Adobe Systems Diseases of the Esophagus Adobe Systems Surgical Diseases of the Esophagus 1.Hiatal Hernia 2.Reflux esophagitis 3.Esophageal motility disorders 4.Cancer 5.Esophageal disruption and trauma Adobe Systems Clinical Divisions of the Esophagus General direction of the oesophagus is vertical Presents two or three slight curvatures At commencement, in the median line Inclines to the left side at the root of the neck Gradually passes to the middle line Again deviates to the left Oesophagus is the narrowest region of alimentary tract except vermiform appendix. During its course it has three indentations: ◦At 15 cm from incisor teeth is crico-pharyngues sphincter (normally closed) (UES) ◦At 25 cm aortic arch and left main bronchus ◦At 40 cms where it pierces the diaphragm where a physiological sphincter is sited (LES) body-fig1 Source: http://www.ispub.com/ispub/ijorl/volume_4_number_2_33/office_procedure_for_management_of_foreign_bo dy_cricopharynx/body-fig1.jpg Adobe Systems Esophagus ̶Upper 1/3 is skeletal muscle ̶Lower 1/3 is smooth muscle ̶middle is combo of both ̶Contains two sphincters ̶Lined by squamous epithelium ̶< 3 cm below diaphragm ̶ Adobe Systems Vascular Supply to Esophagus DSCF0192 Adobe Systems Nerve Supply of the Esophagus DSCF0199 Adobe Systems Motility -- Manometry Adobe Systems Esophageal Dysmotility Adobe Systems Factors Affecting Reflux Adobe Systems Esophageal Function Tests Hiatus hernia Pathophysiology & Classification Type I - sliding Type II - paraesophageal Type III - para and sliding component Type IV - other viscera involved Adobe Systems Clinical Presentation ̶postprandial fullness (63%), ̶Reflux (31%), ̶Dysphagia (34%), ̶Bleeding (24%) ̶Regurgitation/vomiting (36%) ̶Dyspnea (11%) ̶ Adobe Systems Hiatus Hernia - Clinical Presentation ̶Sliding hiatal hernias are more common than paraesophageal hernias by 100:1 ̶The lower esophageal sphincter mechanism becomes incompetent ̶Reflux of acid gastric juice produces a chemical burn ̶Degree of mucosal injury is a function of the duration of acid contact and not a disease of hyperacidity Adobe Systems Hiatus Hernia - Clinical Presentation ̶ ̶Continued inflammation of the distal esophagus may lead to mucosal erosion, ulceration, and eventually scarring and stricture ̶Predominantly in women who have been pregnant ̶Men and women with increased intraabdominal pressure Adobe Systems Clinical Presentation – Type I hernia ̶ ̶Type I hiatal hernia with reflux is frequently found in patients who are overweight. ̶Many patients with type I hiatal hernia have no symptoms. ̶A burning epigastric or substernal pain or tightness ̶Usually the pain does not radiate ̶May be described as a tightness in the chest and can be confused with the pain of myocardial ischemia Adobe Systems Hiatus Hernia - Clinical Presentation ̶Worse when the patient is supine or leaning over ̶Antacid therapy frequently improves the symptoms. ̶A lump or feeling that food is stuck beneath the xyphoid ̶Alcohol, aspirin, tobacco, and caffeine, may exacerbate the symptoms ̶Late symptoms of dysphagia and vomiting usually suggest stricture formation Adobe Systems Hiatus Hernia - Clinical Presentation Type II hernias ̶Generally produce no symptoms until they incarcerate and become ischemic ̶ ̶Dysphagia, bleeding, and occasionally respiratory distress are the presenting symptoms. ̶ Adobe Systems Diagnosis- Hiatus Hernia ̶Usually suspected based on the patient's history ̶Weight loss is a feature due to distal esophageal stricture ̶Hiatal hernia and reflux esophagitis can be confirmed by fluoroscopy during a barium swallow, GFS, CT scan Adobe Systems Barium Swallow – Type I hiatus Hernia Adobe Systems