Oesophagus and dysphagia by

Dr.Mohammad Nauman Mustafa FRCS

The Esophagus

Dr. Mohammad Nauman Mustafa

The Esophagus

Dr. Mohammad Nauman Mustafa

The Esophagus

Dr. Mohammad Nauman Mustafa

Surgical Anatomy
Oesophagus Muscular tube 25 cm long

Extends from cricopharyngeus muscle to junction with cardia of stomach C6 vertebra to T12 Lies Ant. To vertebral column-Post. to trachea Lacks Serosa( other structure Rectum)

The Esophagus

Dr. Mohammad Nauman Mustafa

Nature of muscles upper oesophagus Striated Middle oesophagus Striated + smooth Lower oesophagus Smooth

The Esophagus

Dr. Mohammad Nauman Mustafa

Upper sphincter powerful Lower sphincter subtle Internal lining Squamous epithelium Last 3cm columnar epithelium (OG junction) Submucosa thick and strongest part

The Esophagus

Dr. Mohammad Nauman Mustafa

Segmental blood supply Inf.thyroid, aortic branches, gastric, Inf. Phernic arteries

The Esophagus

Dr. Mohammad Nauman Mustafa

Longitudinal arrangement of veins and lymphatics Veins Inf. Thyroid, brachiocephalic, left. Hemiazygos, Azygos, splenic, and inf. Phrenic veins

The Esophagus

Dr. Mohammad Nauman Mustafa

Lymph nodes paraoesophageal in the wall of oesophagus perioesophageal immediate adjacent to wall deep cervical, scalene, paratracheal, mediastinal, diaphragmatic, gastric, coeliac LNs

The Esophagus

Dr. Mohammad Nauman Mustafa

Nerve supply Parasympathetic Vagus nerve Myenteric (Auerbechs Plexus) Only part of GIT with no Meissners Submucous plexus

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Dr. Mohammad Nauman Mustafa

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Constrictions From incisor teeth seen on endoscopy

Cricopharyngeal impaction

15 cm site of F/B

Aortic and broncheal 25 cm site of endoscopic perforation Diaphragmatic Sphincter 40 cm

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Physiology
Function Transfer of food from mouth to stomach in coordinated fashion Pharyngeal phase Voluntary sequential contraction of pharyngeal muscles+closure of nasal and respiratory passages opening of upper oesophageal sphincter Beyond this swallowing is involuntary Oesophagus propels food through lower relaxed sphincter into stomach Upper oesophageal sphincter closed at rest Prevents stomach contents into respiratory passages Stops air entering into oesophagus

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Lower oesophageal sphincter 3-4cm long A high pressure zone 1025 mmHg (Normal) Prevents Gastric content reflux into oesophagus Opens in response to Primary peristaltic wave Relaxes at time of vomiting Factors influencing sphincter tone Food, gastric distension, GIT hormones, drugs, smoking Specific neurotransmitters, diaphragmatic contraction

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Contractions in oesophagus Primary Progressive,triggered by swallowing Secondary Progressive, generated by distension, irritation Tertiary non progressive

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With What symptoms the patient presents in oesophageal disease? Dysphagia difficulty in swallowing Food /liquids (Rule Out Malignancy) Types of dysphagia Solid/ and or fluids Intermittent/progressive Pain on swallowing Odynophagia retrosternal discomfort after swallowing hot beverages,citrus drinks, alcohol

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Regurgitation/Reflux (Heartburn) Regurgitation return of contents from above obstruction functional or mechenical Reflux Passive return of GIT contents suggests GORD Wt. loss, anaemia, cachexia, change of voice,irritating vocal cords cough, dyspnoea due to tracheal aspiration regurgitation and / or reflux Chest pain Difficult to distinguish from cardiac pain Other causes GI reflux and motility disorders
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If act of conscious swallow fails food to enter into oesophagus Dysphagia due to Chr. Neurological/ muscular disease

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Dysphagia
Dysphagia difficulty in swallowing Odynophagia painful swallowing Dysphagia Acute FB impaction, acute infection Chronic infection stricture or carcinoma Associated hoarseness Advanced Ca. pharynx, post cricoid, laryngeal Dysphagia Intermittent/ Progressive

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Causes of dysphagia
Common causes Gastro-oesophageal reflux diseases (GORD/GERD) Hiatus hernia) Carcinoma oesophagus short duration/progressive/2/3 lumen blocked to develop dysphagia

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 Ca. post. 3rd tongue Corrosive strictures Alkali Oesophageal Candida infection common in immuno-compromised ,HIV, on chemotherapy Plummer-Vinson syndrome Mediastinal swellings Primary tumours, Lymphoma, 2ndries, TB

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Rare causes Diffuse oesophageal spasm distal 3rd400-500 mmHg prssure Oesophageal diverticula

Dysphagia lusoria Aortic arch anomalies

Thyroid swelling
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 Boerhaaves syndrome Full thickness tear inlower oesophagus due vomiting with glottis closed Neurological causes stroke, bulbar palsy, motor neuron disease, Parkinson sdisease Drugs KCL, Quninine Mediastinal fibrosis

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Gastro-oesophageal disease (GERD/GORD)

Definition It is pathological reflux from stomach into oesophagus Causes Anatomical Obesity Altered length of intra-abdominal oesophagus Alteration Phreno-oesophgeal ligament Alteration angle of O-G Junction (Angle of His) Reduced pinch action of Rt. Crus of Diaphragm Alteration in normal mucosal rosette at O-G Junction

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Causes (contd) Physiological Reduced LOS prssure Altered transient relaxation period in LOS Reduced oesophageal clearance Delayed gastric emptying in diabetes, neuromuscular block, gastroperesis, medications gastric distention, Hyperacidity Other factors Alcohol, smoking, stress, lifestyle Seen in children / pregnant women

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Symptoms Substernal / epigastric burning pain Regurgitation or effortless emesis Dysphagia Atypical symptoms Mimic laryngeal, respiratory, cardiac, biliary, pancreatic, gastric, duodenal

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Investigations
Contrast radioghraphy (Upper GI) (head down position) Demonstrates spontaneous reflux 40% Associated Hiatus Hernia Stricture/ulcer

Endoscopy and biopsy Most appropriate investigation Exclude oesophagitis/Barretts changes

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Manomatric testing if surgery contemplating Excludes Achalasia, scleroderma, diffuse oesophgeal spasm Abnormal findings LOS pressure < 6mmHg Length < 2cm Abdominal oesophagus < 1cm

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Complete absence of peristalsis on manometry pathognomonic of Achalasia pH monitoring 24hr monitoring gold standard in diagnosis of GERD used when other investigation equivocal Test has 90%sensitcity and specificity to establish reflux PPIs stopped 2-3 weeks before

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Laparoscopic fundoplicationMost common

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Hiatus Hernia
Distal oesophagus normally held in position by endothoracic & endoabdomial fascia at hiatus A lax / defective fascia allows protrusion of stomach into mediastinum

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Types Sliding hernia 85% Rolling 10-12% Combined Most common abnormality on barium study 10% US population >Women 5th/6th decade Most asymptomatic 5% have symptom related to reflux The disease Esophagus Dr. Mohammad Nauman Mustafa

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It's not the hours you put in your work that count, it's work you put in the hours. The End
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