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Presented by: Anshul Mel
• • • • • • • Introduction Development of esophagus Histology of esophagus Anatomy of esophagus Applied aspects Conclusion References
Development of the oesophagus
• At a very early period the stomach is separated from pharynx by a mere constriction from primitive pharynx. This constriction is future esophagus.
• Previous to this elongation the trachea and oesophagus form a single structure. • This becomes divided into two by the in growth of two lateral septa, which fuse giving rise to trachea in front and oesophagus behind. • At this stage the oesophagus becomes converted into a solid rod of cells, losing its tubular nature. • This eventually becomes canalised to form a tube.
ESOPHAGUS HISTOLOGY .
•The esophageal mucosa contains nonkeratinized stratified squamous epithelium. At the esophageal stomach junction the epithelium changes to simple columnar epithelium. .
•The submucosa contains mucus secreting glands. causing them to secrete mucus which aids in the movement of food. . As a bolus moves through the esophagus. it compresses these glands.
a mixture of skeletal and smooth muscle in its middle third.•The muscularis externa is skeletal muscle in its superior third. . and entirely smooth muscle in its inferior third.
•The serosa is entirely connective tissue which blends with surrounding structures along its route. .
ESOPHAGUS ANATOMY •The esophagus is a muscular tube about 25 cm long which connects the pharynx with the stomach. ESOPHAGUS . The esophagus takes a straight course through the mediastinum of the thorax and pierces the diaphragm at the esophageal hiatus to enter the abdomen and the stomach.
opposite the eleventh dorsal vertebra. • Descends along the front of the spine. through the posterior mediastinum. entering the abdomen. and. 25 cm in length – Collapsed at rest.Oesophagus • A muscular tube. – Flat in upper 2/3 & rounded in lower 1/3 • Commences at the lower border of the cricoid cartilage. • In the newborn Upper limit at the level of 4th or 5th CerVertb and it ends at 9th Dorsal . terminates at the cardiac orifice of the stomach. passes through the Diaphragm. (C6).
:16cm 15th: 19cm • Diameter: Varies whether bolus of food/ fluid passing thru or not. 5th Yr.• Length at birth: 8-10 cm. end of Ist Yr: 12cm. – At rest in adults 20 mm but can stretch up to 30 mm – At birth it is 5mm at 5 yrs it is 15mm .
General direction of the oesophagus is vertical • Presents two or three slight curvatures • At commencement. in the median line • Inclines to the left side at the root of the neck • Gradually passes to the middle line • Again deviates to the left .
.• The oesophagus also presents an antero-posterior flexure. corresponding to the curvature of the cervical and thoracic portions of the spine.
– in front. and part of the lateral lobes of the thyroid gland. on each side.• In the neck. and. with the thyroid gland and thoracic duct. the oesophagus is in relation. where it projects to the left side. it rests upon the vertebral column and Longus colli muscle. the recurrent laryngeal nerves ascend between it and the trachea. . it is in relation with the common carotid artery (especially the left. as it inclines to that side). – behind. with the trachea. at the lower part of the neck.
previous to entering the abdomen. where it passes in front and a little to the left of this vessel. it is at first situated a little to the left of the median line: it passes across the left side of the transverse part of the aortic arch.• In the thorax. . descends in the posterior mediastinum. along the right side of the aorta. until near the Diaphragm.
During its course it has three indentations: – At 15 cm from incisor teeth is cricopharyngues sphincter (normally closed) (UES) – At 25 cm aortic arch and left main bronchus – At 40 cms where it pierces the diaphragm where a physiological sphincter is sited (LES) .• Oesophagus is the narrowest region of alimentary tract except vermiform appendix.
Despite its distinct physiological function.Oesophagus divided into functional sphincters • Upper Oesophageal Sphincter: It is a 2-3 mm zone of elevated pressure between pharynx & oesophagus. usually localized at or just below the diaphragmatic hiatus. It relates to cricopharyngeal muscle • Lower Oesophageal Sphincter: The LES is located at the junction between the esophagus and stomach. . it is not easily distinguished anatomically.
ESOPHAGUS ANATOMY •The pharynx propels food into the esophagus through the upper esophageal sphincter. Upper esophageal sphincter .
ESOPHAGUS ANATOMY •The bolus of food is propelled within the esophagus by peristalsis. .
ESOPHAGUS ANATOMY .
ESOPHAGUS ANATOMY .
Thoracic Oesophagus: Upto tracheal bifurcation Right & Left inferior thyroid Artery direct supply from aorta (tracheo-bronchial tree) Abdominal Oesophagus 11 branches off L gastric artery and Branches of splenic artery posteriorly .Unusual! Arterial supply derived from vessels feeding mainly other organs – thyroid. trachea & stomach Cervical Oesophagus: Right & Left superior & inferior thyroid arteries.
thyroid (into innominate vein). hemiazygos – L gastric & splenic . – Azygos.Venous Relations • Intra-oesophageal (Intrinsic) Drainage – Longitudinally arranged in Submucosa • Extra-oesophageal (Extrinsic) Drainage into locally corresponding veins – Inf.
