You are on page 1of 18

3/27/2012

Anatomy and Physiology


of the Esophagus

The Esophagus
Tube-like structure
Portion of the upper digestive tract
Conducts food from the pharynxstomach via
rhythmic contractions (peristalsis)
Mucous glands lubricate the bolus
25 cm (10 inch) in length, 2.5 cm (20.5mm, 1 inch)
in diameter
~C5/6- T11

By comparison- pharynx 12 cm (5 in) long

Three Arbitrary Divisions


1. Cervical esophagus (proximal)

Left of midline
Cricoid cartilage to thoracic inlet

2. Thoracic esophagus (mid-distal)

Thoracic inlet to diaghragm

3. Abdominal esophagus (distal)

At or just below diaphragmatic hiatus- LES

3/27/2012

(Zimbio.com)

Areas of Natural
Esophageal Narrowing
1.

UES- Narrowest at 14mm in diameter. Area of weakness


to develop diverticula, potential of perforation. High
pressure zone

2.

Bronchoaortic constriction- Cross of Left main bronchus


and aortic arch. 15-17mm in diameter

3.

LES- where esophagus traverses the diaphragm


(diaphragmatic hiatus); 16-19mm in diameter

http://www.sts.org/

3/27/2012

Innervation
Motor innervation is via vagus CNX
UES/ proximal esophagus- striated cell bodies arise in
nucleus ambiguous
Distal esophagus/ LES- smooth fibers originate in the
dorsal motor nucleus also receive sympathetic nerve
supply (motor and sensory) from spinal segments T1-T10
Sensory innervation via vagus- cell bodies originate in
nodose ganglion project to brainstem
Local nervous system- Enteric Nervous System

Mittal, R.K., (1997) New England Journal of Medicine, 336: 924-932.

Physiology

3/27/2012

Functions of the Esophagus


1. Propel swallowed food or liquid into
the stomach, timed relaxation of the
UES and LES
2. Acid clearance of refluxed gastric
contents
3. Reflex activities (vomiting and belching)

Esophageal Stage
Primary peristalsis
contractile wave migrates toward stomach
Relaxation of the UES and LES
Induced by swallowing

Secondary Peristalsis
distention of the esophagus
LES relaxation only

Tertiary Contractions
Non- useful/ non- propulsive

3/27/2012

UES Function

Pressure barrier to prevent retrograde flow


Barrier to entry of air into the esophagus
Tonic state of contraction
With deglutition, neuronal discharge ceases to permit
relaxation
UES opening= relaxation of UES muscles+
anterior/elevation of larynx via suprahyoid mus
1 second

LES Function
Pressure barrier that separates the
esophagus from the stomach
Serves to prevent reflux of gastric contents
into the esophagus
Poor LES pressure GERD

Relaxation of LES
LES promptly relaxes with:
Deglutition
Distention of the esophagus
Belching or vomiting
Swallow induced LES relaxation:

Lasts 5-7 seconds


Bolus should pass unimpeded into the
stomach

3/27/2012

Symptoms of esophageal dysfunction/


disease

Dysphagia
Odynophagia
Heartburn or pyrosis
Regurgitation
Nonheartburn chestpain
Waterbrash
Bleeding
Respiratory symptoms/ cough
Laryngeal symptoms

Disorders of the Esophagus

Disorders overview

Disorders of the pharyngoesophageal segment


Anatomic variants
Reflux and reflux complications
Inflammatory processes- esophagitis (non- reflux
related)
Motor disorders
Obstructive dysphagia- rings, webs, tumors
Diverticulum

3/27/2012

Disorders of the
Cervical Esophagus
Cricopharyngeus hypertension
Prominent cricopharyngeus/ CP bar/ pharyngeal bar
CP hypertrophy
CP fibrosis
Radiation
GERD
Zenkers Diverticulum
Cervical osteophytes
Anterior cervical esophageal web

Anatomic Variants
Hiatal Hernia
Most are acquired
Shortening secondary to GERD
Congenitally short esophagus

