Esophageal benign and malignant diseases m.ppt
kifliegerbaw1
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Oct 08, 2024
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About This Presentation
Esophageal ca.benign lesion risk factors,diagnosis ,managemenu
Slide Content
Esophageal DiseasesEsophageal Diseases
AnatomyAnatomy
Extends from C6 - T11Extends from C6 - T11
The lower 2-5 cm are below the diaphragmThe lower 2-5 cm are below the diaphragm
Found between the left bronchus and the aortaFound between the left bronchus and the aorta
Average peristalsis takes 6-8 seconds to proceed through the Average peristalsis takes 6-8 seconds to proceed through the
esophagus, with average velocity of 3-4 cm/sec. esophagus, with average velocity of 3-4 cm/sec.
UES to LES = 20 cmUES to LES = 20 cm
DiameterDiameter: Varies whether bolus of food/ fluid passing through or : Varies whether bolus of food/ fluid passing through or
not.not.
At rest in adults 20 mm but can stretch up to 30 mmAt rest in adults 20 mm but can stretch up to 30 mm
The esophagus is a very thin-walled organ, measuring about 2 mm The esophagus is a very thin-walled organ, measuring about 2 mm
Extends from C6 - T11Extends from C6 - T11
The lower 2-5 cm are below the diaphragmThe lower 2-5 cm are below the diaphragm
Found between the left bronchus and the aortaFound between the left bronchus and the aorta
Average peristalsis takes 6-8 seconds to proceed through the Average peristalsis takes 6-8 seconds to proceed through the
esophagus, with average velocity of 3-4 cm/sec. esophagus, with average velocity of 3-4 cm/sec.
UES to LES = 20 cmUES to LES = 20 cm
DiameterDiameter: Varies whether bolus of food/ fluid passing through or : Varies whether bolus of food/ fluid passing through or
not.not.
At rest in adults 20 mm but can stretch up to 30 mmAt rest in adults 20 mm but can stretch up to 30 mm
The esophagus is a very thin-walled organ, measuring about 2 mm The esophagus is a very thin-walled organ, measuring about 2 mm
Anatomy and histology of the Anatomy and histology of the
EsophagusEsophagus
7
EsophagusEsophagus
7
Esophageal anatomy
The oesophageal wall has four layers: The oesophageal wall has four layers:
From within outwards:From within outwards:
Mucous Membrane, Mucous Membrane,
Sub-mucosa, Sub-mucosa,
Muscle coat and Muscle coat and
Outer most fibrous layer. Outer most fibrous layer.
Unlike other areas of the gut, it does not Unlike other areas of the gut, it does not
have a distinct serosal covering, but is have a distinct serosal covering, but is
covered by a thin layer of loose covered by a thin layer of loose
connective tissueconnective tissue
The oesophageal wall has four layers: The oesophageal wall has four layers:
From within outwards:From within outwards:
Mucous Membrane, Mucous Membrane,
Sub-mucosa, Sub-mucosa,
Muscle coat and Muscle coat and
Outer most fibrous layer. Outer most fibrous layer.
Unlike other areas of the gut, it does not Unlike other areas of the gut, it does not
have a distinct serosal covering, but is have a distinct serosal covering, but is
covered by a thin layer of loose covered by a thin layer of loose
connective tissueconnective tissue
Unusual! Arterial supply derived from
vessels feeding mainly other organs –
thyroid, trachea & stomach
Cervical Oesophagus: Right &
Left superior & inferior thyroid
arteries.
Thoracic Oesophagus: Upto
tracheal bifurcation Right & Left
inferior thyroid Artery
direct supply from aorta (tracheo-
bronchial tree)
Abdominal Oesophagus 11
branches off L gastric artery and
Branches of splenic artery
posteriorly
vessels feeding mainly other organs –
thyroid, trachea & stomach
Cervical Oesophagus: Right &
Left superior & inferior thyroid
arteries.
