallory-Weiss Syndrome

9. ZenkerDiverticulum and Mallory-Weiss Syndrome Mallory-Weiss syndrome

10. Gastro-Esophageal Reflux Disease (GERD): • Definition: In GERD, there is a backflow of gastric content into the eophagus due to relaxation of LES. • Etiology: this can be idiopathic or precipitated by factors which are lowering LES pressure such as nicotine, alcohol, caffeine, chocolate, peppermint and anticholinergics. GERD occurs particularly when patient is lying down. • Clinical manifestations: epigastric pain/substernal chest pain, bad metal-like taste in the mouth, sore throat, coughing, wheezing and hoarsness. • Diagnosis: • Most accurate with 24-hour pH monitoring (usually not necessary when diagnosis is clear from clinical presentation of the patient). • Treatment: • If patient has MILD, INTERMITTENT symptoms → use H2-blockers (such as ranitidine). • Gold-standard therapy: PPIs (omeprazole). • In patients not responding to omeprazole→ surgery to tighten LES (Nissenfundoplication). • Lifestyle modifications: avoid nicotine, alcohol, caffeine, spicy/fatty food and late night meal. • Barrett’s esophagus: • Definition: it is a complication of long-standing GERD in which the normal squamous epithelium in distal esophagus will be changed to columnar epithelium and predisposing the patient to develop esophageal adenocarcinoma (0.5% risk). • Diagnosis: • Patients with Barrett’s esophagus must undergoe endoscopy every 2-3 years to exclude dysplasia or esophageal adenocarcinoma. • If there is low-grade dysplasia: you must repeat endoscopy in 3-6 months to see if the dysplasia has progressed or resolved. • If there is high-grade dysplasia: patient must undergo surgical removal of the distal part of esophagus. • Treatment: PPIs (omeprazole). GERD and Barrett’s Esophagus

11. GERD and Barrett’s Esophagus

12. GERD and Barrett’s Esophagus

13. Epidemiology: • The increasing prevalence of adenocarcinomas (due to Barrett’s esophagus) as compared to what was mostly squamous cell carcinoma is shifting the epidemiology of esophageal cancer. • Age: < 50 years. • Gender: males. • <50% of patients have unresectable disease at the time of presentation. • Prognosis: 5-year survival rate = 15% • Risk factors: • Smoking. • Alcohol. • Smoked food. • Achalasia. • GERD/Barrett’s esophagus. • Signs and symptoms: • Dysphagia: first for solids and later for both solids and liquids. Notice that dyspahgia does not develop until <60% of esophageal lumen is obstructed. • Pain on swallowing. • Weight loss. • Diagnosis: • Barium swallow (initial diagnostic test). • Endoscopy: to visualize the mass and obtain specimens for biopsy. Notice that: • Adenocarcinoma is found in distal esophagus. • Squamous cell carcinoma is found in middle and lower thirds of esophagus. • Staging: CXR, abdomeno-pelvic CT-scan. • Treatment: • If disease is limited to the esophagus: surgical resection. • If disease is advanced: chemotherapy to promote tumor shrinkage and palliate symptoms. Esophageal Cancer