1. Esophagus Anatomy, Physiology, and Diseases
Alan Chu
March 13, 2013

2. Anatomy 18 – 26cm from UES to LES Esophageal wall layers
Mucosa, submucosa, muscularis propia, adventitia
Proximal 33% skeletal muscle, middle 35-40% mixed, distal 50-60% smooth muscle
Smooth muscle innervated by CN X.
Auerbach plexus: peristalsis
Meissner’s plexus: afferent input

3. Oropharyngeal dysphagia
Difficulty initiating swallow followed by choking/coughing
Esophageal dysphagia
Anatomaic vs neuromuscular defect
Solid vs solid+liquid dysphagia

4. Dysphagia best assessed by MBSS
Demonstrates presence of oropharyngeal dysfunction and aspiration

5. Standard upper endoscope 9mm, transnasal endoscope 4mm
Z line = GE junction
In barrett’s squamocolumnar junction more proximal than GEJ

6. Esophageal Motility disorder
Acalasia
Insufficient LES relaxation
Dilated distal 2/3 esophagus with bird’s beak appearance at LES on esophagram
Upper endoscopy to r/o pseudoachalasia 2/2 to GEJ tumor
Tx: balloon dilation to disrupt circular muscle fibers at LES; Heller’s myotomy via laproscopic approach; Botox/CCB/nitrates

7. Esophageal Motility Disorder
Diffuse Esophageal Spasm
Simultaneous and repetitive contraction in esophagus body with normal LES
Cockscrew esophagus on esophagram
Tx:nitrates/CCB
Nutcraker esophagus
High-amplitude peristalsis
Ineffective esophageal motility
High incidence in patients with GERD

8. Strictures Dysphagia when <15mm
Tx: dilators (Bougies, Savary dilator, balloon dilator)
Risk of perforation 0.5%, higher in XRT induced strictures
Goal >15mm

9. Rings or Webs
Ring
Circumferential, muscle or mucosa, at distal esophagus
Schatzki’s ring
Eosinophilic Esophagitis (>15 eosinophils/hpf in mucosa)
Web
Part of lumen, mucosal, proximal esophagus
Plummer Vinson

10. GERD Chronic symptoms 2/2 abnormal reflux of gastric contents
Heartburn, acid regurgitation, dysphagia, odynophagia, belching
Tx: lifestyle modification, H2 blockers (60%), PPI (90%), surgery
Atypical extraesophgeal symptoms: asthma, chest pain, cough, laryngitis, dental erosion

11. Barrett’s esophagus
Pale pink squamous mucosa replaced with salmon pink columnar mucosa
LSBE vs SSBE (<3cm)
Risk of esophageal adenoCA 0.5% per year

12. Neoplasia AdenoCA SCC Distal esophagus or GEJ Barrett’s
Mid-esopahgus and proximal esophagus
Tobacco, EtOH use in AA

13. Diverticula Zenker’s diverticulum Midesophageal diveticula
Epiphrenic diverticula
Intramural pseudodiverticulosis

14. Transnasal Esophagoscopy
Alan Chu
March 13, 2013

15. Transnasal esophagoscope
3.1 – 5.1mm
Performed without sedation
Shorter procedure time
66% cost of transoral esophagoscope
Conventional Transoral esophagoscope mm
Performed with sedation
Longer procedure time

16. Transnasal esophagoscope Conventional Transoral esophagoscope
Smaller biopsy size
Conventional Transoral esophagoscope

17. Indications Head and Neck SCC Barrett’s esophagus Stricture dilation
Replaces panendoscopy
Barrett’s esophagus
Surveillence of Barrett’s esophagus
Stricture dilation
Balloon dilation
Tracheoesophageal puncture

18. Technique Topical anesthetic and decongestant
Pt’s head flexed and swallows as scope approaches cricoid level
Z-line (squamocolumnar junction) visualized
Retroflex view of gastric cardia