Esophagus

Summary and tips !

Dr. Mahmoud W. Qandeel

 Outlines
• Anatomy
• Physiology
• Zenker Diverticulum
• Achalasia
• DES
• GERD
• Strictures
• Neoplasms and cancer
• MWS

Dr. Mahmoud W. Qandeel

 Anatomy

• A muscular tube
• ~ 25 cm long
• Occupying the posterior mediastinum
• Extending from the upper esophageal sphincter (the
cricopharyngeus muscle) in the neck to the junction with the
cardia of the stomach.

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel
Dr. Mahmoud W. Qandeel
• Three normal areas of esophageal narrowing
• It is helpful to remember the distances 15, 25 and 40 cm for
anatomical location during endoscopy

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel
T8 T 10

T 12

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel
Dr. Mahmoud W. Qandeel
Dr. Mahmoud W. Qandeel
• The musculature of the upper esophagus, including the upper sphincter, is
striated.
• This is followed by a transitional zone of both striated and smooth muscle
• In the lower half of the esophagus, there is only smooth muscle.

• It is lined throughout with stratified squamous epithelium

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel
• The parasympathetic nerve supply is mediated by branches of the
vagus nerve that has synaptic connections to the myenteric
(Auerbach's) plexus.
• Meissner's submucosal plexus is sparse in the esophagus.

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel
Dr. Mahmoud W. Qandeel
Dr. Mahmoud W. Qandeel
Dr. Mahmoud W. Qandeel
Dr. Mahmoud W. Qandeel
Dr. Mahmoud W. Qandeel
Dr. Mahmoud W. Qandeel
Dr. Mahmoud W. Qandeel
Dr. Mahmoud W. Qandeel
Dr. Mahmoud W. Qandeel
Dr. Mahmoud W. Qandeel
Dr. Mahmoud W. Qandeel
Dr. Mahmoud W. Qandeel
Dr. Mahmoud W. Qandeel
Dr. Mahmoud W. Qandeel
• In the early stages of GERD, most pathological reflux occurs as a result
of an increased number of TLESRs rather than a persistent fall in overall
sphincter pressure.

• In more severe GERD, LES pressure tends to be generally low, and this
loss of sphincter function seems to be made worse if there is loss of an
adequate length of intraabdominal esophagus.

Dr. Mahmoud W. Qandeel

• The absence of an intra-abdominal length of esophagus results in a
sliding hiatus hernia.

• The normal condensation of peritoneal fascia over the lower esophagus

(the phreno-oesophageal ligament) is weak, and the crural opening
widens, allowing the upper stomach to slide up through the hiatus.

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel
• The loss of the normal anatomical configuration exacerbates reflux,
although sliding hiatus hernia alone should not be viewed as the cause
of reflux.

• Sliding hiatus hernia is associated with GERD and may make it worse
but, as long as the LES remains competent, pathological GERD does
not occur.

• Many GERD sufferers do not have a hernia, and many of those with a
hernia do not have GERD.
Dr. Mahmoud W. Qandeel
• It should be noted that rolling or paraoesophageal hiatus hernia is a
quite different and potentially dangerous condition.

• A proportion of patients have a rolling hernia and symptomatic GERD or

a mixed hernia with both sliding and rolling components.

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel
Dr. Mahmoud W. Qandeel
Complications of GERD

• Stricture
• Esophageal shortening
• Barrett's esophagus(columnar-lined lower oesophagus)

Dr. Mahmoud W. Qandeel

Barrett Esophagus

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel
Dr. Mahmoud W. Qandeel
Esophageal Strictures

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel
Neoplasms

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel
 Esophageal cancer
Epidemiology
• Of Western countries, Russia, Scotland, and the Scandinavian countries have some
of the highest rates.
• Incidence of esophageal cancer in Western countries is rising faster than that of any
other malignancy.
• More in black people and people from the Far East
• Men are more likely than women to develop esophageal cancer.
• In the 1960s, 90% of all esophageal tumours were squamous cell cancers.
• Adenocarcinomas are now more prevalent than squamous cell carcinomas overall in
the US and Western Europe.

