Esophageal Motility Disorders Iskander Al-Githmi, MD, FRCSC, FRCSC (Ts & CDS), FACS, FCCP Consultant...

Esophageal Motility DisordersEsophageal Motility Disorders

Iskander Al-GithmiIskander Al-Githmi, , MD, FRCSC, FRCSC (Ts & CDS), FACS, FCCPMD, FRCSC, FRCSC (Ts & CDS), FACS, FCCP

Consultant & Asst. Professor of Cardiothoracic SurgeryConsultant & Asst. Professor of Cardiothoracic Surgery King Abdulaziz University College of MedicineKing Abdulaziz University College of Medicine

Anatomy of The Esophagus Anatomy of The Esophagus

The esophagus is a hollow muscular The esophagus is a hollow muscular organ, approximately 25cm in length that organ, approximately 25cm in length that extend from the pharynx to the stomachextend from the pharynx to the stomach

The pharynx is a muscular tube, The pharynx is a muscular tube, approximately 12cm in length that serve approximately 12cm in length that serve as entry to the esophagus and respiratory as entry to the esophagus and respiratory tract.tract.

Anatomy of The EsophagusAnatomy of The Esophagus

Cervical Esophagus:Cervical Esophagus: Just lies to the left of midline Just lies to the left of midline behind the larynx and the trachea. The entry to behind the larynx and the trachea. The entry to esophagus called upper esophageal sphincter esophagus called upper esophageal sphincter (UES).(UES).

Thoracic Esophagus:Thoracic Esophagus: The upper part passes behind The upper part passes behind the carina & Lt. main stem bronchus. The lower part the carina & Lt. main stem bronchus. The lower part passes behind the left atrium.passes behind the left atrium.

Abdominal Esophagus:Abdominal Esophagus: Is the smallest portion of the Is the smallest portion of the esophagus (2-4cm length). It has lower esophageal esophagus (2-4cm length). It has lower esophageal sphincter (LES)- non anatomicalsphincter (LES)- non anatomical

with normal resting pressure 10-20mmHg.with normal resting pressure 10-20mmHg.


Normal esophageal narrowing:Normal esophageal narrowing:• UES at the level of cricoid cartilage 14mm in UES at the level of cricoid cartilage 14mm in

diameter.diameter.• Broncho-aortic constriction 17mm in diameter.Broncho-aortic constriction 17mm in diameter.• LES (19mm) as it travels the diaphragm & LES (19mm) as it travels the diaphragm &

located 3-5cm at distal part of the esophagus.located 3-5cm at distal part of the esophagus.• Clinical Importance of normal esoph. narrowing:Clinical Importance of normal esoph. narrowing:• Potential for development of diverticulum's Potential for development of diverticulum's

(Zenker) in the neck.(Zenker) in the neck.• Potential for perforation during esophagoscopyPotential for perforation during esophagoscopy• Pills-induced stricture.Pills-induced stricture.


The esophageal wall:The esophageal wall:• The proximal esophagus is predominantly The proximal esophagus is predominantly

striated muscle.striated muscle.• The distal esophagus is predominantly smooth The distal esophagus is predominantly smooth

muscle.muscle.• The mid esophagus contained a graded The mid esophagus contained a graded

transition of striated and smooth muscle.transition of striated and smooth muscle.


The esophageal wall:The esophageal wall:• The muscle oriented in two perpendicular opposing The muscle oriented in two perpendicular opposing

layers an inner circular layer and outer longitudinal layers an inner circular layer and outer longitudinal layers both called muscularis propria.layers both called muscularis propria.

• The outermost layer of the esophagus called adventitia The outermost layer of the esophagus called adventitia (fibro-areolar layer), but no serosa. This may contribute (fibro-areolar layer), but no serosa. This may contribute for cancer spread.for cancer spread.

• Underneath the adventitia there is a longitudinal muscle Underneath the adventitia there is a longitudinal muscle layer and beneath there is circular layer.layer and beneath there is circular layer.