Thoracic Oesophagus: Upto
tracheal bifurcation Right & Left
inferior thyroid Artery
direct supply from aorta (tracheo-
bronchial tree)
Abdominal Oesophagus 11
branches off L gastric artery and
Branches of splenic artery
posteriorly
Venous RelationsVenous Relations
Intra-oesophageal (Intrinsic) DrainageIntra-oesophageal (Intrinsic) Drainage
Longitudinally arranged in Longitudinally arranged in
Submucosa Submucosa
Distal end – portal anastamoses Distal end – portal anastamoses
Extra-oesophageal (Extrinsic) Drainage Extra-oesophageal (Extrinsic) Drainage
into locally corresponding veins into locally corresponding veins
Inf. thyroid (into innominate vein),Inf. thyroid (into innominate vein),
Azygos, hemiazygos Azygos, hemiazygos
L gastric & splenicL gastric & splenic
Intra-oesophageal (Intrinsic) DrainageIntra-oesophageal (Intrinsic) Drainage
Longitudinally arranged in Longitudinally arranged in
Submucosa Submucosa
Distal end – portal anastamoses Distal end – portal anastamoses
Extra-oesophageal (Extrinsic) Drainage Extra-oesophageal (Extrinsic) Drainage
into locally corresponding veins into locally corresponding veins
Inf. thyroid (into innominate vein),Inf. thyroid (into innominate vein),
Azygos, hemiazygos Azygos, hemiazygos
L gastric & splenicL gastric & splenic
Nerve SupplyNerve Supply
Parasympathetic Parasympathetic
Vagus – motor to muscular coats & secretomotor to glands Vagus – motor to muscular coats & secretomotor to glands
Sympathetic Sympathetic
From cervical & thoracic sympathetic chain From cervical & thoracic sympathetic chain
Contraction of sphincters, wall relaxation, peristalsis Contraction of sphincters, wall relaxation, peristalsis
Intramural Intramural
Combination of all innervation form plexuses & ganglia Combination of all innervation form plexuses & ganglia
In muscular layers (myenteric or Auerbach’s plexus) In muscular layers (myenteric or Auerbach’s plexus)
In submucosa (Meissner plexus) In submucosa (Meissner plexus)
Parasympathetic Parasympathetic
Vagus – motor to muscular coats & secretomotor to glands Vagus – motor to muscular coats & secretomotor to glands
Sympathetic Sympathetic
From cervical & thoracic sympathetic chain From cervical & thoracic sympathetic chain
Contraction of sphincters, wall relaxation, peristalsis Contraction of sphincters, wall relaxation, peristalsis
Intramural Intramural
Combination of all innervation form plexuses & ganglia Combination of all innervation form plexuses & ganglia
In muscular layers (myenteric or Auerbach’s plexus) In muscular layers (myenteric or Auerbach’s plexus)
In submucosa (Meissner plexus) In submucosa (Meissner plexus)
AnatomyAnatomy
Lymphatic drainage:Lymphatic drainage:
Upper 1/3Upper 1/3: internal jugular, deep cervical and para : internal jugular, deep cervical and para
tracheal nodes. tracheal nodes.
Middle 1/3Middle 1/3: Subcarinal and inferior pulmonary ligament : Subcarinal and inferior pulmonary ligament
nodes. nodes.
Lower 1/3Lower 1/3::drains into the para-esophageal and celiac drains into the para-esophageal and celiac
nodes. nodes.
Lymphatic drainage:Lymphatic drainage:
Upper 1/3Upper 1/3: internal jugular, deep cervical and para : internal jugular, deep cervical and para
tracheal nodes. tracheal nodes.
Middle 1/3Middle 1/3: Subcarinal and inferior pulmonary ligament : Subcarinal and inferior pulmonary ligament
nodes. nodes.
Lower 1/3Lower 1/3::drains into the para-esophageal and celiac drains into the para-esophageal and celiac
nodes. nodes.
In the proximal third of the esophagus, lymphatics drain into the deep In the proximal third of the esophagus, lymphatics drain into the deep
cervical lymph nodes, cervical lymph nodes,
In the middle third, drainage is into the superior and posterior mediastinal In the middle third, drainage is into the superior and posterior mediastinal
nodes. nodes.