Dr. Mahmoud W. Qandeel

• Vast majority of the increase in incidence of adenocarcinoma of the esophagus is
attributed to the rise of Barrett's esophagus in young, otherwise healthy men.

• Squamous cell carcinoma remains a disease of the upper-to mid-esophagus, most

commonly associated with alcohol and tobacco consumption.

Dr. Mahmoud W. Qandeel

Etiology
Important factors implicated in the development of esophageal adenocarcinoma
include:
– Gastro-esophageal reflux and Barrett's esophagus
– High body mass index
– Male sex
– Dietary factors (high in total fat, saturated fat, and cholesterol)

– Other factors that are possibly inversely linked with the risk of esophageal
adenocarcinoma include infection with Helicobacter pylori and
– the use of anti-inflammatory drugs (e.g., aspirin, NSAIDs).

Dr. Mahmoud W. Qandeel

• Factors implicated in the development of esophageal squamous cell carcinoma
include:
• Tobacco smoking (a 3-fold to 7-fold increase in risk)
• Alcohol consumption (a 3-fold to 5-fold increase in risk)
• Human papilloma virus (HPV)
• Achalasia
• Caustic strictures

Dr. Mahmoud W. Qandeel

Pathophysiology
• Esophageal cancer arises in the mucosa of the esophagus.
• It then progresses locally to invade the submucosa and the muscular
layer, and may invade contiguous structures.
• Metastasis typically occurs to the peri-esophageal lymph nodes, liver,
and lungs.

Dr. Mahmoud W. Qandeel

Alcohol
• Alcohol itself does not bind DNA, is not mutagenic, and does not cause cancer in
animals. However, it may act through its conversion to acetaldehyde (a known
carcinogen), acting as a solvent for other carcinogens, and causing nutritional
deficiencies.

Tobacco
• Smoking exposes the body to a large number of carcinogens, such as polycyclic
aromatic hydrocarbons, nitrosamines, and acetaldehyde, which are present in
tobacco smoke.

GERD and Barrett's esophagus

• Chronic GORD causes metaplasia these metaplastic cells may become dysplastic,
and ultimately malignant

Dr. Mahmoud W. Qandeel

Histological classification

• The 2 main histological types are esophageal squamous cell carcinoma and esophageal
adenocarcinoma
• In the US, about 80% of cases are adenocarcinomas (typically arising in Barrett's
esophagus).
• Esophageal adenocarcinoma occurs mainly in the distal esophagus and gastro-
esophageal junction,
• Esophageal squamous cell carcinoma is more evenly distributed throughout the
length of the esophagus.

Dr. Mahmoud W. Qandeel

Clinical features

• Esophageal cancer typically presents late, which in part contributes to the generally
poor prognosis.
• The most common presenting signs of squamous cell carcinoma or locally advanced
adenocarcinoma are dysphagia and odynophagia.
• For patients with Barrett's esophagus and early stage adenocarcinoma of the
esophagus and gastro-esophageal junction, reflux is the most common presenting
sign.

Dr. Mahmoud W. Qandeel

• Upper esophageal tumours can involve the recurrent laryngeal nerve, causing the
patient to have a hoarse voice.

• Phrenic nerve involvement can trigger hiccups.

• A postprandial or paroxysmal cough may indicate the presence of an esophago-

tracheal or esophago-bronchial fistula resulting from local invasion by a tumour.

Dr. Mahmoud W. Qandeel

Investigations
– Upper GI endoscopy assessment of any obstruction, and biopsy to confirm the
histology of mucosal lesions.

– A barium swallow is not routinely required.

