Esophagus

o o

Nonkeratinized stratified squamous epithelium musculature Skeletal mm. striated : upper 1/3 Smooth mm. lower 1/3 Mix of smooth and stiated in middle. o Embryology Develops from foregut by week 10 Upper esophagus : from branchial arches 4,5, and 6. o Blood supply Branches of inferior thyroid aa. upper Branches of aorta middle and lower Branch of gastric aa. lower and middle posteriorly o Nerve supply Symphathetic =sympathetic trunk Parasympathetic = vagus Motor = vagus Esophageal disorders o Dysphagia Difficulty swallowing Selective Solids worst than liquid Schatzkis ring o Intermittent and non progressive disphagia Usually in lower part of esophagus Peptic stricutures o Progressive w/ chronic heart burn Esophageal cancers o Progressive dysphagia o Age >50 YOA Non selective Both solids and liquids Achalasia o Progressive, chronic o Lower esophageal sphincter (LES) fails to relax Loss of Myenteric plexus Dialated esophagus on barium swallow Bird beak appearance nd 2 due to Chagas disease

Gastrointestinal tract GIT

Cardiomyopathy + Megacolon o Increased risk of esophageal carcinoma o Scleroderma: CREST syndrome E: esophageal dysmotility due to pressure proximal to LES. o Clinically Dysphagia solid + liquid Regurgitation of food at night Weight loss o Tx Injection of botulinum toxin endoscopy Pneumatic dilatation of LES w/ a balloon Surgery: Modified Hellers myotomy Diffuse esophageal spasm o Intermittent comes and goes Scleroderma o Chronic heart burn o CREST syndrome

Odynophagia Sharp substernal pain on swallowing Usually severe erosive disease Mostly due to infection o Candidiasis, Herpes virus nd 2 to corrosive injury o Caustic ingestion poison, acid, bleach, etc. o Pill induced Heart burn Substernal burning pain radiating to neck Acid reflux to esophagus Highly specific to GERD Dx tools Esophagoscopy Barium esophagraphy Esophageal manometry Esophageal pH recording Esophagitis Etiology Infectious o Candida, CMV, Herpes virus, HIV, varicella Corrosive esophagitis o 2nd to caustic substance ingestion Pill induced o Alendronate, Doxycycline, ASA, iron sulfate, Quinidine Clinical symptoms

 Dx

Heart burn, Odynophagia

Clinically monitoring the progress w/ antiviral and antifungal agents Endoscopy for resistant cases only Pill induced: prevent by taking pills w/ water in upright position after a meal Barrets Esophagus Premalignant condition Metaplasia Squamous epithelium replaced by columnar epithelium Sequel to chronic reflux d/o Sx Dysphagia Reflux sx: heart burn, regurgitation Dx Edoscopically diagnosed o Circumferential or tongue like orange colored gastric mucosa running up into distal tubular esophagus o 3 types of mucosa Gastric cardiac Gastric fundic Intestinal metaplasia risk of carcinoma w/ this type o If unnoticed / not tx can lead to Stricture and bleeding Adenocarcinoma - rare Tx Proton pump inhibitors Surgery o Endoscopic surveillance w/ biopsy every 2-3 yrs o Endoscopic ablation o Endoscopic mucosal resection high grade dysplasias o Resection of segment w/ metaplasia GastroEsophageal Reflux Disorder GERD Risk factors Incompetent LES Hiatal hernia Irritable effect of refluxate Abnormal esophageal clearance Delayed gastric emptying Sx Heart burn by recumbency, meals, bending Tx Mild GERD: lifestyle changes, Antaacids, H2 receptor blockers Moderate GERD: H2 receptor blockers, Proton pump inhibitors, promotility drugs

Severe GERD: unresponsive to PPIs, surgical w/ Nissans fundoplication Diffuse esophageal spasm DES Esophageal dysmotility syndrome of smooth mm. Spontaneous non peristaltic contractions Sx Dysphagia Non cardiac chest pain Manometery (ambulatory) Simultaneous un coordinated esophageal contactions o CORK SCREW on barium swallow Tx Calcium channel blockers Nitrates Mallory-Weiss Syndrome Nonpenetrating mucosal tear at GastroEsophageal junction Sx Induced by: retching, lifting heavy objects, vomiting in Hx Strong predisposition to alcohol Sudden hemetemesis NO MELENA Tx Fluid resuscitation + blood transfusion Endoscopic hemostatic therapy Angiographic arterial embolization Esophageal webs Thin, diaphragm like membranes of mucosa Congenital, Graft vs. host disease Pemphigus vulgaris, pemphigoid Plummer-Vinson Syndrome w/ iron deficiency anemia Esophageal rings Smooth circumferential thin structures Common in distal esophagus Seen in GERD, Haital hernia Sx: Dysphagia Dx: barium esophagogram Tx: Bougie dilatation Zenkers diverticulum Mucosal protrusion through pharyngoesophageal junction b/w cricopharyngeus + inferior cricopharyngeus mm. due to loss of elasticity of upper esophageal sphincter Sx: dysphagia + regurgiatation of food

Complication: Halistosis bad breath Bronchiectasis, pneumonia, Lung abscess* Tx: diverticulotomy, esophago myotomy Esophageal carcinoma Epidemilogy Age: 50-70 YOA M>F - 3:1 Squamous cell carcinoma common in Blacks Adenocarcinoma common in Whites Common site: distal 1/3 of esophagus Risk factors Squamous cell carcinoma o Alcohol, tobacco o Caustic induced esophageal strictures o Achalasia Adenocarcinoma o Barretts esophagus Sx Progressive dysphagia Malaise, weakness, weight loss Hoarseness of voice* Chest pain Cervical + Supraclavicula lymphadenopathy** Organ infiltration with metastasis Evaluation Non specific changes Anemia Abnormal liver function tests 2ndary metastasis Dx CXR: widened mediastinum -- 2nd adenopathy Barium swallow: polypoid or infiltrative or ulcerative lesion Endoscopy w/ biopsy = definite Dx** Tx Extensive local spread or metastasis = Palliative care Radiation, Laser (yag) Stents placement Photodynamic therapy Surgery o For stage 1 and stage 2A -- esophagectomy Chemotherapy + radiotherapy o Cisplatinum, Flurouracil