The distal-third lymphatics follow the left gastric artery to the gastric and The distal-third lymphatics follow the left gastric artery to the gastric and
celiac lymph nodesceliac lymph nodes
In the proximal third of the esophagus, lymphatics drain into the deep In the proximal third of the esophagus, lymphatics drain into the deep
cervical lymph nodes, cervical lymph nodes,
In the middle third, drainage is into the superior and posterior mediastinal In the middle third, drainage is into the superior and posterior mediastinal
nodes. nodes.
The distal-third lymphatics follow the left gastric artery to the gastric and The distal-third lymphatics follow the left gastric artery to the gastric and
celiac lymph nodesceliac lymph nodes
There is considerable interconnection among these three drainage regionsThere is considerable interconnection among these three drainage regions..
Poorly understood Poorly understood
Important for tumour spread Important for tumour spread
Bi-directional spread Bi-directional spread
Tracheal bifurcation important landmark Tracheal bifurcation important landmark
Of Surgical InterestOf Surgical Interest
Submucosal lymphatics explain why tumours may extend long distance Submucosal lymphatics explain why tumours may extend long distance
before obstructing lumenbefore obstructing lumen
May also explain high recurrence rates May also explain high recurrence rates
Bidirectional lymph flow may explain retrograde tumour seeding if flow Bidirectional lymph flow may explain retrograde tumour seeding if flow
is blockedis blocked
Poorly understood Poorly understood
Important for tumour spread Important for tumour spread
Bi-directional spread Bi-directional spread
Tracheal bifurcation important landmark Tracheal bifurcation important landmark
Of Surgical InterestOf Surgical Interest
Submucosal lymphatics explain why tumours may extend long distance Submucosal lymphatics explain why tumours may extend long distance
before obstructing lumenbefore obstructing lumen
May also explain high recurrence rates May also explain high recurrence rates
Bidirectional lymph flow may explain retrograde tumour seeding if flow Bidirectional lymph flow may explain retrograde tumour seeding if flow
is blockedis blocked
AnatomyAnatomy
Two sphincters Two sphincters
Upper esophageal sphincter (UES): Upper esophageal sphincter (UES): a true sphincter, a true sphincter,
prevents excess air from entering the esophagus.prevents excess air from entering the esophagus.
It is a 2-3 mm zone of elevated pressure between pharynx & It is a 2-3 mm zone of elevated pressure between pharynx &
oesophagus. It relates to cricopharyngeal muscleoesophagus. It relates to cricopharyngeal muscle
Lower esophageal sphincter (UES): Lower esophageal sphincter (UES): not a true anatomical not a true anatomical
sphincter, however functions as one by preventing reflux of sphincter, however functions as one by preventing reflux of
gastric contentsgastric contents
The LES is located at the junction between the esophagus The LES is located at the junction between the esophagus
and stomach, usually localized at or just below the and stomach, usually localized at or just below the
diaphragmatic hiatus. Despite its distinct physiological diaphragmatic hiatus. Despite its distinct physiological
function, it is not easily distinguished anatomically.function, it is not easily distinguished anatomically.
Two sphincters Two sphincters
Upper esophageal sphincter (UES): Upper esophageal sphincter (UES): a true sphincter, a true sphincter,
prevents excess air from entering the esophagus.prevents excess air from entering the esophagus.
It is a 2-3 mm zone of elevated pressure between pharynx & It is a 2-3 mm zone of elevated pressure between pharynx &
oesophagus. It relates to cricopharyngeal muscleoesophagus. It relates to cricopharyngeal muscle
Lower esophageal sphincter (UES): Lower esophageal sphincter (UES): not a true anatomical not a true anatomical
sphincter, however functions as one by preventing reflux of sphincter, however functions as one by preventing reflux of
gastric contentsgastric contents
The LES is located at the junction between the esophagus The LES is located at the junction between the esophagus
and stomach, usually localized at or just below the and stomach, usually localized at or just below the
diaphragmatic hiatus. Despite its distinct physiological diaphragmatic hiatus. Despite its distinct physiological
function, it is not easily distinguished anatomically.function, it is not easily distinguished anatomically.
