ESOPHAGEAL DISORDERS

1. ESOPHAGEAL DIVERTICULA
The esophageal diverticula are the sacciform outpouchings of the esophageal
wall, which filled with mucus and undigested food.

Etiology and pathogenesis

The conducting pathogenic moment in occurrence of esophageal diverticula
is the increase of intraesophageal pressure proximal to muscle sphincters, which
gradually results in herniation in weak sites of the esophageal wall. Such
mechanism of formation is characteristic for pulsion diverticula. Traction
diverticula are formed as a result of paraesophageal inflammatory and sclerotic
processes, which tract esophagus to other organs, more often - with the right
bronchus. During their motions owing to a traction esophageal diverticula also are
gained.
Zenker's diverticula in advanced cases are great in size. There are three
stages in their development:
1) outpouching of mucosa;
2) formation of a globular sack;
3) enlargement of diverticulum with further descending in mediastinum.

Pathology
The restricted blind herniation of the wall of esophagus could be single or
multiple, ring-shaped, cylindrical, oval or sacciform-shaped. The muscle coat
atrophies, that makes difficult differentiation between true and false diverticula.
The latter caused by inflammatory processes. In such cases the paraesophageal
scarring resulting from extrapharyngeal abscesses, mediastinitis, specific and
nonspecific inflammatory processes of bifurcational lymph nodes (traction
diverticula) are revealed.
The small size of the opening of pouch, for example, in globular diverticula,
leads to congestion of contents with the further development of inflammation
(diverticulitis erosive, catarrhal, gangrenous, purulent).

Classification
1. According to the origin:
a) congenital;
b) acquired.
2. According to number:
a) single;
b) multiple.
3. According to histological structure:
a) true (have all layers of esophageal wall);
b) false (absent muscular layer of esophageal wall).
 4. According to localization:
a) pharyngoesophageal (Zenker's);
b) bifurcational;
c) epiphrenic.
5. According to the clinical course:
a) complicated;
b) uncomplicated.

Types of diverticula:
1 – pharyngoesophageal (Zenker's)
2 – bifurcational
3 – epiphrenic

Symptomatology and clinical course

Clinical manifestation of the esophageal diverticula, as a rule, connected
with the occurrence of complications.
The symptomatology of Zenker's diverticula depends on the stage of
development and their size.
Salivation, cervical dysphagia, difficult swallowing and cough usually occur
in advanced stages of the diverticulum.
 The dysphagia is frequently caused by congestion of food in diverticulum.
Also a compressible mass in the neck usually on the left side is frequently
revealed. The patients should press this mass to swallow the food and sometimes
make unusual movements by neck in order to empty the diverticulum. The
gurgling sound when the patient is eating and foul-smell from the mouth resulting
from decay of undigested food in diverticulum cause the patient to alter social
activities.
The sign "of a wet pillow" results from increased salivation and nocturnal
discharge of saliva and mucus from the mouth.
Bifurcational diverticula are usually less 2 cm in size and therefrom rarely
complicated and clinically manifested. At its greater size the complications can
arise rather frequently and determine the course and manifestations of the disease.
The epiphrenal diverticula can achieve considerably size, and more
frequently complicated by diverticulitis. Being filled with food, such diverticulum
can compress cervical organs, and sometimes is complicated with achalasia.
The diagnosis is confirmed by the findings of barium swallow, and also
esophagoscopy.

Pharyngoesophageal (Zenker's) diverticulum)

Variants of clinical course and complications

Diverticulitis. The anginal pain, or the pain in epigastric region, which can resemble
stenocardia or gastric disorders, belching, are the chief manifestations. Sometimes observed
nausea and vomiting.
The perforation of diverticulum can be directed into pleural space, trachea, bronchus or
pericardium. The clinical picture depends on the place of perforation. In part the perforation in
trachea or bronchus results in occurrence of esophago-bronchial fistula. Clinically such
complication is commonly shown by cough during meal. An everlasting esophago-bronchial
fistula can cause the aspiration pneumonia with the further abscessing.
Bleeding from diverticula frequently results from erosion of esophageal mucosa on the
background of diverticulitis. Nevertheless such bleedings, as a rule, are not profuse and rather
easily stopped by conservative treatment.
Malignancy rarely occurs and most often as the outcome of recurrent diverticulites.

