Ali Jassim Alhashli, BSc www.alhashli.com Kingdom of Bahrain Arabian Gulf University College of Medicine and Medical Sciences GI System – Review Problem (3) – Esophagus Ali Jassim Alhashli, BSc www.alhashli.com

Anatomy It is a muscular tube of 25 cm length which begins at the level of lower border of C6. It is divided into 3 parts: Superior third: striated muscle only. Middle third: striated + smooth muscles. Inferior third: smooth muscle only. There are 3 main areas of narrowing (which can be detected by barium swallow): At the level of cricopharyngeus muscle. Where the left mainstem bronchus and aortic arch cross. At the hiatus of diaphragm (at the level of T10). Remember the vertebral levels at which the following traverse the diaphragm: T8 = Inferior Vena Cava (IVC). T10 = esophagus. T12 = aorta. There are 2 sphincters of the esophagus: Upper Esophageal Sphincter (UES = formed by cricopharyngeus muscle): it prevents the passage of excess air into the stomach during breathing. Lower Esophageal Sphincter (LES = physiological sphincter): it prevents the reflux of gastric contents into the esophagus. Histology: non-keratinized stratified squamous epithelium.

Definition: it is the failure of lower portion of esophagus to relax during swallowing which can be caused by 3 mechanisms: Complete absence of peristalsis in esophageal body. Impaired relaxation of LES after swallowing. Increased resting tone of LES. This in turn will result in elevation of intraluminal esophageal pressure and esophageal dilation. Signs and symptoms: Dysphagia (for both solids and liquids). Regurgitation of food. Severe halitosis. Diagnosis: Barium swallow: distal bird’s beak sign. Esophageal motility study: increased LES tone. Treatment: Medical management: Drugs which relax LES: nitrates or Botox injections. Endoscopic dilation: has a lower success rate and a higher complication rate. Surgical management: esophagomyotomy ± fundoplication (treatment of choice). Complications: Squamous cell carcinoma of esophagus. Aspiration pneumonia. Achalasia

Tracheo-esophageal Fistula Tracheoesophageal (TE) fistula: Definition: incomplete separation of esophagus and trachea. Signs and symptoms: Respiratory distress and chocking following the first feed. Postprandial regurgitation. Excess drooling and salivation. There are 5 types of TE fistula: Type-A: pure esophageal atresia. Type-B: esophageal atresia with proximal TE fistula. Type-C (most common): esophageal atresia with distal TE fistula. Type-D: esophageal atresia with proximal and distal TE fistula. Type-E: no esophageal atresia with TE fistula. Diagnosis: Inability to pass feeding tube. CXR: tube coiled in upper esophagus. AXR: presence of air in the stomach. If air is not present, this might indicate the presence of esophageal atresia without TE fistula. Notice that TE fistula is associated with: Polyhydramnios. Pre-term birth. Small for gestational age. Treatment: Decompression of the blind esophageal pouch with constant suction. Prophylactic antibiotics (to prevent complications of aspiration). Search for other anomalies (especially cardiac and renal). Surgical repair: Ligation of fistula and insertion of gastrostomy tube. Anastomosis of the two ends of esophagus (jejunal or colonic grafts are used). Tracheo-esophageal Fistula

Tracheo-esophageal Fistula

Plummer-Vinson Syndrome and Esophagitis Plummer-Vinson Syndrome (PVS): Epidemiology: middle-aged females. Clinical presentation: Iron-deficiency anemia. Glossitis. Esophageal web: which is a thin extension from esophageal mucosa made from squamous cells and occurs mostly in hypopharnyx producing dysphagia mostly to solids. Diagnosis: barrium swallow. Treatment: Treat iron-deficiency anemia with ferrous sulfate. Treat esophageal web with dilation procedures. Esophagitis: Definition: infection/inflammation of the esophagus. Etiology: Candidal albicans in patients with: HIV and CD4 count > 200 cells/mm3. Diabetics. Ingestions of medications or caustic substances. Clinical manifestations: progressive odynophagia especially when swallowing food (why?) → due to mechanical rub of food against the inflamed esophagus. Diagnosis: In HIV patients, assume it is Candida and start treatment with systemic anti-fungal (fluconazole). Regression of symptoms confirm your diagnosis. Otherwise, do upper GI endoscopy with biopsy to determine the cause. If esophagitis is caused by a medication or caustic substance → this will be determined from history. Plummer-Vinson Syndrome and Esophagitis

