IN THE NAME OF GOD

1. IN THE NAME OF GOD Esophagus

2. ANATOMIC CONSIDERATIONS • The GI tract: • From the mouth to the anus, several organs with distinct functions , specialized independently controlled thickened sphincters • The gut wall is organized into well-defined layers… functional activities in each region • The mucosa: barrier to luminal contents or a site for transfer of fluids or nutrients • Gut smooth muscle in association with the enteric nervous system mediates propulsion from one region to the next

3. The GI tract • Many GI organs possess a serosal layer: supportive foundation and permits external input • GI tract is modulated by a rich vascular supply activity, lymphatic channels(gut immune activities), intrinsic nerves(basic controls for propulsions) • Two main functions—assimilating nutrients and eliminating waste • The mouth: food processed, mixed with salivary amylase, and delivered to the gut lumen

4. The GI tract • The esophagus propels bolus into the stomach; esophageal mucosa has a protective squamous histology(not permit significant diffusion or absorption) • The stomach: food preparation by triturating and mixing the bolus with pepsin and acid, proximal stomach (storage function), distal stomach(phasic contractions), Body secretes IF(vitamin B12 absorption) & Acid(sterilizes the upper gut) • The small intestine: nutrient absorptive function, villus architecture (maximal surface area....absorption, specialized enzymes, transporters), triturated and mixed food with pancreatic juice and bile in the duodenum • Pancreatic…. Pancreatic juice: the main enzymes for carbohydrate, protein, and fat digestion, bicarbonate optimize the pH for activation of these enzymes

5. Bile secreted by the liver and stored in the gallbladder… essential for intestinal lipid digestion…. contains by billirubin, toxins, metabolized and unmetabolized medications, and cholesterol • The proximal intestine… optimized for rapid absorption of nutrient and most minerals, whereas the ileum is better for vitamin B12 and bile acids absorption • The small intestine terminates in the ileocecal junction, a sphinctericstructure that prevents coloileal reflux and maintains small-intestinal sterility

6. The colon: prepares the waste material, controlled evacuation, colonic mucosa dehydrates the stool, decreasing daily fecal volumes from 1000–1500 mL delivered from the ileum to 100–200 mL expelled from the rectum,colonic lumen possesses a dense bacterial colonization that ferments undigested carbohydrates and shortchainfatty acids • Whereas transit times in the esophagus are on the order of seconds, in the stomach and small intestine range from minutes to a few hours, propagation through the colon takes more than 1 day in most individuals

7. The colon terminates in the anus, a structure with volitional and involuntary controls to permit retention of the fecal bolus until it can be released in a socially convenient setting.

8. OVERVIEW OF GASTROINTESTINAL DISEASES Abnormalities within or outside of the gut ,range in severity from mild symptoms and no long-term morbidity to those with intractable symptoms or adverse outcomes , localized to one organ or exhibit diffuse involvement at many sites

9. CLASSIFICATION OF GI DISEASES Impaired Digestion and Absorption Altered Secretion Altered Gut Transit Immune Dysregulation Impaired Gut Blood Flow Neoplastic Degeneration Disorders Without Obvious Organic Abnormalities Genetic Influences

10. SYMPTOMS OF GASTROINTESTINAL DISEASE • Abdominal Pain • Heartburn • Nausea and Vomiting • Altered Bowel Habits • GI Bleeding • Jaundice • Other Symptoms

12. EVALUATION OF THE PATIENT WITH GASTROINTESTINAL DISEASE • HISTORY • PHYSICAL EXAMINATION

13. TOOLS FOR PATIENT EVALUATION • Laboratory • Luminal Contents • Endoscopy • Radiography/Nuclear Medicine • Histopathology • Functional Testing

15. TREATMEN • NUTRITIONAL MANIPULATION • PHARMACOTHERAPY • Over-the-Counter Agents • Prescription Drugs • Alternative Therapies • ENTERIC THERAPIES/INTERVENTIONAL ENDOSCOPY AND RADIOLOGY • SURGERY

16. Esophagus • Ahollow, muscular tube coursing through the posterior mediastinum joining the hypopharynx to the stomach with two sphincters at each end(UES , LES), 18-26cm length, Anteroposterior Diameter 2cm, Lateral Diameter 3cm • Function : Effective transport food and fluid between two ends, otherwise remaining empty and collapsed