The diagnostic program

1. Anamnesis and objective examination.
2. General blood and urine analyses.
3. Coagulogram.
4. Chest X-radiography.
5. Roentgenoscopy of esophagus and gastrointestinal tract.
6. Fibrogastroduodenoscopy.

Esophageal diverticula Fibrogastroduodenoscopy

Differential diagnostics
Functional diverticula (pseudodiverticula). Their clinical manifestations resemble a
diffuse idiopathic esophagospasm. Intermittent dysphagia, which usually arises after meal or
strong excitements, are the sings of pseudodiverticula. A retrosternal pain, which accompanied
them, can result in misdiagnosis of stenocardia.
Stenocardia. It is characterized by pain attacks with irradiation in the left arm and left
scapula, feeling of fear. After taking of nitroglycerin the pain, and fear, as a rule, disappear. In
contrast with stenocardia, the retrosternal pain caused by a spastic stricture or diverticulum of
esophagus, is characterized by feeling of compression deeply inside, which usually more
expressed in the back. There is no obvious sensation of fear, irradiation of pain in arm and relief
after nitroglycerin. Usually it is accompanied by disturbances of swallowing, sometimes
vomiting, after that the pain frequently disappears.

Tactics and choice of treatment

The treatment of pharyngoesophageal diverticula is surgical. Conservative therapy is
indicated in case of severe concomitant pathology, the patient's refusal of operation or there are
no conditions for its performance. In such cases mechanically sparing diet with washing down of
solid food.
The bifurcational diverticula require operative treatment only in one patient in ten. The
indications for such operation are frequently recurrent diverticulites, bleeding, perforation,
esophago-bronchial fistula or suspicion on malignancy.
Accesses. In order to expose pharyngoesophageal diverticula the cervical access along
the anterior border of the sternocleidomastoid muscle is applied; in case of bifurcational
diverticula right-sided posterolateral thoracotomy in ІV intercostal space is performed; in
epiphrenal diverticula – left-sided posterolateral thoracotomy in VІІ intercostal space .
The essence of the operation consists of the following: the esophagus mobilized proximal
and distal to diverticulum; after the exposure the latter is sutured or stapled near its basis and cut
off. The line of suturing is covered by muscular layer of esophageal wall.

ACCESSES FOR DIVERTICULA:

Cervical

Right-sided posterolateral thoracotomy in ІV intercostal space

 Left-sided posterolateral thoracotomy in VІІ intercostal space

STEPS OF OPERATION FOR ESOPHAGEAL DIVERTICULUM:

Mobilization of esophageal diverticulum

Suturing of diverticulum base

 Suturing of esophageal muscles over the site of diverticulum

2. ACHALASIA OF THE CARDIA

Achalasia of the cardia is the disease, which is characterized by failure of the lower
esophageal sphincter to relax with swallowing.
Etiology
The cause of this disease is still unknown. Among the underlying mechanisms are the
psycho-emotional trauma, disturbance of parasympathetic and sympathetic innervation and
influence of vegetotrophic substances on muscular fibers.

Pathology
Morphological changes depend on the stage of the disease, character of inflammation and
mainly concern nervous and muscle fibers. Thus the phenomena of the thickening of axial
cylinders of nervous fibers progressively increase, with the development of their fragmentation
and vacuolization. The working hypertrophy of muscular fibers is finished by the dystrophy of
myocytes and the development of sclerosis. The latter is contributed by inflammation, mainly of
immune character. In final stage a mediastinal pleura, paraesophageal fat and diaphragm
consolidate and knitted together.