• Between the two muscle layers there are network of Between the two muscle layers there are network of sympathetic and parasympathetic fibers (myentric sympathetic and parasympathetic fibers (myentric plexus)plexus)


The esophageal wall:The esophageal wall:• Beneath the muscle layers lies the submucosa Beneath the muscle layers lies the submucosa

which contain mucus gland, blood and lymphatic which contain mucus gland, blood and lymphatic vessels and network works of nerve fibers vessels and network works of nerve fibers (meissners).(meissners).

• Beneath the submucosa is the mucosa which Beneath the submucosa is the mucosa which consist of squamous epithelium except the distal consist of squamous epithelium except the distal 2cm at G-E junction (Z-line) or transition to 2cm at G-E junction (Z-line) or transition to columnar epithelium.columnar epithelium.


Blood supply & venous drainageBlood supply & venous drainage• Cervical esophagus received its arterial blood Cervical esophagus received its arterial blood

from inferior thyroid artery.from inferior thyroid artery.• Thoracic esophagus received its arterial blood Thoracic esophagus received its arterial blood

from bronchial, aorta, left gastric artery and from from bronchial, aorta, left gastric artery and from inferior phrenic artery. inferior phrenic artery.

• The esophageal veins drain to periesophageal The esophageal veins drain to periesophageal venous network & to inferior thyroid vein in the venous network & to inferior thyroid vein in the neck and to azygos and hemiazygos veins in the neck and to azygos and hemiazygos veins in the thorax.thorax.


Lymphatic drainage:Lymphatic drainage:• The lymphatic plexus are located in the mucosa and the The lymphatic plexus are located in the mucosa and the

muscular layers drained to mediastinal lymph nodes.muscular layers drained to mediastinal lymph nodes.

Clinical facts about the esophagusClinical facts about the esophagus• Cervical esophagus is 5 cm in length and 15cm distance Cervical esophagus is 5 cm in length and 15cm distance

from upper incisorsfrom upper incisors• Thoracic esophagus is 12cm in length and 25cm Thoracic esophagus is 12cm in length and 25cm

distance from upper incisorsdistance from upper incisors• Lower esophagus is 2cm in length & 38cm from upper Lower esophagus is 2cm in length & 38cm from upper

incisors incisors

Physiology of The EsophagusPhysiology of The Esophagus

The function of the esophagus is to transport the The function of the esophagus is to transport the ingested material from the pharynx to the ingested material from the pharynx to the stomach by peristaltic waves.stomach by peristaltic waves.Primary peristalsis:Primary peristalsis: Triggered by the swallowing Triggered by the swallowing center in the brain stem and the contraction center in the brain stem and the contraction wave travel at speed 2cm/s.wave travel at speed 2cm/s.Secondary peristalsis: Secondary peristalsis: Induced by esophageal Induced by esophageal distension from retained bolus, refluxed material. distension from retained bolus, refluxed material. Its role is to clear the esophagus form retained Its role is to clear the esophagus form retained bolus.bolus.


Tertiary peristalsis:Tertiary peristalsis: Are non peristaltic Are non peristaltic contraction and play no known physiological contraction and play no known physiological role. Frequently observed in elderly people role. Frequently observed in elderly people called (presbyesophagus), also seen in motility called (presbyesophagus), also seen in motility disorders.disorders.


Mechanism of swallowingMechanism of swallowing• During the pharyngeal phase of swallowing, a During the pharyngeal phase of swallowing, a

primary peristalsis is created, that relax the UES primary peristalsis is created, that relax the UES and forces the food bolus through it. The UES and forces the food bolus through it. The UES remain constricted and has resting pressure of remain constricted and has resting pressure of 20-60 mmHg. The peristaltic waves travel at the 20-60 mmHg. The peristaltic waves travel at the speed 2cm/s and reach the stomach in 5-10 speed 2cm/s and reach the stomach in 5-10 secondsecond


• Secondary peristalsis get initiated if the primary Secondary peristalsis get initiated if the primary peristalsis failed to get food to the stomach and peristalsis failed to get food to the stomach and the esophagus became distended.the esophagus became distended.