Diagnosis – Hiatus Hernia ̶ ̶Esophagogastric endoscopy and biopsy of the inflamed esophagus ̶Manometry may show a loss of the lower esophageal high-pressure area ̶ Adobe Systems Treatment – Hiatus Hernia Medical Therapy ̶1.Avoidance of gastric stimulants (coffee, tobacco, and alcohol). ̶2.Elimination of tight garments that raise intraabdominal pressure, such as girdles or abdominal binders. ̶3.The regular use of antacids ( coat the esophagus), and antacid mints (Tums and Rolaids) to provide a steady stream of protection. ̶Proton pump inhibitors ( omeprazole) to increase the pH of the refluxed gastric juice ̶Metoclopramide to stimulate gastric emptying without stimulating gastric, biliary, or pancreatic secretions ̶ ̶ Adobe Systems Treatment – Hiatus Hernia ̶4. Abstinence from drinking or eating within several hours of sleeping. ̶5. Sleeping with the head of the bed elevated to reduce nocturnal reflux. ̶6. Weight loss in obese patients. ̶ About one third of patients fail to respond to initial medical treatment, and half of those who initially respond will ultimately relapse and require surgery. Adobe Systems Treatment Hiatus Hernia -- Surgical ̶Correct the anatomic defect ̶Prevent the reflux of gastric acid into the lower esophagus by reconstruction of a valve mechanism Adobe Systems Fundoplication operation The gastric fundus is wrapped around the abdominal esophagus Fig HIATUS HERNIA Fig. 18.3 A fundoplication operation. The gastric fundus is wrapped around the abdominal esophagus. Adobe Systems Hiatus Hernia Complications post surgery ̶inability to belch or vomit- the "gas-bloat" syndrome ̶Dysphagia ̶Disruption of the repair with recurrent symptoms ̶intraabdominal infection ̶esophageal perforation ̶Splenic injury ̶ ̶ Adobe Systems Achalasia Epidemiology ◦- 1-2 per 200,000 population ◦- usually presents between ages 25 to 60 ◦- male=female ◦- Caucasians > others ◦- average symptom duration at diagnosis: 2-5 years ach-2 Achalasia means “failure to relax.” Incomplete LES relaxation without aperistalsis can be an early manifestation of achalasia, but infrequently. Adobe Systems Pathophysiology -degeneration of NO producing inhibitory neurons -loss of ganglionic cells in the myenteric plexus (distal to proximal) - vagal fiber degeneration - underlying cause: unknown -autoimmune? (antibodies to myenteric neurons in 50% of patients) - that affect relaxation of LES - Basal LES pressure rises Adobe Systems Mechanical End Result ̶dual disorder ̶LES fails to appropriately relax ◦resistance to flow into stomach ◦not spasm of LES but an increased basal LES pressure often seen (55-90%) ̶loss of peristalsis in distal 2/3 esophagus Adobe Systems Clinical Presentation ̶clinical presentation ̶solid dysphagia 90-100% (75% also with dysphagia to liquids) ̶post-prandial regurgitation 60-90% ̶chest pain 33-50% ̶pyrosis 25-45% ̶weight loss ̶nocturnal cough and recurrent aspiration ̶ Adobe Systems Diagnostic Work Up ̶plain film (air-fluid level, wide mediastinum, absent gastric bubble, pulmonary infiltrates) ̶barium esophagogram (dilated esophagus with taper at LES) Bird peak good screening test (95% accurate) ̶endoscopy +endosonography (rule out GE junction tumors, esp. age>60) ̶esophageal manometry (absent peristalsis, ¯ LES relaxation, & resting LES >45 mmHg) Adobe Systems Esophageal Motility Disorders Achalasia -- Diagnosis ̶Generally first confirmed roentgenographically by contrast studies of the esophagus ̶ ̶Dilation of the proximal esophagus is classic ̶ ̶Esophageal diverticula may be present at any level ̶ ̶Endoscopy -- one needs to be particularly careful to avoid diverticular perforation ̶ ̶Esophageal manometry Esophageal Motility Disorders