Classification
Four stages of the disease are distinguished:
1) functional spasm without esophageal dilation;
2) constant spasm with a moderate esophageal dilation and maintained peristalsis;
3) cicatrical changes of the wall with expressed esophageal dilation, the peristalsis is
absent;
4) considerable esophageal dilation with sigmoid-shaped elongation and the presence of
erosive changes of esophageal mucosa.

Symptomatology and clinical course

Dysphagia in the onset of the disease wears a temporary intermittent character with
further permanent interchange. The passing of food after several swallows delayed on the level
of a lower part of breastbone. In some cases during meal the dysphagia arises suddenly without
any cause. The majority of the patients with dysphagia swallow better warm or hot food.
Esophageal vomiting (regurgitation) is the outcome of accumulation in esophagus of two
and more l. of fluid. In initial stages of the disease the regurgitation can arise during or at once
after meal and is accompanied by discomfort pain sensations. In advanced stages observed
regurgitation with a rotten smell. The regurgitation can occur during sleeping – the sign "of a wet
pillow".
Splashing sounds and gurgling behind breastbone are rarely observed.
The sign of nocturnal cough arises owing to aspiration of fluid from esophagus into
trachea. Thereby, the patients try to sleep in a sedentary position.
Pain and sense of tightness in the chest is the result of spasm and esophageal distention.
With the developing of esophagitis, the pain wears a burning character.
Loss of weight is the outcome of prolonged disturbed food intake. It is necessary to
consider roentgenological contrast examination with barium swallow as the chief method, which
enables to confirm the diagnosis. In the beginning of the disease revealed an inappreciable
esophageal dilation and temporary delay of barium above the level of the inferior esophageal
sphincter. In advanced stages of the disease observed a considerable esophageal dilation and
elongation with a long delay of barium. Contours of a distal constricted part of esophagus
described as the "rat tail" or "bird-beak" sign, without filling defects .

Esophageal achalasia

The endoscopic procedure reveals erosive changes of esophageal mucosa and enables to
take a biopsy to rule out malignancy. Frequently in advanced stages it is failed to pass by
endoscope a constricted part of esophagus and cardia.

Variants of clinical course and complications

The disease is characterized by remittent course with the change of the periods of
dysphagia – from inappreciable to intensive. Even in advanced stages in minority of patients
observed a latent course with complete disappearance of dysphagia in considerable esophageal
dilation and cicatrical stenosis of cardia. Nevertheless later (from several months to several
years) there comes an exacerbation of the disease with more severe course.
The bleeding arises owing to complications of erosive esophagitis at long duration of the
disease.
The malignancy occurs in the patients with phenomena of a chronic esophagitis and
chronic character of the disease.
 Pneumonia, abscesses, bronchiectases, atelectases and pneumosclerosis are frequently the
outcomes of decreasing pulmonary excursion which results from compression by dilated
esophagus.
The diagnostic program
1. Anamnesis and physical findings.
2. General blood and urine analyses.
3. Chest X-radiography.
4. Esophagogastroscopy.
5. Contrast roentgenoscopy (barium swallow).

Esophageal achalasia
 Esophageal achalasia

Differential diagnostics
Cancer of the lower part of esophagus and cardial part of stomach. The predominant
place in differential diagnostics possesses X-ray examination. As opposed to achalasia, the
cancer is characterized by irregular contours of constricted part of esophagus with filling defect.
Endoscopic examination and biopsy allows to confirm the diagnosis.
Diaphragmatic hypotonia with inflection of esophagus also can be accompanied with
dysphagia. However chest X-radiography enables to find out high standing of the left dome of
diaphragm.
Pneumothorax. On the plain chest X-radiography the edge of dilated esophagus can
resemble the edge of collapsed lung. Nevertheless in the patient with pneumothorax on the
roentgenogram the lung pattern is absent.

