DISORDER OF

ESOPHAGUS
Prepared By:
Roll.no: 8,9&10
Binita Poudel
Deepa Koirala
EktaThapa
Anatomy
The esophagus or oesophagus
informally known as the food
pipe or gullet, is an organ
in vertebrate through
which food passes, aided
by peristaltic contraction, from
the pharynx to the stomach. It is
a muscular tube-like organ, 25-
28 cm long, approximately 2
cm in diameter in adult.
Cont….
It begins at the base of the pharynx & ends about 4cm below
the diaphragm. Its ability to transport food & fluid is facilitated
by 2 sphincter:
• Upper esophageal (hypopharyngeal) sphincter is located at
the junction of the pharynx & the esophagus.
• Lower esophageal (gastroesophageal / cardiac) sphincter is
located at the junction of the esophagus & the stomach.
An incompetence lower esophageal sphincter allows reflux of
gastric contents.
Cont….
The esophagus is a long tube that connects your mouth to your
stomach. It’s divided into three sections:
• The cervical area is the part of the esophagus inside your
neck.
• The thoracic area is the part of the esophagus in your chest.
• The abdominal area is the part of the esophagus that leads to
your stomach.
Cont…….
The esophagus consist of 4 layers:

Mucosa :-surface epithelium,

lamina propria, and glands.
Submucosa :-connective tissue,
blood vessels, and glands.
Muscularis (middle layer) :-upper
third, striated muscle. ... 
Adventitia :-connective tissue that
merges with connective tissue of
surrounding structures.
Cont……
Esophageal disorder can derive from congenital conditions,
or they can be acquired later in life. Some of the associated
disorder of esophagus are:
1. Esophageal Varices
2. Esophageal Perforation
3. Esophageal Motility Disorder
4. Gastro esophageal Reflux Disease
5. Achalasia Cardia
Cont……
6. Hiatal Hernia
7. Barrets esophagus
8. Esophageal Carcinoma
9. Bourehave Syndrome
10. Eosinophilic Esophagitis
Portal Hypertension
Portal hypertension is an increase in the pressure within
the portal vein (the vein that carries blood from the digestive
organs to the liver). The increase in pressure is caused by a
blockage in the blood flow through the liver.
• Normal pressure of portal vein is 9-12 mmHg
• When it is >12 mmHg, then called as portal hypertension.
1. Esophageal Varices
Esophageal varices are abnormal,
enlarged veins in the esophagus. This
condition occurs most often in people
with serious liver diseases. Esophageal
varices develop when normal blood flow
to the liver is blocked by a clot or scar
tissue in the liver. To go around the
blockages, blood flows into smaller blood
vessels that aren't designed to carry large
volumes of blood.
Cont……
The vessels can leak blood or even rupture, causing life-
threatening bleeding.
 Esophageal varices are portosystemic collaterals that dilate
when portal pressure exceeds 12mm Hg. It is the 2nd most
common cause of upper GI bleeding.
Epidemiology
Incidence
• At diagnosis, 30% of cirrhotic patients have varices which
increase to 90% in 10 years.
• The 1-year rate of first variceal bleeding is 5% for small varices,
15% for large varices.
Prevalence
• It is more common in males than females. Fifty percent of patients
with esophageal varices will experience bleeding at some point.
• Variceal bleeding has 10% to 20% mortality rate in the 6 weeks
following the episode.
Etiology
• Severe liver scarring (cirrhosis):- A number of liver
diseases including hepatitis infection, alcoholic liver disease,
fatty liver disease and a bile duct disorder called primary
biliary cirrhosis can result in cirrhosis.
• Blood clot (thrombosis):-A blood clot in the portal vein or in
a vein that feeds into the portal vein (splenic vein) can cause
esophageal varices.
• Parasitic infection:- Schistosomiasis is a parasitic infection
found in parts of Africa, South America, the Caribbean, the
Middle East and East Asia. The parasite can damage the liver,
as well as the lungs, intestine, bladder and other organs.
Risk Factors
• High portal vein pressure. The risk of varices increases as the
pressure in the portal vein increases (portal hypertension).
• Severe cirrhosis or liver failure. Most often, the more severe your
liver disease, the more likely to develop esophageal varices.
• Continued alcohol use. Your risk of varices is far greater if you
continue to drink than if you stop, especially if your disease is alcohol
related.
Pathophysiology
Portal vein carries 80% of deoxygenated blood along with nutrients
from intestine, duodenum & stomach to liver.