– Serum electrolytes and renal function testing should be performed in advanced
cases(severely volume-depleted and hypokalaemic because of their inability to
swallow fluids and their own potassium-rich saliva)

Dr. Mahmoud W. Qandeel

Diagnostic/staging tests
• CT scan of the chest and abdomen is performed if the suspicion of esophageal
cancer is high or biopsy confirms the diagnosis.
• MRI is an alternative to CT for the staging of esophageal cancer.
• (FDG-PET) improves the accuracy of staging and facilitates selection of patients for
surgery
• EUS is one of the newer modalities used in the staging of esophageal
cancer, although stenosis can limit its use.(Currently, EUS combined with
FNA (EUS/FNA) is the most accurate imaging modality for locoregional
staging of esophageal cancer.)

Dr. Mahmoud W. Qandeel

• Bronchoscopy with biopsy, FNA, or brushings can be helpful in
determining involvement of the tracheobronchial tree.

• If the EUS/FNA shows no lymph node involvement, thoracoscopy and

laparoscopy are still generally utilized as definitive staging tools.

Dr. Mahmoud W. Qandeel

Preoperative assessment

• Management of esophageal carcinoma requires intensive therapy with a

combination of surgery, chemotherapy, and radiotherapy.
• Many patients present with advanced disease and comorbidities that may affect the
suitability of this therapy.
• Pulmonary function tests (PFTs) are crucial to determine the ability of the patient to
withstand combined modality therapy.
• Cardiac risk is assessed with cardiac stress testing and echocardiogram.

Dr. Mahmoud W. Qandeel

Differentials

• Benign stricture
• Achalasia
• Barrett's esophagus

Dr. Mahmoud W. Qandeel

Screening
• In patients with Barrett's esophagus, continued surveillance is indicated to identify
pre-malignant lesions (high-grade dysplasia) and early carcinoma in situ.

• There is a consensus that patients with high-grade dysplasia no longer require

frequent monitoring and 4-quadrant large-forceps biopsy alone, but rather should
undergo endoscopic ablation/resection.

• Monitoring alone is recommended only for non-dysplastic or early dysplasia

Barrett's esophagus.

Dr. Mahmoud W. Qandeel

Treatment Approach

• Critical to treatment decisions are the stage of the disease and the
patient's overall physiological status.
• The degree of mucosal invasion and the presence or absence of lymph
node involvement will determine the clinical stage.

Dr. Mahmoud W. Qandeel

Treatment

• Treatment for high-grade dysplasia and superficial esophageal cancers:

esophagectomy→ endoscopic therapy.
• The goal of surgical resection in esophageal cancer is curative where possible, or, if
not, to provide palliative relief of symptoms.
• However, not all tumours are resectable.

• There is a tendency towards better response with chemoradiation for patients with
squamous cell carcinoma, and those patients with high thoracic or cervical lesions
may be approached with chemoradiation alone.

Dr. Mahmoud W. Qandeel

Primary prevention

• Avoiding tobacco and alcohol are probably the best measures to prevent esophageal
cancer.
• Diets high in cruciferous vegetables (cabbage, broccoli, cauliflower), green and yellow
vegetables, and fruits are associated with a decreased risk of esophageal cancer.
• By contrast, diets high in total fat, saturated fat, and cholesterol seem associated with an
increased risk of esophageal adenocarcinoma.
• There is some evidence that aspirin and non-steroidal anti-inflammatory drugs (NSAIDs)
may reduce the risk of esophageal cancer.
• Additionally, there is some evidence that the use of statins may reduce the risk of
development of esophageal adenocarcinoma, but more data on this are required.

