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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