Esophageal Diseases

Published on 16/04/2015 by admin

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Last modified 22/04/2025

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5 Esophageal Diseases

Anatomy of the Esophagus

image

Esophagus in Situ

• Fibromuscular tube (~25 cm) running from the pharynx in the neck, through the thorax and diaphragm, to the stomach in the abdomen
• Runs just posterior to the trachea and anterior to vertebral bodies in the neck and superior mediastinum
• Runs just posterior to the heart (left atrium and left ventricle) in the posterior mediastinum
• Tends to run to the left below T4 but is pushed to the center by the arch of the aorta and the root of the left lung
• Esophageal hiatus of the diaphragm is to the left of midline, at the level of the T10 vertebra.
• Upper esophageal sphincter: circular muscle of the superior esophagus, including the cricopharyngeus, the first region of anatomical constriction
• Also compressed in its course by 3 structures, as seen on barium swallow (when expanded)

image Arch of the aorta
image Left main bronchus
image Diaphragm: passes between the superior fibers of the right crus

• Ends at the cardial orifice of the stomach, left of midline
• Retropharyngeal danger space: possibility of infection spreading retroesophageally into the thorax

Microscopic Anatomy

Mucosa

• Highly folded stratified squamous epithelium, with walls in apposition unless distended by swallowing
• Mucous glands more numerous inferiorly

Tunica Muscularis

• Inner circular: continuous superiorly with the circumferential fibers of the inferior pharyngeal constrictor
• Outer longitudinal

image Upper third is striated (voluntary muscle) like the pharynx.
image Middle third is a combination of striated and smooth muscle.
image Lowest third is smooth muscle.

Tunica Adventitia

• Fibrous, not serous
• Has embedded arterial, venous, and nerve plexuses
image

Nerves of Esophagus

Innervation

• The esophageal nerve plexus is composed of vagal afferent and efferent, sympathetic efferent, and segmental sensory components.
• Parasympathetic preganglionic fibers

image Upper (cervical) portion from the recurrent laryngeal nerve
image Thoracic portion from the vagus via the pulmonary plexus (peribronchial)
image Ganglion cells located in myenteric plexuses

• Sympathetic postganglionic fibers

image Via nerves from cervical and thoracic chains
image From cervical ganglia and thoracic ganglia

• Sensory fibers (visceral afferent)

image Vagus: stretch, chemoreceptor, nociceptor; to vagal ganglia
image Segmental (parallel to sympathetics) with spinal nerves; to cervical and thoracic dorsal root ganglia

Vessels and Lymphatics

• Extensive submucosal vascular plexuses allow mobilization of large extents of the esophagus with reduced risk of ischemia.
image

Arteries of Esophagus

Arterial Supply

• Cervical portion is supplied by branches of the inferior thyroid arteries from thyrocervical trunks of the right and left subclavian arteries.
• Thoracic branches (unpaired) from the adjacent aorta
• Abdominal portion supplied by branches of the celiac (left gastric) and left inferior phrenic arteries
image

Veins of Esophagus

Venous Drainage

• Esophageal venous plexus has multiple connections.

image Right and left azygos venous channels, segmental body wall drainage (into superior vena cava); includes hemiazygos and accessory hemiazygos on left
image Inferior thyroid veins into subclavian veins (and superior vena cava)
image Inferiorly into the portal vein (directly), splenic vein, and superior gastric venous plexus

• Because of portal and systemic (azygos, etc) connections of the submucosal veins, they can become enlarged (varices) in portal hypertension.
• Risk of rupture of varices and esophageal hemorrhage with alcoholic cirrhosis
• Venous plexus can also be distended in caval obstruction, by venous return shunted through azygos system.
image

Lymph Vessels and Nodes of Esophagus

Lymphatic Drainage

• Parallels the arterial supply
• Upper portions drain into paratracheal and inferior deep cervical nodes.
• Abdominal drainage is into left gastric lymph nodes, then into celiac nodes.
• Extensive submucosal lymphatic channels allow metastatic cells ready access to the deeper drainage.

