Transcript ESOPHAGUS - Tripod.com

Esophagus
Chapter 12
ESOPHAGUS
Objectives
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Anatomy and Physiology
GERD and Hiatal Hernia
Esophageal Dysmotility
Esophageal Diverticula
Benign Esophageal Neoplasms
Malignant Neoplasms
Esophageal Trauma
ANATOMY
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3 Segments
Cervical esophagus
 Thoracic esophagus
 Abdominal esophagus
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Anatomic Relationships
Trachea
 Aorta
 Vagus nerve
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ANATOMY
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Wall
 Mucosa
 stratified squamous epithelium
 goblet cells
 2 muscular layers
 Inner circular
 Outer longitudinal
 upper 1/3 is skeletal; lower 2/3 is smooth muscle
ANATOMY
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Upper esophageal sphincter (UES)
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Cricopharyngeus muscle
Lower esophageal sphincter (LES)
Zone of high pressure 3-5 cm long
 Intrinsic muscular tone
 Diaphragmatic crura
 phrenoesophageal ligament
 intrabdominal pressure
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PHYSIOLOGY
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Food enters the back of the oropahrynx
Coordinated peristaltic wave
Primary
 Secondary
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Relaxation of the LES
GERD
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Gastroesophageal Reflux Disease
 Reflux of acid and bile into the esophagus
 Abnormal clearance from the esophagus
 Resulting erosion and ulceration of mucosal wall
 Scarring and stricture formation
GERD
Pathophysiology
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Abnormal clearance of acid
 peristaltic wave
 Saliva
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Abnormal relaxation of the LES.
 Low resting pressures
 shortened abdominal segment
GERD
Pathophysiology
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Abnormalities in the gastric reservoir
 delayed gastric emptying
 gastric dilation
 increased intragastric or abdominal pressure
 gastric hypersecretion
GERD
Pathophysiology
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Hiatal Hernia
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Type I: Sliding hernia- movement of
gastroesophageal junction
 shortens abdominal segment
 surgery required if sx and unresponsive to
medical mgmt
GERD
Pathophysiology
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Type II: Paraesophageal hernia- no movement of
GE junction
 usually no reflux
 surgery is required.
GERD
Etiology
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Decreased resting LES pressure
 alcohol
 cigarette
 chocolate
 caffeine
 meds:nitrates, calcium channel blockers, MSO4
derivatives
GERD
Etiology
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Increased abdominal pressures
 pregnancy
 obesity
GERD
Clinical presentation
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Burning epigastric or substernal pain
Intensity of pain is often positional
Dysphagia
H/O chronic aspiration bronchitis or
pneumonitis
Often relieved by antacids
GERD
Diagnostic Tests
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Esophagoscopy and biopsy
Barium Swallow
Manometry
pH Monitoring- 24 Hr
Hemocult
GERD
Treatment
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Medical
change habits
 Avoid eating within several hours of sleeping
 Sleep with head of bed elevated
 Weight loss
 Meds: antacids, H2 Blockers, Proton pump
inhibitors(<6 months)
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GERD
Treatment
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Surgical
Nissen Fundoplication
 Toupet
 Belsey Mark IV
 Collis Gastroplexy
 Hill Repair
 Laparoscopy
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ESOPHAGEAL MOTILITY
DISORDERS
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Achalasia
Diffuse esophageal spasm
Nutcracker esophagus
Hypertensive LES
ESOPHAGEAL MOTILITY
DISORDERS
Achalasia
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Failure To Relax
Pathophysiology
Neuronal degeneration in the myenteric plexus
of the esophageal wall
 Causes aperistalsis and proximal dilatation
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Presentation
Dysphagia
 Weight loss
 Regurgitation of undigested food
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ESOPHAGEAL MOTILITY DISORDERS
Achalasia
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Diagnosis
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Cineradiography-Barium swallow
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Bird’s Beak appearance
Manometric studies
Treatment
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Medical
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Balloon Dilatation
Surgical
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Myotomy
Partial wrap
ESOPHAGEAL DIVERTICULA
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Def: outpouching of the wall
Zenker’s Diverticula
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occur between thyropharyngeus and cricopharyngeus muscles
sx with regurgitated food
Treatment: Diverticulectomy and myotomy
Epiphrenic Diverticula- Distal 1/3
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As result of other abnormalities-achalasia, strictures, tight
fundoplications
Esophageal Neoplasm
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Benign neoplasms- rare
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Leiomyomas
Malignant Neoplasms
Squamous cell Carcinoma- 85%
 Adenocarcinoma- 10%
 Malignant Melanoma- 1%
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Malignant Tumors of the Esophagus
Epidemiology
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Geographic areas
Diet
Alcohol- daily consumption > 9gm ETOH
Smoking- >20 cigarettes/day
Achalasia
Barrett’s esophagus10% develop adenocarcinoma
 malignant transformation
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Malignant Tumors of the Esophagus
Presentation
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Insidious onset
Dysphagia is most common
Odynophagia is second most common
Hoarseness
Recurrent aspiration
Malignant Tumors of the
Esophagus
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Pathophysiology
invades locally
 adjacent lymph nodes
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Diagnosis
Upper GI series
 Endoscopy and biopsy
 CT scan for staging
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Malignant Tumors of the
Esophagus
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Treatment
 en bloc resection
 Right thorocotomy- upper and middle
esophagus
 Left thorocoabdominal- distal esophagus
 Ivor-Lewis- Right thorocotomy and midline
laparotomy- middle and distal
 Transhiatal with cervical incision
Malignant Tumors of the
Esophagus
Esophageal replacement with stomach, colon or
jejunum
 Pyloromyotomy
 Radiation and Chemotherapy
 Palliation
Prognosis
 Overall 5 year survival is 5-10%
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Esophageal Trauma
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Borhaave’s Syndrome
Presentation:
 severe chest and abdominal pain
 nausea and vomiting
Diagnosis
 history
 CXR
Treatment
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Immediate surgical intervention
Repair and drainage- Time dependent