AchalasiaAchalasia

Spastic esophageal motility disorders such as Spastic esophageal motility disorders such as diffuse esophageal spasm, nutcracker diffuse esophageal spasm, nutcracker esophagus and hypertensive LESesophagus and hypertensive LES

Secondary esophageal motility disorders related Secondary esophageal motility disorders related to scleroderma, diabetes, alcohol consumption ..to scleroderma, diabetes, alcohol consumption ..


Achalasia (failure to relax)Achalasia (failure to relax)• Is the only esophageal motility disorder with an Is the only esophageal motility disorder with an

established pathology.established pathology.• The predominant pathophysiology of achalasia The predominant pathophysiology of achalasia

is the loss of Auerbach ganglion cells from the is the loss of Auerbach ganglion cells from the wall of the esophagus ,starting at LES and wall of the esophagus ,starting at LES and progress proximally.progress proximally.

• Incidence is 1-3 / 100,000 population / year.Incidence is 1-3 / 100,000 population / year.


Achalasia (failure to relax)Achalasia (failure to relax)• Characterized by failure of LES to relax Characterized by failure of LES to relax

completely during swallowingcompletely during swallowing• The loss of nerve ganglion along the esophageal The loss of nerve ganglion along the esophageal

wall cause a peristalsis leading to stasis of food wall cause a peristalsis leading to stasis of food and subsequent dilatation.and subsequent dilatation.

• Manometry may reveal elevated LES pressure > Manometry may reveal elevated LES pressure > 40 mmHg in 60% of patients.40 mmHg in 60% of patients.


Spastic esophageal motility disordersSpastic esophageal motility disorders• Diffuse esoph.spasm (DES):Diffuse esoph.spasm (DES): This is probably This is probably

related to fragmental degeneration of vagal related to fragmental degeneration of vagal nerve fibers.nerve fibers.

• Characterized by simultaneous, repetitive high Characterized by simultaneous, repetitive high pressure muscular contraction within the pressure muscular contraction within the esophagus.esophagus.

• The muscular wall is thickened, hypertrophied The muscular wall is thickened, hypertrophied and is hypersensitive to stretching.and is hypersensitive to stretching.


Scleroderma esophagusScleroderma esophagus• Collagen vascular disease.Collagen vascular disease.• Characterized by smooth muscle hypertrophy Characterized by smooth muscle hypertrophy

and mainly involve the distal 2/3 of esophagus and mainly involve the distal 2/3 of esophagus gradually lead to loss of peristalsis and gradually lead to loss of peristalsis and weakening of LES causing GERD.weakening of LES causing GERD.

• Involve the esophagus in 80% of patient with Involve the esophagus in 80% of patient with scleroderma.scleroderma.


Clinical HistoryClinical History Achalasia:Achalasia:• The hall mark is dysphagia to both solid and The hall mark is dysphagia to both solid and

liquid.liquid.• Regurgitation commonly occur at night Regurgitation commonly occur at night • Retrosternal chest pain.Retrosternal chest pain.• Heartburn occur in 30% of patients which may Heartburn occur in 30% of patients which may

be related to food fermentation and lactic acid.be related to food fermentation and lactic acid.


Clinical HistoryClinical History Spastic motility disordersSpastic motility disorders• Chest pain is the hall mark which may mimic Chest pain is the hall mark which may mimic

angina due to esophageal distension.angina due to esophageal distension.• Dysphagia to both solid and liquid.Dysphagia to both solid and liquid. SclerodermaScleroderma• Involve the esophagus in 80% of patients. Involve the esophagus in 80% of patients. • Symptoms are related to GERD [dysphagia, Symptoms are related to GERD [dysphagia,

heartburn and regurgitation].heartburn and regurgitation].


