1. Diseases of the esophagus
Jakub Szmytkowski
Dept. of General and Transplant Surgery
Ludwik Rydygier School of Medicine
Nicolaus Copernicus University, Bydgoszcz, Poland

2. Esophagus
 a muscular tube through which food passes from the pharynx to the stomach
22-28 cm long
 esophagus  Latin œsophagus,  Greek oisophagos, lit. "entrance for eating."

3. Esophagus - anatomy
continuous with the laryngeal part of the pharynx at the level of the C6 vertebra.
passes through posterior mediastinum in the thorax and enters abdomen through a hole in the diaphragm at the level of the tenth thoracic vertebrae (T10).
divided into cervical, thoracic and abdominal parts
due to the inferior pharyngeal constrictor muscle, the entry to the esophagus opens only when swallowing or vomiting

4. Esophagus - constrictions
has three anatomic constrictions at the following levels:
At the esophageal inlet, where the pharynx joins the esophagus, behind the cricoid cartilage (14–16 cm from the incisor teeth).
Where its anterior surface is crossed by the aortic arch and the left brocnhus (25–27 cm from the incisor teeth).
Where it pierces the diaphragm (36–38 cm from the incisor teeth).

5. Esophagus - sphincters
At rest, the esophagus is closed at both ends by the upper esophageal sphincter (UES) at the top, and the lower esophageal sphincter (LES) at the bottom.
LES constricted at all times other than during swallowing and vomiting to prevent the contents of the stomach from entering the esophagus.

6. Esophagus - histology mucosa
nonkeratinized stratified squamous epithelium: rapid turnover, protective effect due to the high volume transit of food, saliva and mucus.
lamina propria: sparse.
muscularis mucosae: smooth muscle
submucosa: Contains the mucous secreting glands (esophageal glands), and connective structures (papillae).
muscularis propria :
upper third, or superior part: striated muscle
middle third:  smooth + striated
inferior third: predominantly smooth muscles
fibroareolar adventitia
No serosa

8. Esophagus - pathologies
diverticulae
traction
pushing
achalasia
GERD
Barrett’s esophagus
burns
Esophageal varices
Neoplasms: benign / malignant

9. Esophageal diverticulae
an outpouching  of the esophageal wall
due to traction (inflammatory process) or pulsion
Zenker’s diverticulum – border between pahyrynx and esophagus, false
symptoms: regurgitation, halitosis, dysphagia, lump on the neck
diagnostics: endoscopy, contrast X-ray

10. Esophageal diverticulae - diagnostics

11. Esophageal diverticulae - treatment
Endoscopic: transection of the septum
Surgical: excision

12. Achalasia (cardiospasm)
Esophageal motility disorder, cause unknown
Incomplete LES relaxation, increased LES tone, lack of peristalsis
Difficulty swallowing, regurgitation, sometimes chest pain
Treatment: lifestyle changes (careful chewing, water with meals), Ca blockers, botulinum toxin (up to 6 mths), Heller myotomy

13. Grading of achalasia

14. Achalasia – X-ray findings

15. Heller myotomy

16. Gastro-espohageal reflux (GERD)
usually caused by changes in the barrier between the stomach and the esophagus, including abnormal relaxation of the LES, hiatal hernia
chronic symptom of mucosal damage caused by stomach acid coming up from the stomach into the esophagus
Symptoms: heartburn, coughing, regurgitation, chest pain
Causes: smoking, wrong dietary habits, obesity
Treatment: lifestyle changes, PPI’s, H2 blockers

17. Barret’s esophagus
an abnormal change (metaplasia) in the cells of the lower portion of the esophagus. When the normal stratified squamous epithelium lining of the esophagus is replaced by simple columnar epithelium with goblet cells (cells usually found lower in the gastrointestinal tract), Barrett's esophagus is diagnosed.
Associated with esophageal cancer

18. Nissen fundoplication

19. Esophagitis
Bacterial ,viral, fungal (AIDS, chemotherapy, diabetes, steroid therapy)

21. Esophageal burns
Acid burns: coagulative necrosis, self – limiting, rarely perforate, often strictures
Base burns: liquefactive necrosis  submucosal thrombosis often lead to perforation and mediastinitis
Do not provoke vomiting  second exposition
Early endoscopy, do not perform endoscopy betwee 5-15 day postburn
Endoscopic treatment of strictures

22. Caustic esophageal burn

23. Espohageal perforation
56–90% iatrogenic (endoscopy, endoscopic dilation of strictures, nasogastric tube placement, Sengstaken tube, endoscopy for GI bleeding)
upon forceful vomiting and / or cough
Abdominal, thoracic trauma
foreign body ingestion

24. Boerhaave syndrome
Spontaneous perforation of the oesophagus due to vomiting
in most cases   the tear occurs at the left postero-lateral aspect of the distal oesophagus and extends for several centimeters
fatal in the absence of therapy
Mackler's triad which includes chest pain, vomiting and subcutaneous emphysema, while classical, is only present in 14%
 pleural effusion (80%)
pain can occasionally radiate to the left shoulder
Hamman's sign - a crunching, rasping sound, synchronous with the heartbeat, heard over the precordium in spontaneous mediastinal emphysema produced by the heart beating against air-filled tissues

25. Esophageal rupture - treatment
Broad – spectrum antibiotics
Surgical repair
Anti – shock therapy
Chest / mediastinum drainage
Nil by mouth, TPN
Mortality despite treatment 25%

26. Mallory – Weiss syndrome
Longitudinal tear of mucous membrane
Most frequently due to vomiting
Treatment: endoscopy

27. Esophageal strictures

28. Esophageal varices
extremely dilated sub-mucosal veins in the lower third  of the esophagus
most often a consequence of portal hypertension, commonly due to cirrhosis; patients with esophageal varices have a strong tendency to develop bleeding
Diagnosis: endoscopy
Treatment: endoscopic banding, surgery
Haemorrhage, if endoscopy unavailable: Sengstaken tube

30. Sengstaken – Blakemore tube

31. Esophagus - neoplasms Benign: myoma, lipoma, fibroma, hemangioma
Malignant: squamous cell cancer, adenocarcinoma
Third most frequent malignancy of the GI tract
Most of the people diagnosed with esophageal cancer have late-stage disease, because symptoms usually do not appear until half of the lumen is obstructed, by which point the tumor is fairly large

32. Esophageal cancer - diagnosis

33. Esophageal cancer – radical treatment

34. Esophageal cancer –palliative treatment
Dilation
Brachyterapy
Laser therapy
Endoscopic stenting

35. Esophageal stent