In lower 3rd of esophagus (gastroesophageal junction) there is

superficial vein which have capability to develop collaterals.

In condition like liver cirrhosis, liver becomes hard stiff & that
causes obstruction to portal vein flow & so portal pressure increase.
Cont…..

This obstruction makes portal blood flow to low pressure vein

which are esophagus vein & also other collaterals vein is
developed.

When collaterals are developed, they are usually weak, they

dilate more, their walls are thin.
Cont…..
Collaterals vein developed make anastomosis just like they
make rectum & duodenum.

Hence, Esophageal varices are the dilated superficial vein of

lower esophagus caused due to increase portal vein pressure
which is due to obstruction to flow due to conditions like
cirrhosis.
Clinical features
Esophageal varices usually don't cause signs and symptoms
unless they bleed.
Signs and symptoms of bleeding esophageal varices include:
1.Hematemesis. 2.Black, tarry or bloody stools
Cont……
3.Lightheadedness. 4.Loss of consciousness in severe cases
Cont…..
• Low Blood Pressure
• Rapid Heart Rate
• Dilated abdominal veins
Cont…..
Suspect esophageal varices if you have signs of liver disease,
including:
5. Yellow coloration of your skin and eyes (jaundice)
6. Easy bleeding or bruising
7. Fluid buildup in your abdomen (ascites)
Diagnostic test
• History Taking
• Physical Examination
• Endoscopy
Cont….
• Barium swallow ultrasonography CT, and angiography
Cont…..
• Portal Hypertension measurement
 Indirect measurement :-The measurement requires
insertion of a catheter with a balloon into the antecubital
or femoral vein. 
Cont…….
 Direct measurement
oDuring the laparotomy , a needle may be introduced
into the spleen
o Insertion of a catheter into the portal vein or one of its
branches
Cont……
• Laboratory Test - Liver function test
Abnormal liver function can be approached as a
transaminitis (an elevation of the plasma activity of
aspartate aminotransferase [AST] and alanine
aminotransferase [ALT]) or cholestasis (an elevation of
bilirubin, especially conjugated bilirubin, with or without
increased alkaline phosphatase [ALP] activity), both of
which may occur in cirrhosis. However, normal liver
function studies do not exclude liver disease, as a "burned
out" liver (ie, one that loses features of disease activity) may
not give rise to aminotransferase activity.
Cont….
• Spleenoportography was the first method used for
opacification of the portal system and it has provided
important information about portal hemodynamics, portal-
systemic collateral formation, and hepatic encephalopathy.
Cont…..
• Hepatoportography
The umbilical vein in adults is patent but collapsed. There is a
membranous valve at its entrance into the left portal vein.
Cannulation of the portal vein via the umbilical vein permits direct
access to the portal system for portography and hepatography. It is
useful in the investigation of patients with portal hypertension, and
suspected intrahepatic tumours or abscesses. It gives excellent
contrast visualization of the liver and definition of lesions as small as
1.0 cm. This technique is superior to both hepatic scanning and
splenoportography.
Cont…..
• Celiac Angiography
An angiogram is an imaging test that uses X-rays to look at
your blood vessels. It is done to check for conditions such
as:
Weak, stretched or enlarged portion of a blood vessel
(aneurysm), Narrowing of a blood vessel (stenosis),
Blockages.An abdominal angiogram looks at the blood
vessels in your belly (abdomen). It may be used to check
blood flow to the organs of the abdomen, such as the liver
and spleen. It may also be used to guide in the placement of
medicine or other materials to treat cancer or bleeding in the
abdomen.
Cont…..

