A3.

Esophageal diverticles and tracheo-esophageal fistules

• Esophageal diverticles
 Diverticulum → out-pouching’s of the wall of the esophagus
✓ Can be hollow or filled with fluid
✓ Depending on what layers of the structure are involved, they are described as being true or false
✓ Generally, are pathological, but can also occur naturally during the embryonic stage
 TRUE diverticula = involve ALL layers of the structure, including muscularis propria and adventitia
 FALSE diverticula = do not involve muscular layers or adventitia
✓ Associated with episodic food regurgitation, especially nocturnal; sometimes pain is present
 Pathogenesis

i) Traction d. → pull from outside → fibrous adhesions

ii) Pulsion d. → push from inside → increased luminal pressure

 TYPES
 Upper esophageal sphincter/lower pharynx → Zenker’s (pulsion) d.
 No muscle layer involved and NOT complete, or True diveticulum
 Middle esophagus → Traction d. due to mediastinal and bronchial lesions → scarring of lymph
nodes in pulmonary tuberculosis.
 Lower esophageal sphincter = Epiphrenic - pulsion d.
 Associated with diaphragmatic hernia, GERD, or achalasia
 Epiphrenic is due to dysfunction of lower esophageal sphincter, as in achalasia
 Complications of diverticula
 A) May reach several centimeters
 B) May be site of food accumulation
 C) Nocturnal regurgitation and aspiration during sleep
 D) Aspiration pneumonia
 Killian-Jamieson Diverticulum (not in the lecture)
 Located just below the upper esophageal sphincter
 Are seldom larger than 1.5 cm and are less frequent than Zenker’s diverticulum
 Usually asymptomatic
✓ Most of pathological diverticula are capable of harboring an enterolith (mineral concentration of
calculus). If the enterolith stays in place, it will cause no harm, but a large enterolith expelled
from a diverticulum into the lumen can cause obstruction.
• Hiatal Hernia
 Protrusion of the stomach above the diaphragm through a widened diaphragmatic hiatus
 Symptoms
 Asymptomatic
 Heartburn (A burning sensation behind the sternum)
 Dysphagia (Difficulty in swallowing)
 Pain on swallowing
 Two types

1) Sliding Hernia = 90%, the gastroesophageal junction is pulled into the

thorax

2) Paraesophageal Hernia = 10%, a portion of the stomach rolls up into the

thorax

• Achalasia
 failure to “relax”; a functional disorder characterized by:
 Loss of esophageal peristalsis
 Partial relaxation of the lower esophageal sphincter (LES) at swallowing
 Instead of relaxation, increased resting tone of LES
 Causes
 Primary (unknown)
 Secondary → 1. Scarring, 2. Chagas disease – tropical parasitic disease, 3. Autonomic neuropathy
– diabetes)
 Complications
 Megoesophagus → peristalsis fails to occur properly and the esophagus is enlarged → The
esophagus does not push food down to the stomach and thus, the food is eventually
regurgitated, or enters the lungs via breathing, or decays in the esophagus
 Can be associated with a pulsion diverticulum
• Tracheo-esophageal fistules
 Physiologic narrowing of the esophagus
1. at the esophageal inlet, where the pharynx joins the esophagus, behind the cricoid cartilage
2. where its anterior surface is crossed by the aortic arch and the left bronchus
3. where it pierces the diaphragm
• Atresia
 A congenital defect characterized by the failure of embryonal canalization (absence of a lumen)
of the esophagus.
 Several variants exist → blind upper segment and fistula between the lower segment and the
trachea
 Complications
 Death occurs from aspiration pneumonia.
 Short arteries may be repaired surgically
▪ oesophago-tracheal fistula
▪ oesophago-bronchial fistula
• Fistula
 An abnormal connection or passageway between two epithelium lined organs or vessels that
normally do not connect.
❖ Tracheo-esophageal fistula
 An abnormal connection between the esophagus and the trachea.
 A common congenital abnormality, but when occurring late in life is usually a complication of
surgical procedures such as a laryngectomy
 Several variants exist with the most common being → blind upper segment, and a fistula
between the lower segment of the esophagus and the trachea (tracheo-esophageal fistula)→
the upper esophagus ends and does not connect with the lower esophagus and stomach. The
top end of the lower esophagus connects to the windpipe and this connection is called a trachea
esophageal fistula (type c).
 Other variations include:
 A blind lower segment and a fistula between the upper esophageal segment and the trachea
→type b
 Both the upper and lower segments having a connection with the trachea → 2 fistulas present,
type d
 No blind segment, the esophagus is complete, but with a connection to the trachea → type h
 Can also occur in adults as a rare consequence of laryngeal cancer invading into the trachea
 Causes
 Failed fusion of the tracheo-esophageal ridges during the third week of embryological
development.
 Symptoms
 A newborn with copious salivation associated with choking, coughing, vomiting, and cyanosis
(appearance of a blue or purple coloration of the skin or mucous membranes due to low oxygen
content near the skin surface).
 Complications
 The tracheo-esophageal fistula may or may not have a central cavity if it does then death may
occur from the infant breathing saliva, other fluids or other foreign materials into the lungs
causing aspiration pneumonia, choking and possibly eventual death.
 In a newborn with aspiration, paroxysmal (occasionally and briefly) suffocation and pneumonia
the esophageal atresia and tracheoesophageal fistula may have occurred together.
 Other complications may include
 feeding problems
 Reflux (repeated regurgitation of food from the stomach) after surgery
 narrowing (stenosis or stricture) of the esophagus due to scarring from surgery
✓ Surgical repair is associated with complications including stenosis of the esophagus, leaking of
contents at the point of anastomosis and recurrence of the fistula.