CASE PRESENTATION

OF ESOPHAGUS
Khairul Anam Zamir bin Mohd Sazali
ANATOMY OF ESOPHAGUS

■ The esophagus is a 25 cm long fibromuscular tube extending from the pharynx (C6
level) to the stomach (T11 level).
■ Consists of muscles that run both longitudinally and circularly, entering into the
abdominal cavity via the right crus of the diaphragm at the level of the tenth thoracic
vertebrae.
■ Actively facilitates the passage of the food bolus into the stomach under precise
nervous regulation.
ANATOMY OF ESOPHAGUS

■ The esophagus is divided into three parts:

– Cervical – travels through the neck
– Thoracic – which is located in the thorax, specifically at the mediasternum.
– Abdominal – which travels past the diaphragm, into the abdomen reaching the
stomach.
■ The esophageal wall consists of four layers: mucosa, submucosa, muscular layer, and
external fibrous layer. The upper third of the esophagus consists of striated muscles,
gradually transitioning into completely unstriated muscles in the distal third. Columnar
epithelium lines the distal third and gastroesophageal junction, with squamous
epithelium lining the rest of the esophagus.
ANATOMY OF ESOPHAGUS

■ The trachea and esophagus travel closely together through the neck, with
the vertebral column situated posterior to the esophagus.
■ The thoracic part passes the great vessels and nerves of the thorax, travelling very
closely to the thoracic aorta and azygos vein.
■ After piercing the diaphragm through the esophageal hiatus, the abdominal part
continues close to the left lobe of the liver, finally ending in the stomach.
■ It transports saliva, liquids, and solids all the way to the stomach.
■ Through the action of both skeletal and smooth muscle fibers, the esophagus can
create waves of peristalsis that actively push the contents down the digestive
system.
ANATOMY OF ESOPHAGUS
SPHINCTERS OF ESOPHAGUS

■ It is connected at either end by other structures, resulting in two junctions:

– Pharyngoesophageal junction -> located posterior to the cricoid cartilage and
formed at the union between the pharynx and the esophagus.
– Gastroesophageal junction -> located at the meeting point between the
esophagus and the stomach.
■ Passage of the food bolus through these junctions is regulated by sphincters; bundles
of muscle fibers under involuntary control.
SPHINCTERS OF ESOPHAGUS

■ The pharyngoesophageal junction is surrounded by the upper esophageal sphincter,

also known as the cricopharyngeal muscle. This muscle is actually a portion of
the inferior pharyngeal constrictor.
■ In turn, the gastroesophageal junction is surrounded by the lower esophageal
sphincter, also known as the cardiac sphincter.
■ When food or liquids are transported by peristaltic waves and approach the
sphincters, reflex pathways cause the muscles to temporarily relax and open,
allowing the bolus to pass. At all other times, these sphincters are fully contracted
and closed in order to prevent the reflux of food particles or gastric acid into
previous segments of the digestive tract.
BLOOD SUPPLY OF ESOPHAGUS
(ARTERIES)
■ The arteries supplying the esophagus are generally named ‘esophageal arteries’. The
only difference between them is given by their origins according to the different
esophagus divisions:
– Those supplying the cervical part originate from the inferior thyroid artery, a
branch of the thyrocervical trunk of the subclavian artery.
– The thoracic aorta sends esophageal arteries towards the thoracic part.
– The abdominal part is supplied by arteries from the left gastric artery, a branch of
the celiac trunk.
BLOOD SUPPLY OF ESOPHAGUS (VEINS)

■ The vessels draining the esophagus of deoxygenated blood are called ‘esophageal
veins’. They differ according to the vessels into which they flow:
– Veins from the cervical part drain into the inferior thyroid veins.
– The thoracic part is drained by veins that flow into the azygos and hemiazygos
venous systems, as well as into the intercostal and bronchial veins.
– The vessels from the abdominal part open into the left and short gastric veins.
INNERVATION OF ESOPHAGUS

■ It is under involuntary control by the autonomic nervous system.