Fluoroscopy is often used during an abdominal angiogram. This

is a kind of X-ray "movie" with continuous X-rays showing the
provider real time images of the test procedure.
Contrast dye is used to cause the blood vessels to appear solid on
the X-ray image. This lets the radiologist see the blood vessels
more clearly. Dye is injected into specific blood vessels to look
at a certain area of blood flow more closely.
For an abdominal angiogram, a catheter (small tube) is placed
into a large artery in your groin and then placed into the specific
artery of interest.
Cont…..
Contrast is injected through this tube. Next, the radiologist takes
a series of X-ray pictures. These X-ray images show the blood
flow in the abdomen. You may also have a CT (computed
tomography) scan or MRI (magnetic resonance imaging) scan
with your angiogram.
Treatment
Bleeding from varies is a medical emergency & treatment
should be immediate. If the bleeding is not controlled quickly,
a person may go into shock or die.
The goals of treatment are to:
• Prevent more liver damage.
• Prevent varices from bleeding.
• Control bleeding if it occurs.
Cont…
• Preventing liver damage
People who have liver disease need to avoid toxins that
cause additional stress on the liver and more damage to it.
Some suggestions for maintaining a healthier liver include:
Avoid alcoholic beverages of any kind.
Limit use of household cleaners and chemicals.
Eat a healthier diet that is low in fat and high in fruits and
vegetables, whole grains and lean proteins.
Maintain a healthy body weight (excess body fat puts stress
on the liver).
Cont….
• Treatment to prevent bleeding
Treatments to lower blood pressure in the portal vein may
reduce the risk of bleeding esophageal varices. Treatments
may include:
Medications to reduce pressure in the portal vein. A type of
blood pressure drug called a beta blocker may help reduce
blood pressure in your portal vein, decreasing the likelihood
of bleeding. These medications include propranolol (Inderal,
Innopran XL) and nadolol (Corgard).
Cont…..
Using elastic bands to tie off bleeding veins. If your
esophageal varices appear to have a high risk of bleeding, or
if you've had bleeding from varices before, your doctor might
recommend a procedure called endoscopic band ligation.
Using an endoscope, the doctor uses suction to pull the
varices into a chamber at the end of the scope and wraps
them with an elastic band, which essentially "strangles" the
veins so they can't bleed. Endoscopic band ligation carries a
small risk of complications, such as bleeding and scarring of
the esophagus.
Cont…..
• Treatment if you're bleeding
Bleeding esophageal varices are life-threatening, and immediate
treatment is essential. Treatments used to stop bleeding and
reverse the effects of blood loss include:
Using elastic bands to tie off bleeding veins. Your doctor may
wrap elastic bands around the esophageal varices during an
endoscopy.
Medications to slow blood flow into the portal vein. Drugs such
as octreotide (Sandostatin) and vasopressin (Vasostrict) slow the
flow of blood to the portal vein. The drug is usually continued
for up to five days after a bleeding episode.
Cont…..
Diverting blood flow away from the portal vein. If
medication and endoscopy treatments don't stop the bleeding,
your doctor might recommend a procedure called
transjugular intrahepatic portosystemic shunt (TIPS).
oThe shunt is an opening that is created between the portal
vein and the hepatic vein, which carries blood from your
liver to your heart. The shunt reduces pressure in the portal
vein and often stops bleeding from esophageal varices.
oBut TIPS can cause serious complications, including liver
failure and mental confusion, which can develop when
toxins that the liver normally would filter are passed
through the shunt directly into the bloodstream.
Cont…….
oTIPS is mainly used when all other treatments have failed
or as a temporary measure in people awaiting a liver
transplant.
Placing pressure on varices to stop bleeding. If medication
and endoscopy treatments don't work, doctors may try to stop
bleeding by applying pressure to the esophageal varices. One
way to temporarily stop bleeding is by inflating a balloon to
put pressure on the varices for up to 24 hours, a procedure
called balloon tamponade. Balloon tamponade is a temporary
measure before other treatments can be performed, such as
TIPS.
Cont……

oThis procedure carries a high risk of bleeding recurrence

after the balloon is deflated. Balloon tamponade may also
cause serious complications, including a rupture in the
esophagus, which can lead to death.

Restoring blood volume. You might be given a transfusion to

replace lost blood and a clotting factor to stop bleeding.
Preventing infection. There is an increased risk of infection
with bleeding, so you'll likely be given an antibiotic to
prevent infection.
Cont….
Replacing the diseased liver with a healthy one. Liver
transplant is an option for people with severe liver disease or
those who experience recurrent bleeding of esophageal
varices. Although liver transplantation is often successful, the
number of people awaiting transplants far outnumbers the
available organs.
Cont….
• Re-bleeding
There is a high risk that bleeding will recur in people who've
had bleeding from esophageal varices. Beta blockers and
endoscopic band ligation are the recommended treatments to
help prevent re-bleeding.
After initial banding treatment, your doctor will repeat your
upper endoscopy at regular intervals and apply more bands if
necessary until the esophageal varices are gone or small
enough to reduce the risk of further bleeding.
Potential future treatment
Doctors are exploring an experimental emergency therapy to
stop bleeding from esophageal varices that involves spraying
an adhesive powder. The hemostatic powder is administered
through a catheter during an endoscopy. When sprayed on the
esophagus, hemostatic powder sticks to the varices and may
stop bleeding.
Another potential way to stop bleeding when all other
measures fail is to use self-expanding metal stents (SEMS).
SEMS can be placed during an endoscopy and stop bleeding
by placing pressure on the bleeding esophageal varices.
Cont……
oHowever, SEMS could damage tissue and can migrate after
being placed. The stent should be removed within seven
days and bleeding could recur. This option is experimental
and isn't yet widely available.