Achalasia -- Diagnosis Endosonography Manometric Features Incomplete LES relaxation Elevated resting pressure (>45 mmHg) Aperistalsis of esophageal body Adobe Systems Esophageal Motility Disorders Achalasia -- Treatment ̶Medical treatment has generally not been helpful ̶Invasive endoscopic procedure --forceful dilation ̶Aplication of botulinum toxin ̶Surgical transaction of the muscle -- esophageal kardiomyotomy- Heller Adobe Systems Goals ̶reduce LES pressure and ̶increase emptying Adobe Systems Nitrates and Calcium Channel Blockers ̶Isosorbide dinitrate Reduces LES Pressure 66% for 90 min ̶Nifedipine Reduces LES pressure 30-40% for > 60 minutes ◦50-70% initial response; <50% at 1 year ◦limitations: tachyphylaxis and side-effects ̶ Adobe Systems Pneumatic Dilatation ̶Balloon dilatation to 300 psi ̶disrupt circular muscle ̶60-95% initial success; 60% at 5 years ̶recent series suggest 20-40% will require re-dilation ̶Success increases with repeat dilatations ̶risk of perforation 1-13% (usually 3-5%); death 0.2-0.4% achalasia_3 Adobe Systems Botulinum Toxin ̶90% initial response; 60% at 1 year ̶Needs repetitive sessions ̶ Surgical Treatment ◦ ◦surgical myotomy (open or minimally-invasive) ◦>90% initial response; 85% at 10 years; 70% at 20 years (85% at 5 years with min. inv. techniques) ◦<1% mortality; <10% major morbidity ◦10-25% acutely develop reflux, up to 52% develop late reflux Adobe Systems Esophageal Motility Disorders Esophageal Diverticulum ̶ ̶The second most common manifestation of esophageal motility disorders ̶ ̶ ̶Pulsion or Traction, depending on the mechanism that leads to their development Adobe Systems Esophageal Motility Disorders Esophageal Diverticulum ̶Upper third cervical esophageal diverticula - usually pulsion ̶Cervical diverticula, or Zenker's -- pulsion and are closely related to dysfunction of the cricopharyngeal muscle ◦a) complain of regurgitation of recently swallowed food or pills, choking, or a putrid breath odour ◦b) treated by excision of the diverticula and myotomy of the cricopharyngeal muscle Adobe Systems Esophageal Motility Disorders Esophageal Diverticulum – Zenker’s cow191-zenkers cow191-trac%20tic2 cow192-2 Zenker’s diverticulum resection Adobe Systems Esophageal Motility Disorders Esophageal Diverticulum ̶Middle-third esophageal diverticula are almost always traction, not related to an intrinsic abnormality in esophageal motility a) Result of mediastinal inflammation (usually inflammatory nodal disease from tuberculosis or histoplasmosis, with formation and subsequent contracture that places "traction" on the esophagus b) Usually asymptomatic and do not warrant treatment. ̶ ̶ Adobe Systems Esophageal Motility Disorders Esophageal Diverticulum ̶Diverticula of the distal third of the esophagus ̶ a) associated with dysfunction of the esophagogastric junction due to chronic stricture from acid reflux, antireflux surgical procedures, achalasia b) Excision of these diverticula should always be accompanied by correction of the underlying pathologic process ̶ showimage Adobe Systems Traumatic Esophageal Disorders Perforation. ̶Instrumentation by endoscopic and/or biopsy ̶Passage of blind nasogastric tubes ̶Instruments designed for dilation of strictures ̶Sengstaken-Blakemore tubes, balloon dilation for alchalasia ̶Boerhaave’s syndrome -- spontaneous perforation secondary to forceful vomiting (Plummer-Vinson) ̶Treatment requires aggressive surgical intervention ̶ Adobe Systems Traumatic Esophageal Disorders Perforation -- Symptoms ̶May be dramatic or occult ̶Profound shock ̶Mediastinal sepsis ̶Subcutaneous emphysema ̶Severe chest or abdominal pain ̶Hypotension ̶Diaphoresis ̶Nausea/Vomiting