AnatomyAnatomy
Three physiologic constrictions:Three physiologic constrictions:
Cricopharyngeal Cricopharyngeal 15cm15cm
Aortic and bronchialAortic and bronchial25cm25cm
DiaphragmaticDiaphragmatic 40cm40cm
Importance:Importance:
Foreign body lodgmentForeign body lodgment
Perforation during endoscopyPerforation during endoscopy
MalignancyMalignancy
Three physiologic constrictions:Three physiologic constrictions:
Cricopharyngeal Cricopharyngeal 15cm15cm
Aortic and bronchialAortic and bronchial25cm25cm
DiaphragmaticDiaphragmatic 40cm40cm
Importance:Importance:
Foreign body lodgmentForeign body lodgment
Perforation during endoscopyPerforation during endoscopy
MalignancyMalignancy
Oesophagus is the narrowest region of alimentary Oesophagus is the narrowest region of alimentary
tract except vermiform appendix. During its course it tract except vermiform appendix. During its course it
has three indentations:has three indentations:
At 15 cm from incisor teeth is crico-pharyngues At 15 cm from incisor teeth is crico-pharyngues
sphincter (normally closed) (UES)sphincter (normally closed) (UES)
At 25 cm aortic arch and left main bronchusAt 25 cm aortic arch and left main bronchus
At 40 cms where it pierces the diaphragm where At 40 cms where it pierces the diaphragm where
a physiological sphincter is sited (LES)a physiological sphincter is sited (LES)
Oesophagus is the narrowest region of alimentary Oesophagus is the narrowest region of alimentary
tract except vermiform appendix. During its course it tract except vermiform appendix. During its course it
has three indentations:has three indentations:
At 15 cm from incisor teeth is crico-pharyngues At 15 cm from incisor teeth is crico-pharyngues
sphincter (normally closed) (UES)sphincter (normally closed) (UES)
At 25 cm aortic arch and left main bronchusAt 25 cm aortic arch and left main bronchus
At 40 cms where it pierces the diaphragm where At 40 cms where it pierces the diaphragm where
a physiological sphincter is sited (LES)a physiological sphincter is sited (LES)
These areas are where most oesophageal foreign bodies These areas are where most oesophageal foreign bodies
become entrappedbecome entrapped..
The most common site of oesophageal The most common site of oesophageal
impaction is at the thoracic inletimpaction is at the thoracic inlet
Defined as the area between the clavicles on Defined as the area between the clavicles on
chest radiograph, this is the site of anatomical chest radiograph, this is the site of anatomical
change from the skeletal muscle to the smooth change from the skeletal muscle to the smooth
muscle of the oesophagus. The muscle of the oesophagus. The
cricopharyngeus sling at C6 is also at this level cricopharyngeus sling at C6 is also at this level
and may "catch" a foreign body. and may "catch" a foreign body.
About 70% of blunt foreign bodies that lodge About 70% of blunt foreign bodies that lodge
in the oesophagus do so at this location. in the oesophagus do so at this location.
become entrappedbecome entrapped..
The most common site of oesophageal The most common site of oesophageal
impaction is at the thoracic inletimpaction is at the thoracic inlet
Defined as the area between the clavicles on Defined as the area between the clavicles on
chest radiograph, this is the site of anatomical chest radiograph, this is the site of anatomical
change from the skeletal muscle to the smooth change from the skeletal muscle to the smooth
muscle of the oesophagus. The muscle of the oesophagus. The
cricopharyngeus sling at C6 is also at this level cricopharyngeus sling at C6 is also at this level
and may "catch" a foreign body. and may "catch" a foreign body.
About 70% of blunt foreign bodies that lodge About 70% of blunt foreign bodies that lodge
in the oesophagus do so at this location. in the oesophagus do so at this location.
Another 15% become lodged at the Another 15% become lodged at the mid mid
oesophagusoesophagus, in the region where the aortic arch and , in the region where the aortic arch and
carina overlap the oesophagus on chest radiograph. carina overlap the oesophagus on chest radiograph.
The remaining 15% become lodged at the lower The remaining 15% become lodged at the lower
oesophageal sphincter oesophageal sphincter (LES)(LES) at the gastroesophageal at the gastroesophageal
junction.junction.
