Understanding Esophagus Anatomy, Physiology, and Diseases
Explore the anatomy and function of the esophagus, including its layers, innervation, and common disorders like dysphagia, motility disorders, strictures, and rings/webs. Learn about diagnostic methods such as barium swallow studies and endoscopy, as well as treatment options for conditions like achalasia and diffuse esophageal spasm.
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Esophagus Anatomy, Physiology, and Diseases Alan Chu March 13, 2013
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
Oropharyngeal dysphagia Difficulty initiating swallow followed by choking/coughing Esophageal dysphagia Anatomaic vs neuromuscular defect Solid vs solid+liquid dysphagia
Dysphagia best assessed by MBSS Demonstrates presence of oropharyngeal dysfunction and aspiration
Standard upper endoscope 9mm, transnasal endoscope 4mm Z line = GE junction In barrett s squamocolumnar junction more proximal than GEJ
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
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
Strictures Dysphagia when <15mm Tx: dilators (Bougies, Savary dilator, balloon dilator) Risk of perforation 0.5%, higher in XRT induced strictures Goal >15mm
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
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
Barretts esophagus Pale pink squamous mucosa replaced with salmon pink columnar mucosa LSBE vs SSBE (<3cm) Risk of esophageal adenoCA 0.5% per year
Neoplasia AdenoCA Distal esophagus or GEJ Barrett s SCC Mid-esopahgus and proximal esophagus Tobacco, EtOH use in AA
Diverticula Zenker s diverticulum Midesophageal diveticula Epiphrenic diverticula Intramural pseudodiverticulosis
Transnasal Esophagoscopy Alan Chu March 13, 2013
Transnasal esophagoscope 3.1 5.1mm Performed without sedation Shorter procedure time 66% cost of transoral esophagoscope Conventional Transoral esophagoscope 10 - 12mm Performed with sedation Longer procedure time
Transnasal esophagoscope Smaller biopsy size Conventional Transoral esophagoscope
Indications Head and Neck SCC Replaces panendoscopy Barrett s esophagus Surveillence of Barrett s esophagus Stricture dilation Balloon dilation Tracheoesophageal puncture
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
