Esophagus
Esophagus
• Achalasia
• Barrett's Esophagus
• Esophageal Cancer
• Gastroesophageal Reflux Disease (GERD)
• Peptic Stricture
• Webs, Rings and Diverticula
Achalasia
Achalasia is a motor
disorder characterized
by a complete loss of
contraction and
relaxation of muscles
used to move contents
down the esophagus. It
is due to loss of the
ganglion cells in the
myenteric (Auerbach’s)
plexus.
Pathophysiology.
Achalasia is an esophageal disease of unknown etiology, although it
may be secondary to ganglionic dysfunction, which causes:
(1) High resting LES pressure
(2) Failure of the LES to relax during swallowing
(3) Absence of coordinated peristalsis in the body of the esophagus
b. The body of the esophagus becomes dilated, and the muscle
hypertrophies in an attempt to force material through the dysfunctional
LES. A similar symptom complex can be caused by Chagas disease,
which is caused by the organism Trypanosoma cruzi.
c. Carcinoma of the esophagus is 10 times more common in patients
with achalasia than in the general population.
Symptoms of achalasia include dysphagia, followed
by regurgitation and weight loss. Frequently,
respiratory symptoms caused by aspiration are
present.
Diagnosis
a. Radiographic studies reveal a dilated esophagus
with a bird's beaklike extension into the lower
narrowed segment at the LES.
b. Esophageal manometry reveals the high resting
LES pressure, failure of relaxation during
swallowing, higher than normal resting pressure in
the body of the esophagus, and absence of
peristalsis.
c. Esophagoscopy is required to rule out neoplasia
and to document the extent of esophagitis.
Treatment for achalasia is palliative because LES function can never be
restored to normal.
a. Nonsurgical treatment consists of forced pneumatic dilatation of the
spastic lower esophageal sphincter, which is just above the
gastroesophageal junction.
b. b. Surgical treatment is esophagomyotomy by the modified Heller
procedure, via laparotomy! laparoscopy, or occasionally left
thoracotomy. Care is taken not to disturb the vagus nerve attachments
to the esophagus to prevent reflux. The myotomy is confined to the
lower portion of the esophagus, usually 6-8 cm in length.
(I) Surgical results with the Heller procedure are generally better than with
pneumatic dilatation for relief of dysphagia.
Barrett's Esophagus
• Barrett’s esophagus is a metaplastic change in the lining mucosa of
the esophagus in response to chronic gastroesophageal reflux
GASTRO-ESOPHAGEAL REFLUX DISEASE
Benign tumors
Benign tumors of the esophagus are relatively rare. True papillomas,
adenomas and hyperplastic polyps do occur, but the majority of
‘benign’ tumors are not epithelial in origin and arise from other layers
of the esophageal wall (gastrointestinal stromal tumor (GIST), lipoma,
granular cell tumor). Most benign esophageal tumors are small and
asymptomatic, and even a large benign tumor may cause only mild
symptoms. The most important point in their management is usually to
carry out an adequate number of biopsies to prove beyond reason.
Malignant tumors
• Non-epithelial primary malignancies are also rare, as is malignant
melanoma. Secondary malignancies rarely involve the esophagus with
the exception of bronchogenic carcinoma by direct invasion of either
the primary and/or contiguous lymph nodes.
• Cancer of the esophagus is the sixth most common cancer in the
world. In general, it is a disease of mid to late adulthood, with a poor
survival rate. Only 5–10 per cent of those diagnosed will survive for
five years.
The exact cause is
unknown. Associated
factors are tobacco use,
excessive alcohol
ingestion, nitrosamines,
poor dental hygiene, and
hot beverages. Certain
pre-existing conditions
also increase the
likelihood of developing
esophageal cancer,
including achalasia and
Barrett's esophagus.
Pathology:
Type
(1) Squamous cell carcinoma is the most common form.
(2) Adenocarcinoma, the next commonest, is the type that occurs in
patients with Barrett's esophagus.
(3) Rare tumors of the esophagus include mucoepidermoid carcinoma
and adenoid cystic carcinoma.
Tumor spread.
Esophageal malignancies metastasize through both the lymphatic system
and the bloodstream, with metastases occurring in liver, bone, and brain.
Diagnosis
a. A history of dysphagia and weight loss is almost always present.
b. Contrast study of the esophagus demonstrates the location and extent of
the tumor.
c. Computed tomography ( CT) scan of the chest and abdomen is done to
evaluate local lymphatic spread, and a thorough search is made for distant
metastases.
d. Esophagoscopy is essential for tissue diagnosis and determination of the
extent of the tumor.
e. EUS is done to assess the depth of the invasion and staging.
f. Bronchoscopy is performed in patients with proximal esophageal lesions to
assess the possibility of invasion of the tracheobronchial tree.
Treatment
a. Overall, surgical therapy is associated with
less than a 5% mortality rate. Several
procedures are described for resection of
the esophagus. Transhiatal
esophagectomy through a laparotomy and
cervical incisions. A complete thoracic
esophagectomy is performed bluntly with
reconstruction of gastrointestinal
continuity with the stomach or, rarely, the
colon.
b. Ivor Lewis esophagectomy through a right
thoracotomy and laparotomy.
Reconstruction is also accomplished with
the stomach or, rarely, the colon.
Radiotherapy and chemotherapy are currently being investigated as
adjuncts to surgery or as primary treatment modalities.
(1) Neoadjuvant chemotherapy in combination with X-Ray Therapy (XRT)
given before surgical resection appears to shrink the tumor mass.
Several studies have shown an impact on long-term survival.
Combination chemotherapy with cisplatin have shown up to a 50%
response rate. However, a significant long-term survival has not been
demonstrated.
(2) Radiotherapy alone for carcinoma of the esophagus results in a 5-year
survival of less than 10%.
(3) In patients who have advanced disease with either invasion of the
tracheobronchial tree or advanced metastases, palliative effects may
be obtained by utilizing endoscopically placed metallic stents to allow
swallowing of saliva and soft foods.
MOTILITY DISORDERS AND DIVERTICULA