Dr. Mahmoud W. Qandeel

Mallory Weiss Syndrome

Dr. Mahmoud W. Qandeel

The most common location for a boerhaave's syndrome is:
(4/2018)

a. The left posterior lower esophagus

b. The left posterior middle esophagus
c. The left posterior upper esophagus
d. The right posterior middle esophagus
e. The right posterior upper esophagus

Dr. Mahmoud W. Qandeel

The most common location for a boerhaave's syndrome is:
(4/2018)

a. The left posterior lower esophagus

b. The left posterior middle esophagus
c. The left posterior upper esophagus
d. The right posterior middle esophagus
e. The right posterior upper esophagus

Dr. Mahmoud W. Qandeel

The typical management finding in patient with achalasia is;
(4/2018)

a. Normal LES pressure and absent peristalsis

b. Failure of LES to relax and absent peristalsis
c. Increased of LES pressure and normal peristalsis
d. Increased of LES pressure and high peristalsis
e. Low of LED pressure and Absent peristalsis

Dr. Mahmoud W. Qandeel

The typical management finding in patient with achalasia is;
(4/2018)

a. Normal LES pressure and absent peristalsis

b. Failure of LES to relax and absent peristalsis
c. Increased of LES pressure and normal peristalsis
d. Increased of LES pressure and high peristalsis
e. Low of LED pressure and Absent peristalsis

Dr. Mahmoud W. Qandeel

One of the following passes through the aortic hiatus in the
diaphragm ? (1/2017)

A . Vagal trunks
B . Right phrenic nerve
C . Thoracic duct
D . Esophagus
E. Branches from left gastric artery

Dr. Mahmoud W. Qandeel

One of the following passes through the aortic hiatus in the
diaphragm ? (1/2017)

A . Vagal trunks
B . Right phrenic nerve
C . Thoracic duct
D . Esophagus
E. Branches from left gastric artery

Dr. Mahmoud W. Qandeel

Which of the following statement about the anatomy of the esophagus is
correct ? (1/2017)

A . The cervical esophagus passes behind and to the right of the trachea .
B . The esophagus deviates anteriorly and to the left as it enters the abdomen .
C. The thoracic esophagus enter the posterior mediastinum anteriorly to the
aortic arch .
D . The thoracic esophagus passes behind the right mainstem bronchi and the
pericardium .
E . The esophagus enters the Diaphragmatic hiatus at the level of T8 .

Dr. Mahmoud W. Qandeel

Which of the following statement about the anatomy of the esophagus is
correct ? (1/2017)

A . The cervical esophagus passes behind and to the right of the trachea .
B . The esophagus deviates anteriorly and to the left as it enters the abdomen .
C. The thoracic esophagus enter the posterior mediastinum anteriorly to the
aortic arch .
D . The thoracic esophagus passes behind the right mainstem bronchi and the
pericardium .
E . The esophagus enters the Diaphragmatic hiatus at the level of T8 .

Dr. Mahmoud W. Qandeel

Which of the following statement about esophageal
leiomyoma is false ? (7/2016)

A . It is the most common benign esophageal neoplasm .

B . Most common sites middle and lower third
C . They have risk of malignant degeneration
D . Preoperative endoscopic biopsy should be done .
E . Treatment of choice is endoscopic enucleation

Dr. Mahmoud W. Qandeel

Which of the following statement about esophageal
leiomyoma is false ? (7/2016)

A . It is the most common benign esophageal neoplasm .

B . Most common sites middle and lower third
C . They have risk of malignant degeneration
D . Preoperative endoscopic biopsy should be done .
E . Treatment of choice is endoscopic enucleation

Dr. Mahmoud W. Qandeel

All are true about Achalasia except ? (7/2016)

A . It can be congenital or acquired .

B . In young patient , myotomy is the best treatment .
C . CCB exacerbate this condition .
D . Caused by neurogenic degeneration .
E . Dysphagia , regurgitation , weight loss

Dr. Mahmoud W. Qandeel

All are true about Achalasia except ? (7/2016)

A . It can be congenital or acquired .

B . In young patient , myotomy is the best treatment .
C . CCB exacerbate this condition .
D . Caused by neurogenic degeneration .
E . Dysphagia , regurgitation , weight loss

Dr. Mahmoud W. Qandeel