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The esophagus1st LectureM.A.Kubtan1 . .M.A.Kubtan2 The anatomy and physiology of the esophagus

Their relationship to diseaseThe clinical features.Investigations .Treatment of benign and malignant disease with particular reference to the common adult disordersM.A.Kubtan3

LEARNING OBJECTIVES To understand

The esophagus is a muscular tube.Approximately 25 cm long .Mainly occupying the posterior mediastinum .Extending from the upper esophageal sphincter (the cricopharyngeus muscle) in the neck to the junction with the cardia of the stomach.M.A.Kubtan4Surgical anatomy

The upper esophagus, including the upper sphincter, is striated.This is followed by a transitional zone of both striated and smooth muscle .There is only smooth muscle in the lower half of the esophagus .

M.A.Kubtan5Muscular Type

It is lined throughout with squamous epithelium.

M.A.Kubtan6Histological lining

The parasympathetic nerve supply is mediated by branches of the vagus nerve .Has synaptic connections to the myenteric (Auerbachs) plexus.Meissners sub mucosal plexus is sparse in the esophagus.M.A.Kubtan7Nerve supply

The upper sphincter consists of powerful striated muscle.The lower sphincter is more subtle, and is created by the asymmetrical arrangement of muscle fibers in the distal esophageal wall just above the esophagogastric junction.M.A.Kubtan8Esophageal sphincters

Remember the distances 15, 25 and 40 cm for anatomical locationduring endoscopy

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The main function of the esophagus is to transfer food from the mouth to the stomach in a coordinated fashion.The initial movement from the mouth is voluntary.

M.A.Kubtan10Physiological Function

Sequential contraction of the oropharyngeal musculature .Closure of the nasal and respiratory passages .Cessation of breathing .Opening of the upper esophageal sphincter .Beyond this level, swallowing is involuntary.The body of the esophagus propels the bolus through a relaxed lower esophageal sphincter (LES) .

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The pharyngeal phase of swallowing

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The coordinated esophageal wave that follows a conscious swallow is called primary peristalsis.It is under vagal control .Also there are specific neurotransmitters that control the LES.

M.A.Kubtan13primary peristalsis

The upper esophageal sphincter is normally closed at restServes as a protective mechanism against regurgitation of esophageal contents into the respiratory passages.It serves to stop air entering the esophagus other than the small amount that enters during swallowing.M.A.Kubtan14Upper Esophageal Sphincters Function

The LES is a zone of relatively high pressure that prevents gastric contents from refluxing into the lower esophagus .It opens in response to a primary peristaltic wave .It relaxes to allow air to escape from the stomach and at the time of vomiting.

M.A.Kubtan15LES Function

Food .Gastric distension . Gastrointestinal hormones . Drugs and smoking.M.A.Kubtan16Factors influence LES sphincter tone

The arrangement of muscle fibers, their differential responses to specific neurotransmitters. The relationship to diaphragmatic contraction.The normal LES is 34 cm long .LES has a pressure of 1025 mmHg.M.A.Kubtan17

Factors contributing to LES Function

Dysphagia .Odynophagia .Regurgitation and reflux .Chest pain .

M.A.Kubtan18Esophageal Symptoms

Described as difficulty with swallowing.Food fails to enter the esophagus .Food stays in the mouth .Food enters the airway causing coughing or spluttering.M.A.Kubtan19Dysphagia

Oral or pharyngeal .Food fails to enter the esophagus .Stays in the mouth or enters the airway causing coughing or spluttering.Causes are chronic neurological or muscular diseases or inflammatory or traumatic origin.

M.A.Kubtan20Dysphagia in Voluntary Phase

characterized by :A sensation of food sticking.Is often informative of the likely diagnosis.

M.A.Kubtan21dysphagia occurs in the involuntary phase

Acute .Chronic .Can affect solids .Can affect fluids .Can affect solids & fluids .Can be intermittent .Can be progressive.M.A.Kubtan22Mode of Dysphagia

pain on swallowing.Patients with reflux esophagitis often feel retrosternal discomfort .Is a feature of infective esophagitis and may be particularly severe in chemical injury.

M.A.Kubtan23Odynophagia

Regurgitation should strictly refer to the return of esophageal contents from above a functional or mechanical obstruction.Reflux is the passive return of gastro duodenal contents to the mouth as part of the symptomatology of gastro esophageal reflux disease (GERD).

M.A.Kubtan24Regurgitation and reflux

Loss of weight .Anemia .Cachexia .Change of voice .Cough or dyspnoea .

M.A.Kubtan25Symptoms & Signs accompany regurgitation and/or reflux.

Similar in character to angina pectoris .

M.A.Kubtan26Chest pain

Radiography .Endoscopy .Endosonography .Esophageal manometry .24-hour pH recording .

M.A.Kubtan27Investigations

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Dilatation of strictures .Thermal recanalisation .

M.A.Kubtan29Therapeutic procedures

Difficulty in swallowing described as food or fluid sticking (esophageal dysphagia) Must rule out malignancy .Pain on swallowing (Odynophagia)Suggests inflammation and ulceration .Regurgitation or reflux (heartburn) Common in gastro-esophageal reflux disease .Chest pain Difficult to distinguish from cardiac pain M.A.Kubtan30

Correlation of Symptoms of esophageal disease

The most common impacted material is food.Usually occurs above a significant pathological lesion .Plain radiographs are often useful for foreign bodies .Modern denture materials are not always radiopaque .Diagnosis made by endoscopy .M.A.Kubtan31FOREIGN BODIES IN THE ESOPHAGUS

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