■ The parasympathetic component of the cervical part is supplied by the recurrent
laryngeal nerve (a branch of the vagus nerve (CN X)) while the sympathetic fibers arise
from the cervical sympathetic trunk.
■ The thoracic part of the esophagus is innervated by the esophageal plexus, an
autonomic nervous network surrounding the esophagus. The parasympathetic
component of the plexus originates from the vagus nerve, while the sympathetic
fibers also stem from the sympathetic trunk running along the neck.
■ The abdominal part of the esophagus is slightly different. Its parasympathetic
innervation arises from the thoracic esophagealnervous plexus, while its sympathetic
component originates from the fifth to twelfth thoracic spinal nerves (T5-T12).
Peristalsis

■ The food bolus is forced inferiorly from the pharynx into the esophagus after the sequential
contraction of the three pharyngeal constrictor muscles (the superior, middle and inferior
constrictor muscles), which together make up the external circular layer of the pharynx. This muscle
contraction creates a peristaltic ridge. Once the food bolus has fully entered the esophagus, the upper
esophageal sphincter will contract and close again.
■ The food bolus then moves through the esophagus via peristalsis, the sequential contractions of
adjacent smooth muscle to propel food in one direction. Gravity also aids in the movement of food to
the stomach. The esophagus pierces the diaphragm at the esophageal hiatus, and continues to join the
stomach at the cardiac orifice, which is surrounded by the lower esophageal sphincter. It is also known
as the gastroesophageal sphincter or cardiac sphincter.
■ As the bolus approaches the stomach, the lower esophageal sphincter around the cardiac orifice will
open and allow the food bolus to pass into the stomach. Once the bolus has entered, the lower
esophageal sphincter will close to prevent regurgitation of stomach contents therefore protecting the
esophagus from acid reflux.
 RADIOLOGICAL
INVESTIGATIONS OF
ESOPHAGUS
FLUOROSCOPY (ESOPHAGRAM)

■ Modified barium swallow is used to evaluate pharyngeal motility during swallowing;

the procedure utilises barium of varying consistencies given by mouth with video
recording of swallowing
■ Barium swallow is the main radiological method of assessing the oesophagus; double
contrast oesophagogram using CO2 gas-forming crystals and barium contrast are used
to distend the oesophagus and coat the mucosa
 Upper esophageal sphincter

Aortic arch
Diaphragmatic pinch

L Mainstem bronchus
ENDOSCOPIC ULTRASONOGRAPHY

• Endoscopic ultrasound (EUS) is a procedure combining the range of endoscopy with the diagnostic
abilities of ultrasound. EUS is used in the imaging of the upper GI tract and surrounding structures
as well as the respiratory tract (where it is referred to as endobronchial ultrasound (EBUS)). A high-
frequency transducer crystal is used, typically in the range of 12-20 megahertz.
• Innermost layer (hyperechoic): superficial mucosal layer corresponding to the interface of the
oesophageal lumen and the mucosa
• Second layer (hypoechoic): mucosa
• Third layer (hyperechoic): submucosa
• Fourth layer (hypoechoic): muscularis propria
• Fifth layer (hyperechoic): oesophageal adventitia
• Endoscopic ultrasonography is used for evaluation of the depth of the oesophageal tumour.
Endoscopic ultrasound
features of normal
esophageal wall. Each
numbered circle, 1-9, with a
white arrow, indicates the
corresponding numbered
tissue layer, first through
ninth.