Tactics and choice of treatment

Diet. The food should be semisoft, without pungent relishes, chemically inactive and
enriched with proteins, fat, carbohydrates and vitamins.
The medicament treatment should include local anesthetics, spasmolytics, and sedative
drugs. Atropin and other anticholinergic agents only increase the spasm of a cardial sphincter,
therefrom their usage is undesirable. The medicament treatment results only in temporary relief.
Cardiodilatation is indicated in І-ІІ stage of achalasia. It is one of the chief methods of the
treatment of this pathology. The treatment is performed as follows: under local anesthesia by
aerosol or solution of anesthetic agent (lidocain, trimecain) through constricted part of the cardia
under roentgenological check cardiodilatator (metal, pneumatic) is passed. The air is pumped up
in balloon making pressure 200-350 mm H 2O. Repeated procedure is performed in 2-3 days. The
course of dilatation includes 3-10 procedures, depending on obtained effect.
Surgical treatment is managed in ІІІ-ІV stage of achalasia or in recurrence of the disease
after dilatation.
Heller's method (esophagomyotomy). Operation is performed through upper median
laparotomy or left thoracotomy in VІІ intercostal space. After exposing of constricted part of
esophagus and taking it on tourniquets a muscular layer of anterior wall of esophagus dissected
down to mucosa. The myotomy performed from dilated part of esophagus to cardial part of
stomach. The complete transsection of all muscular layer of esophagus, particularly its circular
fibers, is the requirement of relapse prevention.

HELLER'S OPERATION:

Myotomia of the cardia (1 – muscles, 2– mucosa)

Shift of stomach fundus to the esophageal cardia

 Nissen fundoplication

The defect of a muscular layer of esophageal wall is covered with a gastric fundus or by
means of interrupted suture or diaphragmatic flap.
Helerovsky's method. The operation is indicated for the patients with ІІІ-ІV stage of the
disease in case of considerable esophageal dilation, when performance of Heller's operation is
impossible owing to cicatrical changes. However the indication for this operation should be
restricted, because of frequent development of expressed esophagitis in postoperative period.
The same accesses, as in Heller's operation are applied. Constricted part of esophagus to its
dilation exposed and cardial part of stomach is mobilized. Dilated part of the esophagus is
anastomosed with the fundus of stomach.

Helerovsky's method
 ESOPHAGEAL STICTURE
The cicatrical esophageal stenosis can arise owing to chemical, thermal and radial burns,
and as a result of esophagitis or peptic ulcers. The most frequent cause of cicatrical strictures is
considered to be chemical burns of esophagus, which are usually the result of accidentally or
purposely (suicide) drink of acids or alkalis.

Pathology
The morphological changes in esophageal burns pass four stages:
І – stage of acute esophagitis. Lasts from one to two months. It is characterized by edema
and divestment of necrotic tissues. This stage is hazardous for erosive bleedings.
ІІ – stage of chronic esophagitis. The ulcers of different sizes with granulating tissue in
their bottom, focal constrictions of esophageal lumen are formed.
ІІІ – stage of cicatrical stricture of esophagus. Begins from 2-4th month and lasts to 2
years.
ІV – stage of late complications. Develops in two years after the burn and is characterized
by formed cicatrical stricture of esophagus.

Classification
According to the clinical course:
I. The period of acute manifestation has three degrees of severity:
1 - mild;
2 - moderate;
3 - severe.
ІІ. The latent period (false improvement).
ІІІ. The period of cicatrization.

According to the depth of lesion:

I degree – superficial burn with the damage of epithelial layer of esophagus;
ІІ degree – the burn with the damage of entire mucosa of esophagus;
ІІІ degree – the burn damage of all layers of esophagus;
ІV degree – the spread of postburn necrosis on paraesophageal tissue and adjacent
organs.

SYMPTOMATOLOGY AND CLINICAL COURSE

The clinical signs of esophageal burn directly depend on the period of lesion and degree
of gravity.

