Esophageal Diseases

Posted by e-Medical PPT
Essential Esophageal Anatomy
The esophagus is 25 cm in length.  The lower 5-7 cm are below the diaphragm
Average distance from incisors to GE junction is 38-40 cm in men.  The distance from the incisors to the cricopharyngeus is 15 cm
Topographically, the esophagus begins at the lower border of C6.  The diaphragmatic hiatus is at T10
The upper 1/3 esophagus is slightly to the left of midline, the middle 1/3 slightly to the right, and the lower 1/3 slightly to the left
The upper 1/3 is composed of striated muscle and is innervated by the vagus and its recurrent branch. The lower 2/3 is composed of smooth muscle and is supplied by the vagus and the intrinsic autonomic nerve plexus

Esophageal Spasm Syndromes
Inadequate LES relaxation
 Achalasia, epiphrenic diverticulum
Uncoordinated esophageal contraction
 Diffuse esophageal spasm (DES)
 High-amplitude peristaltic contraction (HAPC, “nutcracker esophagus”), Hypertensive lower esophageal sphincter (HLES)
 Ineffective esophageal motility (IEM)

Achalasia is best confirmed by:
A birds beak appearance on barium esophagogram
Aperistalsis of the cervical esophagus
Failure of the LES to relax on swallowing
LES pressure < 5 mmHg
Biopsy proven esophagitis on flexible endososcopy

Treatment of Achalasia
Surgical Myotomy
Transabdominal vs Transthoracic
Dysphagia relief about 90% at 2 years
Recurrent dysphagia within 2 months likely due to incomplete myotomy, torsion of the repair or scarring of the mucosa from cautery
Late-onset dysphagia due to mucosal stricture from reflux, or the latent effects of delayed gastric emptying.  These patients ultimately need gastric or esophageal resection

Pneumatic Dilatation
Disrupts LES muscle fibers and produces relief of symptoms in 50-85% of patients.  However, most patients require multiple dilatations, increasing the risk of perforation (up to 8%).  Long term relief of symptoms in 40-65%

Esophageal Diverticulum
Epiphrenic Diverticulum
Usually pulsion diverticulum located within the distal 10 cm of the thoracic esophagus
Usually right sided
Most are found incidentally, however, the most common symptoms are dysphagia, regurgitation
Barium esophagogram remains the best test for diagnosis
Endoscopy, 24 Hr PH and manometry should be performed
Symptomatic, anatomically dependent and enlarging diverticulum should be surgically repaired
Surgical therapy includes diverticulectomy, myotomy and a partial fundoplication as indicated (Transthoracic or Transabdominal)..

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