Diseases of The Esophagus Plummer-Vinson syndrome Esophagitis caused by Candida albicans

Zenker Diverticulum and Mallory-Weiss Syndrome Definition: it is outpouching of posterior pharyngeal constrictor muscles at the back of the pharynx (simply: outpouching of posterior pharynx). Clinical manifestations: Dysphagia: inability to initiate swallowing because it is a proximal problem. Halitosis (bad breath). Patient waking up at night with undigested, regurgitated food on his pillow which has been eaten several day ago  Diagnosis: barrium swallow. Notice that endoscopy is contraindicated due to the high risk of perforation. Treatment: surgical resection. Mallory-Weiss syndrome: Etiology: non-transmural (not involving the whole wall) tears in lower esophagus due to repeated retching and vomiting (especially in alcoholics). PAINLESS upper GI bleeding. Melena (black stool) when amount of blood is < 100ml. Hematemesis: if there is continuous vomiting. Diagnosis: upper GI endoscopy. Treatment: Most cases resolve spontaneously. If there is severe bleeding: inject the area with epinephrine or perform cauterization. Zenker Diverticulum and Mallory-Weiss Syndrome

Zenker Diverticulum and Mallory-Weiss Syndrome Mallory-Weiss syndrome

GERD and Barrett’s Esophagus Gastro-Esophageal Reflux Disease (GERD): Definition: In GERD, there is a backflow of gastric content into the eophagus due to relaxation of LES. Etiology: this can be idiopathic or precipitated by factors which are lowering LES pressure such as nicotine, alcohol, caffeine, chocolate, peppermint and anticholinergics. GERD occurs particularly when patient is lying down. Clinical manifestations: epigastric pain/substernal chest pain, bad metal-like taste in the mouth, sore throat, coughing, wheezing and hoarsness. Diagnosis: Most accurate with 24-hour pH monitoring (usually not necessary when diagnosis is clear from clinical presentation of the patient). Treatment: If patient has MILD, INTERMITTENT symptoms → use H2-blockers (such as ranitidine). Gold-standard therapy: PPIs (omeprazole). In patients not responding to omeprazole → surgery to tighten LES (Nissen fundoplication). Lifestyle modifications: avoid nicotine, alcohol, caffeine, spicy/fatty food and late night meal. Barrett’s esophagus: Definition: it is a complication of long-standing GERD in which the normal squamous epithelium in distal esophagus will be changed to columnar epithelium and predisposing the patient to develop esophageal adenocarcinoma (0.5% risk). Patients with Barrett’s esophagus must undergoe endoscopy every 2-3 years to exclude dysplasia or esophageal adenocarcinoma. If there is low-grade dysplasia: you must repeat endoscopy in 3-6 months to see if the dysplasia has progressed or resolved. If there is high-grade dysplasia: patient must undergo surgical removal of the distal part of esophagus. Treatment: PPIs (omeprazole). GERD and Barrett’s Esophagus

GERD and Barrett’s Esophagus

GERD and Barrett’s Esophagus

Esophageal Cancer Epidemiology: The increasing prevalence of adenocarcinomas (due to Barrett’s esophagus) as compared to what was mostly squamous cell carcinoma is shifting the epidemiology of esophageal cancer. Age: < 50 years. Gender: males. <50% of patients have unresectable disease at the time of presentation. Prognosis: 5-year survival rate = 15% Risk factors: Smoking. Alcohol. Smoked food. Achalasia. GERD/Barrett’s esophagus. Signs and symptoms: Dysphagia: first for solids and later for both solids and liquids. Notice that dyspahgia does not develop until <60% of esophageal lumen is obstructed. Pain on swallowing. Weight loss. Diagnosis: Barium swallow (initial diagnostic test). Endoscopy: to visualize the mass and obtain specimens for biopsy. Notice that: Adenocarcinoma is found in distal esophagus. Squamous cell carcinoma is found in middle and lower thirds of esophagus. Staging: CXR, abdomeno-pelvic CT-scan. Treatment: If disease is limited to the esophagus: surgical resection. If disease is advanced: chemotherapy to promote tumor shrinkage and palliate symptoms. Esophageal Cancer