2 types
Sliding
Paraesophageal

Sliding Hiatal Hernia


Circumferential cuff of cardia and proximal
stomach migrates through diaphragmatic
hiatus and into the thorax
May reduce and reform spontaneously
Very common, increased incidence with age
Presence may increase GERD
Displaces GE junction

3/27/2012

http://heartburn-home-remedies.net/hiatal-hernia-pictures/

GERD
Gastroesophageal reflux represents the
backflow of gastric contents from the
stomach into the esophagus. When it is
frequent or severe, it is considered GERD

Complicated GERD
1.Esophagitis
2.Peptic stricture
3.Barretts esophagus
4.LPR/ Respiratory
complications

3/27/2012

LPR Definition
Laryngopharyngeal reflux represents the
backflow of gastric contents from the
stomach through the esophagus and into
the laryngopharynx

3/27/2012

Non-Reflux Induced
Esophagitis
1. Infectious esophagitis
a. Candida esophagitis
b. Herpes simplex esophagitis

2. Esophagitis-Immune Mediated Disease


3. Chemical-Induced
a. Caustic chemical ingestion
b. Pill-induced esophagitis

4. Radiation-induced esophagitis

10

3/27/2012

Motor Disorders
Primary motor disorders

Secondary motor disorders

Motor Disorders
Primary- (no known etiology)
Hypertensive peristaltic or nutcracker
esophagus
Diffuse esophageal spasm or corkscrew
esophagus
Achalasia

11

3/27/2012

Nutcracker Esophagus
Normally propagated, high amplitude
peristaltic waves in distal esophagus
Duration of contraction wave prolonged
LES relaxation normal, but resting LES pressure
is elevated
May progress to diffuse esophageal spasm or
achalasia
C/o:
Angina-like chest pain
Do not generally c/o dysphagia

Diffuse Esophageal Spasm/ corkscrew


esophagus
Normal peristaltic wave interspersed with high pressure,
nonpropagated tertiary waves
Advanced, barium study shows corkscrew esophagus
C/o:
Dysphagia, Chest pain, food/liquid not going down
Etiology: Unknown, thought to be degenerative changes
in the esophagus

12

3/27/2012

Achalasia
Aperistalsis in the body of the esophagus
Elevated LES pressure
Absent or incomplete LES relaxation in
response to swallowing
Progressive dilation of esophagus
bird beak appearance of LES
C/o: dysphagia for solids and liquids,
regurgitation, fullness, possible chest pain

13

3/27/2012

Motor Disorders
Secondary-(caused by systemic/ local
condition, age)
Acid-induced dysmotility
Related to neuropathy (diabetes or alcoholism)
Esophageal involvement in scleroderma or
other connective tissue disorders
presbyesophagus

Esophageal Rings
Schatzkis ring- a lower esophageal mucosal ring
Squamos epithelium on superior, columnar
inferior border
Common cause of dysphagia (lumen <13mm)
(intermittent 13-20mm)
Cause unknown
Intermittent solid-food dysphagia
Episodic food-bolus obstruction

14

3/27/2012

15

3/27/2012

Esophageal Diverticula

Zenkers diverticulum
Midesophageal diverticulum
Lower esophageal or epiphrenic diverticulum
(Intramural diverticulosis)

Zenkers Diverticulum
Mucosal weakness
Arises posteriorly in the midline between the
oblique inferior pharyngeal constrictor muscles
and transverse cricopharyngeal fibers Killians
dehiscence
Enlarges shifts left of midline
Result of decreased compliance of the CP
muscle abnormally high pressures in the
hypopharynx during deglutition

16

3/27/2012

Zenkers Diverticulum (cont)


C/o:
Dysphagia d/t external compression of the
cervical esophagus, CP dysfunction
Regurgitation of undigested (stagnant, foultasting) food or liquid
Aspiration
chronic mucus production
Large- can have neck mass (left side)

17

3/27/2012

18