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Esophagus Anatomy, Physiology, and Diseases

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

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Esophagus Anatomy, Physiology, and Diseases

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  1. Esophagus Anatomy, Physiology, and Diseases Alan Chu March 13, 2013

  2. Anatomy • 18 – 26cm from UES to LES • Esophageal wall layers • Mucosa, submucosa, muscularispropia, adventitia • Proximal 33% skeletal muscle, middle 35-40% mixed, distal 50-60% smooth muscle • Smooth muscle innervated by CN X. • Auerbachplexus: peristalsis • Meissner’splexus: afferent input

  3. Oropharyngealdysphagia • Difficulty initiating swallow followed by choking/coughing • Esophageal dysphagia • Anatomaicvs neuromuscular defect • Solid vssolid+liquiddysphagia

  4. Dysphagia best assessed by MBSS • Demonstrates presence of oropharyngeal dysfunction and aspiration

  5. Standard upper endoscope 9mm, transnasal endoscope 4mm Z line = GE junction In barrett’ssquamocolumnar junction more proximal than GEJ

  6. 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

  7. 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

  8. Strictures Dysphagia when <15mm Tx: dilators (Bougies, Savary dilator, balloon dilator) Risk of perforation 0.5%, higher in XRT induced strictures Goal >15mm

  9. Rings or Webs • Ring • Circumferential, muscle or mucosa, at distal esophagus • Schatzki’sring • EosinophilicEsophagitis(>15 eosinophils/hpf in mucosa) • Web • Part of lumen, mucosal, proximal esophagus • Plummer Vinson

  10. 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

  11. Barrett’s esophagus Pale pink squamous mucosa replaced with salmon pink columnar mucosa LSBE vs SSBE (<3cm) Risk of esophageal adenoCA 0.5% per year

  12. Neoplasia • AdenoCA • Distal esophagus or GEJ • Barrett’s • SCC • Mid-esopahgus and proximal esophagus • Tobacco, EtOH use in AA

  13. Diverticula Zenker’sdiverticulum Midesophagealdiveticula Epiphrenicdiverticula Intramural pseudodiverticulosis

  14. Transnasal Esophagoscopy Alan Chu March 13, 2013

  15. Transnasalesophagoscope • 3.1 – 5.1mm • Performed without sedation • Shorter procedure time • 66% cost of transoralesophagoscope • Conventional Transoralesophagoscope • 10 - 12mm • Performed with sedation • Longer procedure time

  16. Transnasalesophagoscope • Smaller biopsy size • Conventional Transoralesophagoscope

  17. Indications • Head and Neck SCC • Replaces panendoscopy • Barrett’s esophagus • Surveillence of Barrett’s esophagus • Stricture dilation • Balloon dilation • Tracheoesophageal puncture

  18. 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

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