. receive venous drainage from the mid-esophagus. • From the dense submucosal plexus the venous blood drains into the superior vena cava. Collaterals of the left gastric vein. • The submucosal connections between the portal and systemic venous systems in the distal esophagus form esophageal varices in portal hypertension.• The venous supply is also segmental. a branch of the portal vein. These submucosal varices are sources of major hemorrhage in conditions such as cirrhosis. The veins of the proximal and distal esophagus drain into the azygous system.
lymphatics drain into the deep cervical lymph nodes. drainage is into the superior and posterior mediastinal nodes. • The distal-third lymphatics follow the left gastric artery to the gastric and celiac lymph nodes .lymphatics drainage • In the proximal third of the esophagus. • In the middle third.
wall relaxation. peristalsis .Nerve Supply • Parasympathetic – Vagus – motor to muscular coats & secretomotor to glands • Sympathetic – From cervical & thoracic sympathetic chain – Contraction of sphincters.
and TEF Congenital anomaly .Atresia.
becomes cyanotic and vomits Source: http://www.com/gimo/contents/pt1/fig_tab/gimo6_F10.nature.html .Common Congenital Tracheo-esophageal anomalies • Oesophago-tracheal fistula – Commonest type – Newborn has violent fits of vomiting & coughing on swallowing • Partial Obstruction of Oesophaugs – Stricture – Atresia – newborn salivates excessively.
Oesophageal atresia and/or tracheoesophageal (TE) fistula Aetiology: A= 8% (atresia). . C= 87% (atresia +distal Incomplete fusion of the tracheo-oesophagel septum. TEF).
Investigations: 1. .Atresia & distal TEF: Management Clinical Picture: 1. 2. X-ray : increased inhaled air in stomach. X-ray with aqueous contrast like di-ionosil blind pouch and connection if spill-over occurs. Choking 2. Regurgitation. A rubber catheter : not pass along 1.
end-to-end anastomosis of the oesophagus.Atresia & distal TEF: Treatment: Management Immediate: any delay will ↑ mortality. .
FB Lodgment .
Oesophagus: Foreign Bodies Aetiology: Accidental in children and insane Suicidal in adults. Safety pin Usually at the inlet of the or anywhere . Dentures. Pathology: The commonest FB is a coin Bolus of food. Fish bones.
The cricopharyngeus sling at C6 is also at this level and may "catch" a foreign body. . • About 70% of blunt foreign bodies that lodge in the oesophagus do so at this location. • The most common site of oesophageal impaction is at the thoracic inlet • Defined as the area between the clavicles on chest radiograph.These areas are where most oesophageal foreign bodies become entrapped. this is the site of anatomical change from the skeletal muscle to the smooth muscle of the oesophagus.
in the region where the aortic arch and carina overlap the oesophagus on chest radiograph. .• Another 15% become lodged at the mid oesophagus. • The remaining 15% become lodged at the lower oesophageal sphincter (LES) at the gastroesophageal junction.
Salivation. Regurgitation. Mediastinits. Ulceration. . Perforation.Oesophagus: Foreign Bodies Clinical Picture: Dysphagia. Investigation: X-ray show the coin or bones or metal FB Complications: Oesophagitis.
.Oesophagus: Foreign Bodies Treatment: 1. Approach via the neck or thorax: failure of endoscopic or if the FB migrates outside the oesophagus. Sharp FB need special instruments. 3. Endoscopic removal: Hypopharyngoscope or oesophagoscope 2.
GERD Reflux .
It is a common disease especially above 40. LPR: laryngo-pharyngeal reflux Aetiology: Unknown .Gastro-Esophageal Reflux Disease "GERD“ : Definition Frequent transient relaxation of the LES Reflux of gastric contents to the oesophagus Gastric fumes may reach pharynx or larynx.
but this is usually absent. Retro-sternal burning.Gastro-Esophageal Reflux Disease "GERD“. Hoarseness and chronic irritative cough and sometimes choking attacks. 2. Burning and sense of FB in throat with frequent trials of throat clearing. Clinical Picture Burning: 1. .
Investigations Oesophagoscopy: multiple superficial oesophageal ulceration Oesophageal motility tracing and 24-hour pH monitoring are diagnostic. NB: 5-10 mm Hg: Normal resting LES pressure 40-60 mm Hg is characteristic for achalasia .Gastro-Esophageal Reflux Disease "GERD“.
"GERP" Chronic laryngitis. "GERL" Oesophageal ulcerations Cancer oesophagus and larynx. .Gastro-Esophageal Reflux Disease "GERD" Complications Chronic pharyngitis.
Avoid eating two hours before bed time. alcohol. at night. Proton pump inhibitors: Surgical: Nissen's fundoplication: failure of medical treatment. . and corset. coffee. Medical treatment: H2 histamine receptor antagonist: Prokinetic drugs: Domperidone. Avoid eating: spicy or fatty foods. Avoid: tight belts. or drinking citrus. Quit smoking.Gastro-Esophageal Reflux Disease "GERD“: Treatment Medical instructions: Bed position: anti-trendlenberg 15 degree.
Oesophagoscopy Procedure .
Oesophagoscopy Flexible: By using fibreoptic oesophagoscope. Always done under GA . For diagnosis and biopsy. Sclerotheray: varices Rigid: By using rigid oesophagoscope. May be done with or without sedation.
and 3. 2. Sauttar's tube application in advanced cancer oesophagus . Non-malignant stricture dilatation. FB extraction.Rigid Oesophagoscopy: Indications Diagnostic: For diagnosis and biopsy taking Therapeutic: 1.
Oesophageal FB .
Severe Kyphosis 2. Aortic aneurysm. Oesophageal Varices. . Acute corrosive oesophagitis. 4. 3.Rigid Oesophagoscopy: Contraindications 1.
lip. and Perforation of the Oesophagus.Rigid Oesophagoscopy: Complications Injury: Teeth. tongue. Perforation of the pharynx. Anaesthetic complications . Injury of the varices leading to bleeding.
Oesophageal Prforation: endotracheal intubation Abscess: ↑ prevertebral ST + air .
References • • • • • • Gray’s anatomy 39th edition Human anatomy . Snell`s Clinical anatomy by regions 8th edition Harcourt.Laskin McMinn`s colour atlas for Human Anatomy 5th edition.11th edition . Burket’s oral medicine.Chaurasia 3rd edition Oral and maxillofacial surgery Volume 1.D.B.
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