Treatment with variceal ligation is effective in controlling

first-time bleeding episodes in about 90% of patients.
However, about half of patients treated with variceal ligation
will have another episode of bleeding within 1 to 2 years.
Medication and lifestyle changes can help reduce the risk of
recurrence (return of bleeding).
Cont……..
A liver transplant is considered when the liver no longer
functions adequately (liver failure), either because of an
infection, or from complications from certain medications
and disorders. A potential transplant patient must be
evaluated prior to any surgery. A liver might be obtained
from a living donor or a cadaver
Prevention
The best way to prevent esophageal varices is to correct the
underlying cause. If you have liver disease, consider the
following preventive measures to reduce your risk of
developing esophageal varices:
• Stop drinking alcohol. People with liver disease are often
advised to stop drinking alcohol, since the liver processes
alcohol. Drinking alcohol may stress an already vulnerable
liver.
Cont…..
• Eat a healthy diet. Choose a plant-based diet that's full of
fruits and vegetables. Select whole grains and lean sources of
protein. Reduce the amount of fatty and fried foods you eat.

• Maintain a healthy weight. An excess amount of body fat can

damage your liver. Obesity is associated with a greater risk of
complications of cirrhosis. Lose weight if you are obese or
overweight.
Cont……

• Use chemicals sparingly and carefully. Follow the directions

on household chemicals, such as cleaning supplies and insect
sprays. If you work around chemicals, follow all safety
precautions. Your liver removes toxins from your body, so
give it a break by limiting the amount of toxins it must
process.
Cont…..
• Reduce your risk of hepatitis. Sharing needles and having
unprotected sex can increase your risk of hepatitis B and C.
Protect yourself by abstaining from sex or using a condom if
you choose to have sex. Get tested for exposure to hepatitis
A, B and C, since infection can make your liver disease
worse. Also ask your doctor whether you should be
vaccinated for hepatitis A and hepatitis B
Cont….
It’s very important to stick with your treatment plan and attend
regular appointments with your doctor if you have esophageal
varices. Call or go to the hospital immediately if you believe
your esophageal varices have ruptured. Bleeding esophageal
varices are life-threatening and can lead to serious
complications.
Complication
The most serious complication of esophageal varices is
bleeding. Once you've had a bleeding episode, your risk of
another bleeding episode greatly increases. If you lose enough
blood, you can go into shock, which can lead to death.
2. Esophageal Perforation
An esophageal perforation is a hole in the
esophagus. The esophagus is the tube that
food and liquids pass through on the way
from your mouth to your stomach.
Perforation of the esophagus is
uncommon, but it’s a serious medical
condition.
The condition can be life-threatening if
it’s left untreated.
Cont…..
The fluid that leaks out of the hole in your esophagus can
become trapped in the tissue between your lungs. This area is
called the mediastinum. It’s located behind your breastbone.
The accumulation of fluid there can cause breathing
difficulties and lung infections.
A permanent stricture, or narrowing of the esophagus, can
develop if your esophageal perforation isn’t treated right away.
This condition can make swallowing and breathing more
difficult.
Cause
The most common cause of esophageal perforation is injury to
the esophagus during another medical procedure.
• Endoscopic:- Diagnostic endoscopy, Endoscopic biopsy,
Endoscopic dilatations, Variceal Sclerotherapy, Endoscopic
laser therapy, Endoscopic Photodynamic therapy, Endoscopic
Stent