Acute period
The mild degree of clinical course manifests by satisfactory general state of the patient.
At swallowing the patient feels a moderate pain, sometimes salivation, hoarseness.
Roentgenologically – the lumen of esophagus without changes, with free passage of barium, the
mucous folds with regular contours, but in some places it is possible to observe its graduation.
The esophageal peristalsis is maintained. As a rule, in 5-7 days the clinical manifestations of the
burn disappear.
The moderate degree of gravity of acute period is characterized by acute substernal and
pharyngeal pain at swallowing, repeated vomiting, feeling of fear and excitement. Tachycardia –
120-130 beats/min. The body temperature rises to 39°C. Oliguria develops frequently.
Roentgenologically – the esophagus dilated, but in some places can be constricted as a result of
edema or spasm. The lumen is filled with considerable amount of slime. The contours of mucosal
folds are irregular, the peristalsis is weakened or absent at all. If there will be no complication, in
10-15 days the clinical manifestation of the disease disappear and general state of the patient is
improved.
Severe degree is characterized by the clinic of shock. Pulse of weak filling and tension,
expressed tachycardia, acute substernal pain. The excitement of the patient is accompanied by
feeling of fear, further transmits into adynamia, frequently the patients are unconsciousness. The
skin is pale, covered with cold sweat. One patient in four except esophageal burns, suffers from
burn of the stomach. The clinical course of the disease is worsened by oliguria, which can
transfer into anuria, and also occurrence of other complications. It determines the unfavorable
forecast.
The barium swallow in the majority of patients is problematic. Nevertheless if the general
state of the patient allows to carry out it, on the first day after a burn already have been observed
expressed manifestations of esophagitis: the esophagus dilated, mucosal folds are failed to
reveal. The deposits of destructive changed tissues in the lumen of esophagus resemble the
picture of filling defects; the peristalsis is absent, complete atony.

Latent period
This period is connected with replacement of necrotic tissues by granulations. The
general state of the patient is improved. The acute signs disappear. The patient swallows freely,
without feeling of discomfort at passage of food.

Period of cicatrize
It frequently lasts from 1 to 12 months. It is connected with replacement of granulations
by cicatrical tissue that results in progressing of esophageal stricture and disturbance of
swallowing at first of solid, and further of liquid food. Such strictures develop at the orifice of
esophagus, in projection of tracheal bifurcation and in the place of gastroesophageal juncture.
The passage of food through the constricted regions of esophagus is possible at first only due to
careful grinding and watering, but further it is inefficient. Thereafter food delay in esophagus,
choking, salivation, belching and vomiting develop. If the stricture is located in the lower part of
esophagus, the vomitis can be of putrefactive character. Progressing loss of weight observed,
which without correction can transfer into cachexia. The level and degree of the stricture, its
extension circumstantiated after X-ray examination.

Cicatrical stricture of the lower esophagus

 Variants of clinical course and complications
The esophageal burns in 30 % of cases are accompanied by disturbances of valvular
function of epiglottis. It in reinforced salivation causes the aspiration of fluid in trachea,
infection of airways, development of bronchitis and pneumonia.
In 25 % of the patients the esophageal burn combined with gastric burn, mainly of its
pyloric part. It can result in lot of complications, which sometimes prevail on the manifestations
of esophageal burn. Especially dangerous among such complications of the early period is the
gastric bleeding and perforation. The postburn stricture of pylorus belongs to the late
complications.
Gastrointestinal bleedings usually occur in 3-10 days after the burn and are characteristic
for the stage of formation of ulcers and granulations. Despite the rare arrosion of major vessels in
such pathology, these bleedings are accompanied by considerable hemorrhage, because bleeds a
considerable surface of the mucous membrane of esophagus or stomach.
Mediastinitis is mostly observed in deep burns of ІІІ-ІV degree. It can be the outcome of
perforation of esophagus or of hematogenic or lymphogenic spread of infection to mediastinum.
The clinical manifestations mainly caused by a septic state of the patient and severe intoxication.
The fever, difficult respiration, chest pain and tachycardia to 130 and more beats/min are
observed. Temperature rises to 39-40°С and has hectic character. Roentgenologically observed
distention of the mediastinal shadow, sometimes detached mediastinal pleura. Pleurisy,
pericarditis and lung abscesses can arise as the early complications of esophageal burns. To the
late complications, except cicatrical stricture, it is necessary to regard tracheo-esophageal and
broncho- esophageal fistula, and also malignancy of the cicatrical changed esophagus.