Clinical Correlates

Surgical Approaches to the Esophagus

• Cervical: left sided preferred, because esophagus runs slightly to the left of the trachea
• Upper (1/3) thoracic: right, avoids aorta
• Lower (2/3) thoracic: left, because esophagus here typically lies to the left of midline

Zenker’s Diverticulum

• False (posterior) diverticulum
• Occurs between the cricopharyngeus and the rest of the inferior constrictor
• Caused by increased swallowing pressure
• Symptoms: upper esophageal dysphagia, halitosis, choking
• Treatment: cricopharyngeal myotomy, resected or suspended (without removal of diverticulum) via left cervical incision

Traction Diverticulum

• True diverticulum, typically lateral
• Caused by granulomatous disease, chronic inflammation, or tumor
• Typically in mid-esophagus

Achalasia

• Failure of peristalsis and lack of lower esophageal sphincter relaxation with swallowing
• Secondary to neuronal degeneration in muscular layers
• Can lead to dilated esophagus and diverticula (epiphrenic)
• Trypanosoma cruzi can produce similar symptoms
• Treatment: calcium channel blocker, nitrates, and sphincter dilation; surgery with failure
• Surgical treatment: left thoracotomy with Heller myotomy (upper and lower circular muscle transection)
image

Gastroesophageal Reflux Disease

Gastroesophageal Reflux Disease (GERD)

• Failure of normal anatomical mechanisms: lower sphincter competence, normal esophageal structure, normal gastric reservoir
• Symptoms: heartburn 30-60 min. after meals, worse lying down, can have cough, asthma, choking
• Pharmacologic therapy first: omeprazole
• Surgical indications: failure of medical treatment, GERD with pH monitoring, complications including stricture, Barrett’s esophagus, cancer
• Surgical treatment: Nissen fundoplication
• Most patients with significant reflux have type I hiatal hernia (see next).

Hiatal Hernia (see Chapter 10, p. 143)

• Type I

image Dilation of hiatus with sliding hernia
image Most common
image May be associated with GERD, although most type I patients do not reflux

• Type II

image Paraesophageal, hole in diaphragm next to the esophagus
image Symptoms: dysphagia, chest pain, early satiety

• Type III: combined
• Type IV

image Entire stomach in thorax
image Other organ such as spleen or colon may be included.

Esophageal Cancer

• Adenocarcinoma, typically found distally, is now more common in the U.S.
• Squamous cell carcinoma can be found anywhere in esophagus and is more common worldwide.
• Diet is implicated as a causative factor in developing countries.
• Tobacco and alcohol are prominent risk factors in the Western world.
• Adenocarcinoma may be seen in patients with long-standing GERD.
• Barrett’s esophagus (BE) is metaplastic replacement of normal squamous mucosa by specialized intestinal epithelium.

image A high-risk precursor to adenocarcinoma
image Requires biopsy and monitoring

• Symptoms: dysphagia (primary), weight loss, dyspnea, hoarseness, chest pain (especially in advanced disease)

Leiomyoma

• Most common benign tumor of the esophagus
• Submucosal, hyperproliferating smooth muscle with connective tissue capsule
• Radiographic and endoscopic study
• Biopsy contraindicated owing to risk of scarring
• Symptoms: dysphagia and lower esophageal pain

Esophageal Polyps

• Second most common type of benign tumor
• Usually in cervical region
• Symptoms: dysphagia and hematemesis

Perforations

• Spontaneous: Boerhaave’s syndrome, associated with forceful prolonged retching and extended vomiting
• Traumatic: blunt or penetrating
• Iatrogenic: associated with endoscopic and surgical procedures

Caustic Injury

• Stricture and death can follow severe injuries.
• Survivors tend to develop long strictures.
• Primary treatment for strictures: esophageal dilation (risk of perforation)

Degrees of Chemical (or Caustic) Injury

• Primary burn: hyperemia

image Treatment: conservative therapy and observation
image IV fluids, antibiotics, spitting
image Can lead to strictures, cervical or near aortic impression, or shortening

• Secondary burn: ulcerations, exudates, sloughing

image Treatment: conservative therapy and observation
image Surgery on indications: sepsis, peritonitis, mediastinitis, free or mediastinal air, pneumothorax, crepitance, contrast extravasation, air in stomach walls

• Tertiary burn: charring, deep ulcers, lumen narrowing

image Treatment: conservative therapy and observation, esophagectomy typically needed
image Surgery on indications: sepsis, peritonitis, mediastinitis, free or mediastinal air, pneumothorax, crepitance, contrast extravasation, air in stomach wall

• Acid: causes coagulation necrosis and gastric injury
• Alkali (e.g., drain cleaner): causes deep necrosis with liquefaction, worse than acid

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