• Placement of Nasogastric tube

Cont…..
• Foreign bodies-Bones, dentures, button
batteriesTrauma    
• Boerhaave’s syndrome
• Infectious causes:- Candida, Herpes, Syphilis,
Tuberculosis    
Clinical features
Pain is the first symptom of esophageal perforation. You’ll
usually feel pain in the area where the hole is located. You may
also feel chest pain and have trouble swallowing. 
Other symptoms of this condition include:
• increased heart rate
• rapid breathing
• Low blood pressure
• Fever, Chills
Cont…..
• vomiting, which may include blood
• pain or stiffness in your neck in the case of a perforation in
the cervical area
Diagnostic test
• History taking
• Physical examination
• X-ray 
•  CT Scan
to check for signs of esophageal perforation. These tests are used to
look in the chest for air bubbles and abscesses. Abscesses are sacs filled
with pus. The imaging tests can also help doctor see if fluid has leaked
out of your esophagus into your lungs.
Treatment
Operative
• Primary Closure
• T-tube Drainage
• Drainage only
• Esophagectomy with
oImmediate reconstruction
oDelayed reconstruction
• Exclusion & diversion
Cont….
Non operative
• Conservative management
• Esophageal stenting
• Fibrin glue application
• Endoclip application
Management

• The appropriate management of esophageal perforation is a

controversial issue.
• Early diagnosis, in less than 24 hours is vital to good
outcomes. The mortality is 10% with early diagnosis and
appropriate treatment but the mortality is up to 50% with late
diagnosis .
• The choice of treatment depends on the etiology, site of
perforation, general physical condition of the patient and the
extent of contamination as determined by radiology.
Cont…..
• The treatment also depends on the status of the esophagus:
perforation in a healthy esophagus and perforation with a
preexisting underlying intrinsic esophageal disease causing
distal obstruction need different approach.
• Non operative treatment is appropriate when esophageal
perforation is encountered late.
• Surgery is the mainstay of treatment, but recently there has
been a trend toward more non operative management.
Cont…
• Treatment should be started as early as possible and that
should include:
ointravenous fluid
onothing by mouth
obroad spectrum antibiotics
o narcotic analgesics
ototal parenteral nutrition
o decision regarding surgical closure versus non operative
management
Cont…..
• Patients with hemodynamic instability or any degree of
airway compromise should undergo treatment in an intensive
care setting with complete resuscitative facilities, including
emergency airway equipment and artificial respiratory
support.
Complication
• Mediastinitis.
• Intrathoracic abscess.
• Sepsis.
• Respiratory failure.
• Shock.
3. Esophageal Motility Disorder
An esophageal motility disorder (EMD) is
any medical disorder causing difficulty in swallowing,
regurgitation of food and a spasm-type pain which can be
brought on by an allergic reaction to certain foods. Many
generalized disorders of neuromuscular function
(eg, myasthenia gravis, amyotropic lateral sclerosis, stroke,
parkinson disease) can affect swallowing but are not typically
classified as esophageal motility disorders. The most promient
one is dysphagia.
Cont…..
Esophageal motility disorders (EMD) are rare disorders of
esophageal peristalsis and the lower esophageal sphincter.
Although sometimes asymptomatic, they are usually
characterized by symptoms of dysphagia, chest pain,
regurgitation, and if severe may manifest as weight loss,
aspiration pneumonia and malnutrition. Primary EMDs are not
associated with systemic diseases whereas secondary motility
disorders accompany a systemic disease such as scleroderma
or malignancy.
Causes
• Ulcer
• Stricture
• Irritation
• Infection
• Inflammation
• Cancer in the esophagus
• Uncoordinated or abnormal muscles in the mouth, throat
or esophagus.
Clinical features
Although sometimes asymptomatic, they are usually characterized by
symptoms of:
• Regurgitation
• Chest pain
• Difficulty swallowing
• The feeling that food is stuck in the throat or chest
• Weight loss and malnutrition
• Aspiration pneumonia
• Malnutrition
Diagnostic test
• History taking
• Physical examination
• Barium esophagram
• Esophageal manometry
Treatment
Therapy for esophageal motility disorders focuses initially on
the status of the pressure in the lower esophageal sphincter. If
the pressure is elevated then medical or surgical treatment
aimed at lowering this pressure is required.
Medical treatment
• nitrates such as isosorbide dinitrate and calcium channel
blockers like diltiazem or nifedipine
• Tricyclic antidepressants (TCAs) or Selective serotonin
reuptake inhibitors (SSRIs).
Cont…..
The newest endoscopic treatment for achalasia and related esophageal
motility disorders is per-oral endoscopic myotomy (POEM).