The diagnostic program

1. Anamnesis and physical findings.
2. X-ray examination of esophagus and stomach.
3. Chest X-radiography.
4. Endoscopic examination of esophagus, stomach and duodenum.
5. General blood analysis.
6. Coagulogram.
7. Biochemical investigation of plasma.

Differential diagnostics
It is necessary in advanced stages of esophageal and gastric strictures.
As there is the similar symptomatology, such cicatrical changes of the pyloroantral part of
stomach can suggest pylorostenosis caused by peptic ulcer. The differential diagnosis is based on
careful analysis of the history and endoscopic investigation of esophagus and stomach.
Esophageal cancer. As this pathology can have the similar roentgenological picture, it
requires thorough differential diagnostics. Besides anamnesis and clinical manifestations, the
question of the diagnosis finally confirmed by histological investigation of a biopsy material,
obtained during endoscopy.

Tactics and choice of treatment

The treatment of esophageal burns first of all should be guided to save the life of the
patient, and also to prevent the development of esophageal strictures. The first aid must be given
as soon as possible after taking of the chemical substance, which have caused the burn. In such
cases by means of gastric tube and great amount of water (to 10-15 l.) immediately wash out the
esophagus and stomach. It is better to use for this purpose the neutralizing solutions. If the burn
is caused by acid applied 2 % solution of sodium hydrocarbonatis, and in the burns by alkalis –
vinegar in the ratio 1:20 with water. For prophylaxis of shock and decreasing of psychoemotional
excitement of the patient instituted anesthetizing agents. If asphyxia arise owing to edema of
pharynx and epiglottis, a tracheostomy is performed.
The further aid – the treatment of shock and hypovolemia by massive intravenous
infusions (up to 4-5 l. per day) of saline solutions, solutions of glucose, dextrans and blood
plasma. With the purpose of detoxycation also applied forced diuresis.
Antibacterial therapy is nominated for prevention of infection complications.
In first two days after the burn the patients get parenteral feeding. Nevertheless, if the
swallowing is not disturbed, it is possible to add feeding by grinding cold food. The early
application of enteric feeding can be as a weak bougienage of esophagus and simultaneous
prophylaxis of cicatrical strictures. The development of complications requires the treatment of
their liquidation.
In the third period of the course of disease it is important not to miss a possible formation
of cicatrical stenosis of esophagus. In overwhelming majority at timely and correct performance
of esophageal dilatation it is possible to achieve positive effect and avoid multistep and
hazardous operations. The dilatation is carried out by special elastic thermolabile bougies. The
first procedures of bougienage are necessary to carry out under the roentgenological check. It
enables to prevent perforation of esophagus. The latter, as the complication of esophageal
bougienage, can occur not only in places of cicatrical stricture, but also in the region of piriform
sinus. Thereby the bougie penetrates in mediastinum and can result in mediastinitis. With the
purpose of prevention of such complication the esophageal bougienage is better to carry out with
conductor. It can be represented by a cord (thick thread), passed through the mouth and
gastrostoma. The bougie should have the canal for conductor, nevertheless it is possible to apply
the usual one with the loop, on its end.
In advanced cases if failed to reach the restore of esophageal patency by a bougienage,
the esophagoplasty by stomach, small and large intestine is applied.

ESOPHAGEAL PLASTIC:

By stomach
By large intestine

By small intestine