Problems to be consideredProblems to be considered Coronary Artery Disease (CAD).Coronary Artery Disease (CAD). Mechanical obstruction (tumor).Mechanical obstruction (tumor). Achalaisa and scleroderma increase risk of Achalaisa and scleroderma increase risk of

esophageal cancer.esophageal cancer.


DiagnosisDiagnosis HistoryHistory Physical examination-unremarkablePhysical examination-unremarkable Barium SwallowBarium Swallow

Bird peak appearance- classic Bird peak appearance- classic for for achalasiaachalasia

Rosary beads or corkscrew-Rosary beads or corkscrew-classic for DESclassic for DES


DiagnosisDiagnosis Esophagoscopy to rule out tumor or Esophagoscopy to rule out tumor or

inflammatory lesion but not to diagnose inflammatory lesion but not to diagnose esophageal dysmotility.esophageal dysmotility.

Manometry study is to evaluate the esophageal Manometry study is to evaluate the esophageal motor pattern, contraction amplitude and LES motor pattern, contraction amplitude and LES pressure.pressure.

Flexible Gastro-EsophagoscopeFlexible Gastro-Esophagoscope

Esophageal Manometry Cath.Esophageal Manometry Cath.

Esophageal ManometryEsophageal Manometry

AchalasiaAchalasia


TreatmentTreatment The primary goal is symptomatic relief directed The primary goal is symptomatic relief directed

at relieving the physiologic obstruction at the at relieving the physiologic obstruction at the level of LES by surgical or balloon dilatation.level of LES by surgical or balloon dilatation.

Nitrate and Ca channel & B blockers are Nitrate and Ca channel & B blockers are currently used in all patients with esophageal currently used in all patients with esophageal motility disorders.motility disorders.

Antireflux therapy e.g proton pump inhibitors Antireflux therapy e.g proton pump inhibitors (esomeprazol) + prokinetic such as motilium or (esomeprazol) + prokinetic such as motilium or erythromycin.erythromycin.


TreatmentTreatment Botulinum toxin injection (Botox):Botulinum toxin injection (Botox): Injected edoscopically Injected edoscopically

in 4 quadrants into LES in treating patient with achalasia.in 4 quadrants into LES in treating patient with achalasia.Botox is a potential inhibitor of acetylcholine release Botox is a potential inhibitor of acetylcholine release from nerve terminals. It is indicated in those pt. not from nerve terminals. It is indicated in those pt. not candidate for surgery or refuse surgery.candidate for surgery or refuse surgery.

Endoscopic balloon dilatation:Endoscopic balloon dilatation: This is the standard This is the standard therapy for patients with achalasia.therapy for patients with achalasia.

The mechanism based on disruption of circular muscle.The mechanism based on disruption of circular muscle. Balloon dilatation response rate is 70%Balloon dilatation response rate is 70%


TreatmentTreatment Surgery (Heller Myotomy): Surgery (Heller Myotomy): surgical treatment surgical treatment

targets to disrupt the LES.targets to disrupt the LES. This can be performed thoracoscopic or This can be performed thoracoscopic or

laparascopic.laparascopic. Outcome is excellent 80-100% response rate.Outcome is excellent 80-100% response rate.

Normal EsophagusNormal Esophagus

Barrett Esophagus

Risk factorsAgeMaleGERDSmoking

Definition: Intestinal metaplasia

Treatment:Antireflux therapyMedical: Pump inhibitors (esomeprazole)

Prokinetic meds (Motilium) Annual Surveillance (esophagoscopy)

Surgical: Fundoplication + Annual Surveillance

Complications: DysplasiaAdenocarcinoma <1%/Yr

Esophageal Motility Disorders Iskander Al-Githmi, MD, FRCSC, FRCSC (Ts & CDS), FACS, FCCP Consultant...

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Transcript of Esophageal Motility Disorders Iskander Al-Githmi, MD, FRCSC, FRCSC (Ts & CDS), FACS, FCCP Consultant...