18. The esophagus originates in the neck at the level of the cricoid cartilage, passes through the chest in posterior mediastin (post.Trachea and left main bruncus) and ends after passage through the hiatus in the right crus of the diaphragm(T10 level) and joining the stomach • On barium esophagogram, adjacent structures may indent the esophageal wall, including the aortic arch, left mainstem bronchus, left atrium, and diaphragm

20. UES: Skeletal, coalescence Inf.Pharyngeal Cons. & Cricopharyngeus , high pressure and contracted muscle functional zone in the rest…. Block passed air into esophagus • LES: Within the diaphragmatic hiatus the esophageal body ends in a 2- to 4-cm length of asymmetrically thickened circular smooth muscle known as the lower esophageal sphincter (LES)

23. Upper: Skeletal muscle • Lower: Smooth muscle • 4layers : Mucosa(The most inner layer), sub mucosa, muscularispropria, advantis(the most external layer), not serosa • Muscularis propriaor Organ motor Function: upper and lower

26. ARTERIES • Upper: Sup& Inf thyroid arteries • Middle: Bronchial & Right intercostal arteries , descending aorta • Inferior: Left gastric, Left inf.frenic, splenic arteries • Veines • Upper: drain to SVC • Middle: drain to Azigus • Inferior: drain to Left & short gastric …… PV(varicess)

27. Lymphatic • Upper: drain to Deep cervical nodes • Middle: drain to Mediastinal nodes • Inferior: drain to Celiac & Gastric nodes • Innervation ;Two networks • Auer bach’s(myenteric) plexus(circular and longitudinal muscle) • Sensory Meissner’splexus(sub mucosal) • Sympathetic • Parasympathetic: Regulate peristalsis through the vagus nerve

30. SWALLOW

31. SWALLOW • Voluntary (oral) phase…food is masticated and mixed with saliva…thentransfer phase … the bolus is pushed into the pharynx by the tongue and entry into the hypopharynx… pharyngealswallow response… centrally mediated and involves a complex series of actions… propel food through the pharynx into the esophagus while preventing its entry into the airway • To accomplish this, the larynx is elevated and pulled forward, actions that also facilitate upper esophageal sphincter (UES) opening.

32. Tongue pulsion then propels the bolus through the UES, followed by a peristaltic contraction that clears residue from the pharynx and through the esophagus • The LES relaxes as the food enters the esophagus and remains relaxed until the peristaltic contraction has delivered the bolus into the stomach. • Peristaltic contractions elicited in response to a swallow are called primary peristalsisand involve sequenced inhibition followed by contraction of the musculature along the entire length of the esophagus

33. SWALLOW • The inhibition that precedes the peristaltic contraction is called deglutitive inhibition • Local distention of the esophagus anywhere along its length, as may occur with gastroesophagealreflux, activates secondary peristalsis that begins at the point of distention and proceeds distally • Tertiary esophageal contractions are nonperistaltic, disordered esophageal contractions that may be observed to occur spontaneously during fluoroscopic observatio

34. SWALLOW • The musculature of the oral cavity, pharynx, UES, and cervical esophagus is striated and directly innervated by lower motor neurons carried in cranial nerves • Oral cavity muscles are innervated by the fifth (trigeminal) and seventh (facial) cranial nerves; the tongue, by the twelfth (hypoglossal) cranial nerve • Pharyngeal muscles are innervated by the ninth (glossopharyngeal) and tenth (vagus) cranial nerves. • Physiologically, the UES consists of the cricopharyngeusmuscle, the adjacent inferior pharyngeal constrictor, and the proximal portion of the cervical esophagus

36. UES innervation is derived from the vagus nerve, whereas the innervation to the musculature acting on the UES to facilitate its opening during swallowing comes from the fifth, seventh, and twelfth cranial nerves • UES opening during swallowing involves both cessation of vagal excitation to the cricopharyngeus and simultaneous contraction of the suprahyoid and geniohyoid muscles that pull open the UES in conjunction with the upward and forward displacement of the larynx.

