Diseases of esophagus

I. General
1. Anatomy
Length 25 cm diameter 2 cm, it extends from the pharyngeal esophageal junction (blow
15 cm below the dental arch (C5 C6)) to the cardiac.

2. Segments
It has 3 segments:
Cervical located behind the trachea, 3 cm in the length. It extends from the cricoid cartilage to
the thoracic inlet.
Thoracic: from T1 to the diaphragmatic hiatus. Located behind the trachea and pericardium
passing posterior left atrial.
Abdominal esophagus from diaphragmatic hiatus to the cardiac.

3. Structure
Mucosa ⅔ upper upper-stratified squamous epidermis epithelium The normal squamous
mucosal surface appears whitish-pink in color, Sub mucosa, muscularis (⅓ upper striated
muscle fibers; ⅔ lower flat fiber).

4. Physiology
Passage of foods from the mouth to the stomach by peristaltic movement; prevent the
reflux of the gastric juice from the stomach to the esophagus through the lower esophageal
sphincter.

5. Sphincters
2 sphincters: UES 3cn in length pressure 15-30 mmHg, LES 2-5 length 12-15 mmHg.
Sphincter pressure increase by:
 M2 and M3 muscarinic agonists, alpha adrenergic agonists, gastrin, substance P
and prostaglandin F2α
 and LES pressure reduced by: Nicotine, cholecystokinin, secretin, dopamine, VIP,
adenosine, prostaglandin E and nitric oxide donors such as nitrates.
6. investigation
Radiology: empty stomach, with contrast “Barium iodine” for visualization of esophageal
fistula. CT, Endoscopy.
Other investigations: mucosa biopsy for tumor, esophageal manometer for peristaltic mvmt,
Bernstein test to measure esophageal function.

7. Symptoms
Dysphagia, retrosternal pain, regurgitation, vomiting esophageal contains Heartburn.

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II. Esophageal diverticula
Is the penetration of the esophageal wall (looks like apendicite).

III. Esophageal varices

Dilation of sub mucosal veins in the lower half of the esophagus. Occur mostly in portal
hypertension (in cirrhosis, thrombosis in portal and suprahepatic vein).

IV. Hiatal hernia

It’s a herniation of part of stomach into chest cavity through the esophageal hiatus of
the diaphragm. (incr in elder and obese persons).
there are 3 types: sliding hiatus, rolling and 3 one is combination btw the 1st and the
2nd.
Symptoms: food or acids regurgitation, chest pain, dyspnea cyanosis during night,
cough, chronic blood loss.
Diagnostic: Endoscopy, manometer and scintigraphy (the presence of GER).
Treatment: elevate the head and avoid lying down after meal, stress reduction, weight
loss, medications to reduce LES pressure and H2 receptor blockers (reduce acid secret). When
the symptoms are severe and the presence of chronic acid reflux: need surgery.

V. Achalasia
Is motor disorder of esophageal Smooth muscle: loses of peristaltic mvmnt. it’s rare
Condition 1/10000(25-60 YO), is unknown -> LOSS OF INTRAMURAL NEURONS “VIP”.
Is characterized by the dilatation of esophageal body (2-10cm).
Sym: dysphagia, regurgitation, chest pain, weight loss,
Inv: chest X-ray (shows absence of gastric air) Barium (dilated esophagus without
normal peristaltic), manometer, endoscopy.
Differential diagnosis: peptic esophageal stenosis, scleroderma, gastric carcinoma,
motility disorder in (Diabetes mellitus, amyloidosis, alcoholism and smoking).
Complication: acute and chronic esophagitis, esophageal ulcer, cancer, brochitis,
bronchiectasis, bronchopneumonia, lung abscess.
Treatment: soft food, Ca2+ channel blockers (nifedipine), esophageal balloon to dilate
LES, Nitrites.

VI. Esophagitis
Is an inflammation and irritation of mucosal cell of the esophagus.
Classifications: inflammatory esophagitis (peptic esophagitis) post caustic esophagitis
(by acids and strong bases), infectious (virus like herpes, varicella) and iatrogenic esophagitis
(tetracycline, vibramycin, quinidine).

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 Barrett’s esophagus: replacement of esophageal squamous mucosa by colonnaire
mucosa of the stomach.
Develops in 10-20% of patients with GERD or Inflammatory esophagus. Men >Women
(3:1), its increases with age (55)
Symptoms: Barrett's esophagus does not produce.

VII. The pathogenesis of esophageal episode

Is related to: 1-incr in intragastric pressure (obesity, pregnancy and ascites), 2- Decr of
LES (smoking, medication, pregnancy, and scleroderma), 3- incr in gastric volume.
Classifications of endoscopic esophagitis
 stage 1
 stage 2 the presence of erosive lesions and exudate
 stage 3 the presence of hemorrhagic lesion
 stage 4 complications (ulceration, presence of esophageal stricture).
Symptoms: heartburn (after meal), retrosternal pain, dysphagia, severe esophageal
reflux may reach the pharynx causing hoarseness, sore throat and cough.
Investigations: barium X-ray, scintigraphy, Bernstein test, esophagoscopy, and biopsy.
Complications: ulcer, stenosis, cancer (adenocarcinoma), Barrett’s esophageal.
Treatment: weight reduction, elevated head during sleeping, elimination of the factors
that increase the pressure within abdomen, avoid smoking, fatty foods, coffee, chocolate,
alcohol, orange juice and some medications like Ca channel blockers and other smooth muscle
relaxation.
 H2 blockers: ranitidine famotidine 2*20mg
 mucosal protection: sucralfate 1g before meal.
 prokinetic: (incr motility) metoclopramide 3x10mg before meals or domperidone
(Motilium 10 mg), cisapride 20mg 3x10-30 min before meals
 In resistant cases are recommended: Proton pump inhibitors: omeprazole 2x20 mg / day
or esomeprazole (Nexium) 2x20mg.

VIII. esophageal tumor

Benign T are the epithelium, papilloma’s; adenomas, cysts.
Esophageal T of mesenchyme origin are leiomyoma hemangioma, fibroma & lipoma.
squamous cell carcinoma occurs in all the length of the esophagus and adenocarcinoma
generally occur above the esophagogastric junction.
occurs in elders (50-70), and blacks.
Factors: peptic esophagitis after 15-30 years, achalasia, esophageal diverticula, gastric
hernia, Barrett’s esophagus.
Risk factors: alcohol, smoking, smoked food, nutrition (iron and vitamin A deficiencies,
low consumption of: fresh and frozen meat, fish, egg products, fruits, vegetables; and ingestion
of food at elevated T°).
Location: 50% of malignant tumor located in the middle third and 30% in the lower
third.

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 Symptoms: Difficulty swallowing (dysphagia), Weight loss, Chest pain retrosternal,
pressure or burning. heartburn. Coughing or hoarseness. In advanced stage dysphagia for
liquids and solids.
Investigation: X-ray with barium, CT, MRI.
Differential diagnosis: benign esophageal stenosis, esophagitis, esophageal motor
disorder.
Treatment: surgical: age below 75 years old and no metastasis.