The 1 to the 4 layers

represent the mucosa, with
- 1 & 2 layers = epithelium
- 3 =lamina propria
- 4 = layer to the muscularis
mucosa.
- 5 = submucosa.
- 6 to eighth layers are
the proper muscle layers
- 6 layer = circular muscle
- 7 = connective tissue
- 8 = longitudinal muscle.
- 9 = adventitia (Figure 4)
CT SCAN

■ A CT scan uses x-rays to make detailed cross-sectional images of your body. Instead
of taking 1 or 2 pictures, like a regular x-ray, a CT scanner takes many pictures and
a computer then combines them to show a slice of the part of your body being
studied.
■ This test can help tell if esophageal cancer has spread to nearby organs and lymph
nodes (bean-sized collections of immune cells to which cancers often spread first)
or to distant parts of the body.
■ Before the test, you may be asked to drink 1 to 2 pints of a liquid called oral
contrast. This helps outline the esophagus and intestines. If you are having any
trouble swallowing, you need to tell your doctor before the scan.
CT SCAN
MRI SCAN

■ Like CT scans, MRI scans show detailed images of soft tissues in the body. But MRI
scans use radio waves and strong magnets instead of x-rays. MRI can also be used
to look for possible cancer spread to the brain and spinal cord.
■ Magnetic resonance imaging (MRI), which is a non-irradiating and non-invasive
modality, can provide identification of the esophageal wall and esophagogastric
junction. MRI has shown encouraging capabilities in regional and local staging of EC
as well as in the assessment of treatment response to therapy.
NUCLEAR MEDICINE (PET SCAN)

■ For a PET scan, a slightly radioactive form of sugar (known as FDG) is injected into
the blood and collects mainly in cancer cells. These areas of radioactivity can be
seen on a PET scan using a special camera.
■ A PET-CT scan combines a CT scan and a PET scan into one. You have a PET-CT
scan to find out more about where exactly your esophageal cancer is and whether it
has spread. It can help doctors work out whether tissue is active cancer or not.
■ PET/CT scans can be useful:
– In diagnosing esophageal cancer.
– If your doctor thinks the cancer might have spread but doesn’t know where.
They can show spread of cancer to the liver, bones, or some other organs. They
are not as useful for looking at the brain or spinal cord.
GERD

■ Gastroesophageal reflux disease (GORD), often shortened to reflux disease, is a

spectrum of disease that occurs when gastric acid refluxes from the stomach into
the lower end of the esophagus across the lower esophageal sphincter.
■ Findings associated with gastroesophageal reflux disease include:
– gastroesophageal reflux (demonstrated with provocative maneuvers)
– hiatal hernia (associated with presence of reflux esophagitis)
– reflux esophagitis
– in more advanced cases, stricturing and/or esophageal shortening may be
present
– impaired esophageal motility
BARRETT’S ESOPHAGUS

■ Barrett oesophagus is a term for intestinal metaplasia of the oesophagus. It is

considered the precursor lesion for oesophageal adenocarcinoma.
■ In Barrett esophagus, healthy esophageal epithelium is replaced with metaplastic
columnar cells—the result, it is believed, of damage from prolonged exposure of the
esophagus to the refluxate of gastroesophageal reflux disease (GERD).
■ The classic picture of a patient with Barrett esophagus is a middle-aged (55 yr)
white man with a chronic history of gastroesophageal reflux—for example, pyrosis,
acid regurgitation, and, occasionally, dysphagia. Some patients, however, deny
having any symptoms.
■ The features of GERD in relation to long-segment Barrett esophagus (LSBE, >3 cm)
and short-segment Barrett esophagus (SSBE, < 3 cm) are quite different.
Spot radiograph from double-contrast
esophagography shows a smooth stricture
in the midesophagus. Multiple ulcerations
in the region of the stricture are seen.
ENDOSCOPY

■ Endoscopy is a nonsurgical procedure used to examine a person's digestive tract.

Using an endoscope, a flexible tube with a light and camera attached to it, your
doctor can view pictures of your digestive tract on a color TV monitor.
■ During an upper endoscopy, an endoscope is easily passed through the mouth and
throat and into the esophagus, allowing the doctor to view the esophagus, stomach,
and upper part of the small intestine
■ An endoscopy offers an opportunity to collect tissue samples (biopsy) to test for
diseases and conditions that may be causing anemia, bleeding, inflammation or
diarrhea. It can also detect some cancers of the upper digestive system.
ENDOSCOPY