37. The neuromuscular apparatus for peristalsis is distinct in proximal and distal parts of the esophagus, the cervical esophagus consists of striated muscle and is directly innervated by lower motor neurons of the vagus nerve(nucleus ambiguous) • In contrast, the distal esophagus and LES are composed of smooth muscle and are controlled by excitatory and inhibitory neurons within the esophageal myentericplexus

39. Medullary preganglionic neurons from the dorsal motor nucleus of the vagus trigger peristalsis during primary peristalsis • Neurotransmitters of the excitatory ganglionic neurons are acetylcholine and substance P; those of the inhibitory neurons are vasoactive intestinal peptide and nitric oxide • Peristalsis results from the patterned activation of inhibitory followed by excitatory ganglionic neurons, with progressive dominance of the inhibitory neurons distally • LES relaxation occurs with the onset of deglutitive inhibition and persists until the peristaltic sequence is complete

40. At rest, the LES is contracted because of excitatory ganglionic stimulation and its intrinsic myogenic tone, a property that distinguishes it from the adjacent esophagus • The function of the LES is supplemented by the surrounding muscle of the right diaphragmatic crus, which acts as an external sphincter during inspiration, cough, or abdominal straining.

42. SYMPTOMS OF ESOPHAGEAL DISEASE • The clinical history :central evaluation of esophageal symptoms • Important details include weight gain or loss, gastrointestinal bleeding, dietary habits including the timing of meals, smoking, and alcohol consumption

43. SYMPTOMS OF ESOPHAGEAL DISEASE • Heartburn (pyrosis) • Regurgitation • Vomiting • Rumination • Chest pain • Esophageal dysphagia • Odynophagia • Globus sensation “globus hystericus,” • Water brash

44. pyrosis • The most common esophageal symptom • Discomfort or burning sensation behind the sternum that arises from the epigastrium and radiate toward neck • Intermittent symptom (after eating, during exercise, and lying recumbent) , Relieved(water or antacid), occur frequently interfering with normal activities including sleep • The association between heartburn and gastroesophageal reflux disease (GERD) is so strong that empirical therapy for GERD has become accepted management • “heartburn” is often misused and/or referred to with other terms such as “indigestion”

45. Regurgitation • Effortless return of food or fluid into the pharynx without nausea or retching • Sour or burning fluid in the throat or mouth may also contain undigested food particles • Increase by Bending, belching, or maneuvers that increase intra abdominal pressure • Regurgitation, vomiting, and rumination • Vomiting : nausea and accompanied by retching • Ruminationis a behavior in which recently swallowed food is regurgitated and then reswallowed repetitively for up to an hour(Mental deficiency , Normal)

46. Chest pain • A common esophageal symptom • Similar to cardiac pain, distinction difficult • A pressure type sensation in the mid chest, radiating to the mid back, arms, jaws • Similarity to cardiac pain(share a nerve plexus) • Esophageal distention or even chemostimulation (e.g., with acid) • Gastroesophageal reflux : the most common cause

47. Dysphagia • Feeling of food “sticking” or even lodging in the chest (solid food dysphagia &liquid and solid), episodic & constant dysphagia, progressive & static • Oropharyngeal dysphagia : aspiration, nasopharyngeal regurgitation, cough, drooling • Esophageal dysphagia : • Motility disorder(achalasia) :dysphagia for liquids as well as solid food • Structural :Stricture, ring, or tumors…. solid food dysphagia • Localization , approximately 30% of distal perceived as cervical

48. Odynophagia • Pain either caused by or exacerbated by swallowing • Although typically distinct from dysphagia but may manifest concurrently with dysphagia • More common with pill or infectious esophagitis than reflux esophagitis • When odynophagia does occur in GERD, it is likely related to an esophageal ulcer or deep erosions

49. Globus sensation • “globus hystericus,” • Perception of a lump or fullness in the throat that is felt irrespective of swallowing(relieved by swallowing) • Although such patients are frequently referred for dysphagia evaluation • Globus sensation occurs in the setting of anxiety or obsessive compulsive disorders & GERD

50. Water brash • Excessive salivation resulting from a vagal reflex triggered by acidification of the esophageal mucosa • Un common symptom • Afflicted individuals will describe the unpleasant sensation of the mouth rapidly filling with salty thin fluid, often in the setting of concomitant heartburn