GIT

Fifth stage

surgery
Lec-5
د.سمير الصفار

4/10/2015

The Esophagus
Introduction
Anatomy
Physiology
Clinical features
Investigations
Diseases of esophagus

Surgical anatomy

The esophagus is a muscular tube approximately 25 cm long.
The musculature of the upper 5%, including the upper esophageal sphincter, is striated; the middle 40% has mixed striated and smooth muscle, the distal 55% is entirely smooth muscle.
The parasympathetic nerve supply is mediated by the vagus.
There are an upper and lower esophageal sphincters.


Physiology

The main function of the oesophagus is to transfer food from the mouth to the stomach.

The initial movement of food from the mouth is voluntary.
The upper esophageal sphincter is normally closed at rest and serves as :

A protective mechanism against regurgitation of esophageal contents into the respiratory passages.
Also it serves to stop air entering the esophagus.

The lower esophageal sphincter(LOS) is a physiological sphincter, about 3-4 cm in length and has a pressure of 10-25 mmHg.
The tone of it is influenced by many things including food, gastric distension, smoking, and GI hormones.
Its main function is to prevent gastric and duodenal contents from refluxing into the lower esophagus.

Clinical features:

Symptoms

Dysphagia:

Is the term used to describe difficulty, but not necessarily pain, on swallowing.
The type of dysphagia is important; it may be dysphagia for solids or fluids, intermittent or progressive.


Odynophagia

It refers to pain on swallowing.

Regurgitation and reflux

Regurgitation strictly refer to the return of esophageal contents from above an obstruction in the esophagus.
Reflux is the passive return of gastroduodenal contents to the mouth.

Chest pain

Chest pain similar in character to angina pectoris may arise from an esophageal cause.

Other symptoms of esophageal disorders include; loss of wt, anemia, cachaxia, change of voice, and cough.

Investigations

Radiography
Plain X ray; may show opaque foreign bodies.
Contrast radiography (Barium swallow) is a useful investigation for demonstrating narrowing, space-occupying lesions, anatomical distortion or abnormal motility.
Endoscopy
Is the investigation of first choice for most oesophagial disorders.
It is either for diagnostic or for therapeutic purposes.
Diagnosis is by visual inspection of the inside of oseophagus and also by taking a biopsy or cytology specimen.
For therapy, can be used for;
Removal of FB
Dilatation of strictures
Oseophagial varices


There are two types;
Rigid oesophagoscopy; which is now virtually obsolete.

Disadvantages:

Needs general anesthesia, difficult to introduce, and carry high risk of perforation

Fibre-optic endoscopy

It has virtually supplanted the rigid instrument.
It is done under local anesthesia on an out-patient basis, easy to enter, and carry low risk of perforation.

Oesophageal manomerty

Is widely used to diagnose esophageal motility disorders.
Recordings are usually made either by;
Multilumen catheter 2- Catheters with solid-state transducer
24-hour PH recording
Prolonged measurement of esophageal pH is now accepted as the most accurate method for the diagnosis of gastro esophageal reflux.

Diseases of the esophagus

Congenital abnormalities
Atresia and tracheo-oesophageal fistula
Oesophageal stenosis
Dysphagia lusoria


Foreign bodies in the oesophagus
A lot of things may become arrested in the oesophagus such as coins, pins, dentures. The commonest impacted material is food.
Plain radiographs are the most useful examination.
Endoscopy is good tool for the dx specially of non-opaque FB.

Treatment:

Flexible endoscopy is now the method of choice and the majority of objects can be extracted with suitable grasping forceps, a snare or a basket.
An impacted food bolus will often break up and pass on if the patient is given fizzy drinks and confined to fluids for a short time

Perforation of the oesophagus

Perforation of the oesophagus is a serious condition that requires prompt diagnosis and treatment

Causes:

Barotrauma _ Boerhaave’s syndrome
So-called “spontaneous” perforation of the oesophagus is usually due to severe barotrauma when a person vomits against a closed glottis.
Usually at the lower third
The clinical history is of severe pain in the chest or upper abdomen following a meal or a bout of drinking.

Pathological perforation

Perforation of ulcers, such as a Barrett’s ulcer or tumours.
Penetrating injury
Foreign bodies
Instrumental perforation


Diagnosis
Beware and beware of perforation
Chest pain
Subcutaneous emphysema in the neck
Emphysema around the pericardium can be detected on auscultation as a mediastinal crunch
Chest XR may show gas in the mediastinum
Contrast swallow using barium suspension

Treatment

Prompt dx and treatment is essential for the best results
There are two options:

Operative

Non-operative

Management options in perforation of the oesophagus:

Factors that favour

Nonoperative Operative

Small septic load Large septic load
Minimal CV upset Septic shock
Perforation confined to Pleura breached
Mediastinum
Endoscopic perforation Boerhaave syndrome
Perforation of cervical Perforation of abdominal
Oesophagus oesophagus


Nonoperative management
Analgesia
Nil by mouth
Antibiotics
General supportive care…IV fluids
When stable…enteral or paenteral nutrition
Nasogastric tube is not recommended

Operative management

It involves thoracotomy and repair of the perforation
This is best done within a few hours of perforation

Corrosive injury Sodium hydroxide Sulphuric acid

Drug induced injury
Antibiotic tab
Potassium tab