Esophageal Diseases

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 Anatomy

• True length= 25 cm

• Extends from crico-pharyngeal sphincter to the cardio-esopha

geal junction, from C6 - T11

• The lower 2-5 cm is below the diaphragm

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 Arterial supply to the esophagus.

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 Venous drainage of the esophagus.

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 Anatomy

• Upper 1/3 = Striated muscle, innervated by the vagus and its r

ecurrent branch.

• Middle 1/3 = Smooth and striated muscles, supplied by the va

gus and the intrinsic autonomic nerve plexus

• Lower 1/3 = Smooth muscles, supplied by the vagus and the i

ntrinsic autonomic nerve plexus

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 Anatomy
• Lymphatic drainage:

– Upper 1/3: internal jugular, deep cervical and para- trach

eal nodes.

– Middle 1/3: Subcarinal and inferior pulmonary ligament n

odes.

– Lower 1/3: drains into the para-esophageal and celiac no

des.

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 Anatomy
• Two sphincters

– Upper esophageal sphincter (UES): a true sphincter, preve

nts excess air from entering the esophagus.

– Lower esophageal sphincter (UES): not a true anatomical

sphincter, however functions as one by preventing reflux
of gastric contents

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 Esophageal anatomy

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 Anatomy
• Three physiologic constrictions:
– Cricopharyngeal 15cm
– Aortic and bronchial 25cm
– Diaphragmatic 40cm

– Importance:
• Foreign body lodgment
• Perforation during endoscopy
• Malignancy

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 Anatomy

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 Esophageal diseases
I: Neuro-muscular

Inadequate LES relaxation

• Achalasia

Uncoordinated esophageal contraction

• Diffuse esophageal spasm (DES)

Hypo-contarction
• Ineffective esophageal motility (IEM)

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 Esophageal diseases
Hyper-contraction
– Nutcracker(chronic dilatation bronchi ) esophagus
– Hypertensive lower esophageal sphincter (HLES)

Inflammatory
• Reflux esophagitis
• Caustic esophagitis
• Infectious esophagitis
• Foreign body

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 Esophageal diseases

Anatomic:
– Sliding hiatus hernia
– Rolling (Para-esophageal) hiatus hernia
– Mixed hiatus hernia
– Esophageal diverticular diseases

Neoplastic
– Esophageal carcinoma
– Benign tumors

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 Achalasia

• Achalasia (“failure to relax"): Characterized by

– loss of peristalsis in the distal esophagus
– failure of LES relaxation
– Increased resting tone of the lower esophagus

• The etiology of achalasia is not known

– ? Autoimmune disorder
– ? Chronic infections with herpes zoster or measles
– ? Chaga’s disease

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 Achalasia: Pathology

• Decrease or loss of myenteric ganglion cells

• Ineffective relaxation of the LES

• loss of esophageal peristalsis → impaired esophageal emptyin

g and gradual dilatation

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 PATHOPHYSIOLOGY

PATHOPHYSIOLOGY

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 Achalasia

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 Incidence

• Annual incidence of approximately 1 case per 100,000.

• Men and women are affected with equal frequency.

• Usually diagnosed between the ages of 25 and 60 years.

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 Symptoms

• Dysphagia: Longer duration and progressive, both for fl

uid and solid

• Weight loss

• Regurgitation of undigested food and aspiration

• Halitosis(foul smelling breath)

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 Achalasia: Investigations

• Barium swallow: Dilated esophagus with Bird's beak deformit

y.

• Manometry: gold standard

– Elevated LES resting pressure (> 35mmHg)
– Incomplete sphincter relaxation
– Complete absence of peristalsis

• Endoscopy: dilated esophagus with tightly closed LES

→ gentle pressure will admit the scope with a "pop“.

• CXR: Esophageal air fluid levels

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 Achalasia: Pseudo-achalasi
a

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 Achalasia: Treatment

• Palliation(to make less painfull) of dysphagia is the key:

→ relieve functional obstruction of distal esophagus

Options of treatment
• Pharmacotherapy
• Botulinum toxin
• Esophageal dilation
• Operative myotomy (Heller’s cardiomyotomy)

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 Achalasia: Pharmacotherapy

• Nitrates

• Ca++ channel blockers

• Anticholinergics

• Opiods

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 Botulinum toxin injection

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 Baloon dilatation

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 Modified Heller’s cardiomyotomy

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 Esophageal Cancer: Introduction

• Causes 1-2% of all cancer related deaths

• Most occur above 50 years of age

• M:F = 3:1

• Common in Ethiopia

• Causes death due to starvation and dehydration

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 Esophageal Cancer: Risks and causes

1. Chronic alcohol consumption

2. Chronic smoking and tobacco chewing
3. Diets high in nitrites or nitrosamines
4. GERD
5. Spicy foods with spirits
6. Deficiency of Zink and Selinium
7. Frequent very hot diet

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 Pre-cancerous conditions

1. Achalasia

2. Corrosive (weak) stricture

3. Plummer-vinson syndrome with Squamous metaplasia(repla

cement of one tissue by another)

4. Reflux esophagitis with barret’s esophagus

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Early cancer Stricture

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Circumferential Ulcerative

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 Esophageal cancer: Sites

• Middle 1/3: 50%

• Lower 1/3: 33%
• Upper 1/3: 17%

• Histology
1. Squamous cell carcinoma: More common in Ethiopia

2. Adenocarcinoma(malignant tumor)

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Squamous Adenocarcinoma

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 Esophageal Cancer: Symptoms

• Gradual onset of dysphagia first for solids, then for both liquid
s and solids, then to saliva, short duration

• Anorexia and odeno-phagia(painfull swallowing )

• Profound weight loss, weakness

• Rarely, features of metastasis

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 Esophageal cancer: signs

• In early disease: may be entirely normal

• Cachexia(loss of muscle tissue), dehydration and shock

• Cervical and supra-clavicular LAP(lymphadenophaty)

• Rarely, features of metastasis

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 Esophageal Cancer: Staging

Staging
T1: invades lamina propria or sub mucosa
T2: invades muscularis propria
T3: invades adventitia
T4: invades adjacent structures

N0: no lymph nodes

N1: regional lymph nodes

M1: distant metastasis, including celiac or cervical nodes

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 Esophageal Cancer: Staging

Stage I : T1 N0

Stage 2A: T2 N0 and T3 N0

Stage 2B: T1 N1 and T2 N1

Stage 3: T3 N1 and T4 any N

Stage 4: M1

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 Esophageal Cancer: Investigation

• Esophagoscopy and biopsy: Gold standard

• Endo-esophageal ultra sound

• Barium swallow

• CT- Scan

• Abdominal ultrasound

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 Palliative treatment

1. Dilatation

2. Stenting

3. Local laser ablation

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 Definitive treatment
• Esophagectomy: The gold standard
– Trans hiatal
– Ivor lewis:the esophageal tumor is removed
– Mc. Kweon
• Chemotherapy
– Very limited benefit
• Radiotherapy
– Very limited benefit
– through an abdominal incision and a right
– thoracotomy (a surgical incision of the chest wall).

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 Thank you

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