Post on 30-Jul-2020
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ESOPHAGUS 101
Dr. Kevin J. Dolehide
Disclosures: Stocks in ExactScience; Speaker for Allergin/Ironwood Pharmaceuticals and Romark Laboratories
OBJECTIVES
▪ Anatomy & Physiology▪ Structure, Segments and Layers
▪ Motility and Sphincter activity
▪ Diseases▪ GERD and Barrett’s esophagus
▪ Dysphagia
▪ Carcinomas
▪ Treatment▪ Medical
▪ Endoscopic
▪ Surgical
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THE ESOPHAGUS▪ Approx. 10 in. long from pharynx to stomach
▪ Begins at level of cricoid cartilage opposite 6th
cervical vertebra▪ UES posterior to trachea
▪ Travels down the midline, then inclines to the left
▪ Passes through diaphragm at level of 10th thoracic
vertebra into the stomach▪ LES just below diaphragm
▪ Only the lower segment stays open▪ Collapsed at rest
▪ Upper 2/3 flat
▪ Lower 2/3 rounded
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MUSCLES OF THE ESOPHAGUS▪ UES: cricopharyngeus portion of the inferior pharyngeal constrictor.▪ Prevents: air from entering stomach, food from entering
oropharynx = aspiration
▪ LES: esophago-gastric junction▪ Internally – squamo-columnar junction, Z-line or B ring
▪ Prevents acidic gastric contents from entering esophagus = GERD
▪ The orientation of the muscles▪ Inner = Circular▪ Outer = Longitudinal
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SURROUNDING STRUCTURES
▪ Anteriorly▪ Trachea, heart
▪ Recurrent laryngeal nerves
▪ Posteriorly▪ Vertebral column
▪ Spinal ligaments
▪ Laterally▪ Lobes of thyroid gland
▪ Aorta (L) and IVC (R)
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BLOOD SUPPLY
▪ Arterial supply▪ Upper third – inferior thyroid artery
▪ Middle third – branches of aorta
▪ Lower third – branches of left gastric artery
▪ Venous supply▪ Upper third – inferior thyroid veins
▪ Middle third – azygous veins
▪ Lower third – left gastric vein (contributes to portal vein)
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PHYSIOLOGIC CONSTRICTIONS
▪ Pharyngoesophageal junction
▪ Aortic arch and bronchus
▪ Diaphragm
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MOTILITY
▪ Swallowing▪ Epiglottis moves backward to cover larynx
▪ UES relaxes and opens to allow bolus to enter
▪ Peristalsis▪ Primary peristaltic wave lasting 8-9secs travels from UES to
stomach, pushing food down▪ Rate stays the same despite transit time of bolus
▪ If bolus is stuck, stretch receptor stimulate a second
peristaltic wave that continues until bolus moves down
▪ Peristalsis stimulates LES to relax
▪Emesis is due to abdominal muscle contraction, not
reverse peristalsis
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DISEASES OF THE ESOPHAGUS
▪ Dysphagia
▪ Definition
▪ Causes
▪ Barrett’s esophagus
▪ Carcinomas
DYSPHAGIA
▪ Difficulty swallowing▪ Initiating swallow reflex
▪ Sensation of food being stuck
▪ Choking
▪ Regurgitation and aspiration
▪ Causes▪ Infection
▪ Motility dysfunction
▪ Anatomic abnormalities
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INFECTIOUS CAUSES
▪ Tonsillitis, epiglottitis
▪ Abscess
▪ Opportunistic esophagitis
▪ Candida, herpes, CMV esophagitis
▪ Eosinophilic esophagitis
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MOTILITY DYSFUNCTION
▪ Discoordination in muscles of swallowing
▪ Peristalsis impairment▪ Weak contractions
▪ Spasms
▪ Impaired sphincter motility
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ANATOMIC ABNORMALITIES
▪ Diverticula
▪ Webs and Rings
▪ Strictures
▪ Foreign bodies
▪ Varices
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ACHALASIA
▪ Inability of LES to relax
▪ Increased pressure causes slowed
emptying of food into stomach
▪ Leads to dysphagia solids > liquids
▪ Can cause regurgitation and
aspiration
BARRETT’S ESOPHAGUS
▪ Sequelae of GERD, the most common esophageal disease▪ LES insufficiency, hiatal hernia
▪ Gastritis
▪ H. pylori, NSAIDs, PUD, idiopathic
▪ Marked by squamous epithelium replaced by columnar epithelium and pseudo-goblet cells
▪ S/S: heartburn, dysphagia, chest pain, hematemesis, weight loss
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CANCERS OF THE ESOPHAGUS
▪ Squamous cell carcinoma▪ Tobacco
▪ Alcohol
▪ Hot beverages, caustic agents
▪ Nitrosamines (processed and bbq meats, pickled foods)
▪ Poor diet, poor hygiene
▪ Adenocarcinoma▪ GERD
▪ Previous radiation
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SquamousCellCarcinoma
Adenocarcinoma
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DIAGNOSTIC TESTING
▪ Ultrasound
▪ Radiographic swallow studies▪ Barium
▪ Gastrografin
▪ Endoscopy▪ UGI series
▪ Biopsy
▪ pH testing and Manometry
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MEDICAL TREATMENTS
▪ PPIs
▪ Prostaglandins or Bismuth
▪ Antimicrobial agents
▪ Amyl nitrate▪ Achalasia
▪ Spasms
ENDOSCOPIC TREATMENTS
▪ Stenting
▪ Balloon dilation
▪ Caudery
▪ Endoscopic clipping
▪ TIFS
▪ PEG placement
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SURGICAL TREATMENTS
▪ Incision and drainage
▪ Abscesses
▪Resection▪Cancers or masses
Thank you