Another 15% become lodged at the Another 15% become lodged at the mid mid
oesophagusoesophagus, in the region where the aortic arch and , in the region where the aortic arch and
carina overlap the oesophagus on chest radiograph. carina overlap the oesophagus on chest radiograph.
The remaining 15% become lodged at the lower The remaining 15% become lodged at the lower
oesophageal sphincter oesophageal sphincter (LES)(LES) at the gastroesophageal at the gastroesophageal
junction.junction.
Key revision points anatomy and physiology of the Key revision points anatomy and physiology of the
oesophagusoesophagus
Upper 2/3. Stratified squamous epithelial-lined (develops Upper 2/3. Stratified squamous epithelial-lined (develops
squamous carcinoma), striated skeletal muscle, lymphatic squamous carcinoma), striated skeletal muscle, lymphatic
drainage to neck and mediastinal nodes, somatic innervation of drainage to neck and mediastinal nodes, somatic innervation of
sensation (e.g. moderately accurate location of level of sensation (e.g. moderately accurate location of level of
pathology).pathology).
Lower 1/3. Transition to columnar epithelium (develops Lower 1/3. Transition to columnar epithelium (develops
adenocarcinoma), transition to smooth muscle, lymphatic adenocarcinoma), transition to smooth muscle, lymphatic
drainage to gastric and para-aortic nodes, visceral innervation drainage to gastric and para-aortic nodes, visceral innervation
(poor localization of pathology).(poor localization of pathology).
oesophagusoesophagus
Upper 2/3. Stratified squamous epithelial-lined (develops Upper 2/3. Stratified squamous epithelial-lined (develops
squamous carcinoma), striated skeletal muscle, lymphatic squamous carcinoma), striated skeletal muscle, lymphatic
drainage to neck and mediastinal nodes, somatic innervation of drainage to neck and mediastinal nodes, somatic innervation of
sensation (e.g. moderately accurate location of level of sensation (e.g. moderately accurate location of level of
pathology).pathology).
Lower 1/3. Transition to columnar epithelium (develops Lower 1/3. Transition to columnar epithelium (develops
adenocarcinoma), transition to smooth muscle, lymphatic adenocarcinoma), transition to smooth muscle, lymphatic
drainage to gastric and para-aortic nodes, visceral innervation drainage to gastric and para-aortic nodes, visceral innervation
(poor localization of pathology).(poor localization of pathology).
Key revision points anatomy and physiology of the Key revision points anatomy and physiology of the
oesophagusoesophagus
Gastro-oesophageal junction is site of porto-systemic anastomosis Gastro-oesophageal junction is site of porto-systemic anastomosis
(between left gastric and (hemi)azygous veins) may develop gastric (between left gastric and (hemi)azygous veins) may develop gastric
or oesophageal varices.or oesophageal varices.
Upper oesophageal sphincter (UOS) = cricopharyngeus.Upper oesophageal sphincter (UOS) = cricopharyngeus.
Lower oesophageal sphincter (LOS) = functional zone of high Lower oesophageal sphincter (LOS) = functional zone of high
pressure above the gastro-oesophageal junction. Relaxants include pressure above the gastro-oesophageal junction. Relaxants include
alcohol.alcohol.
Swallowing requires intact and coordinated innervation from vagus Swallowing requires intact and coordinated innervation from vagus
(UOS, oesophagus, LOS) and intramural myenteric plexus.(UOS, oesophagus, LOS) and intramural myenteric plexus.
oesophagusoesophagus
Gastro-oesophageal junction is site of porto-systemic anastomosis Gastro-oesophageal junction is site of porto-systemic anastomosis
(between left gastric and (hemi)azygous veins) may develop gastric (between left gastric and (hemi)azygous veins) may develop gastric
or oesophageal varices.or oesophageal varices.
Upper oesophageal sphincter (UOS) = cricopharyngeus.Upper oesophageal sphincter (UOS) = cricopharyngeus.
Lower oesophageal sphincter (LOS) = functional zone of high Lower oesophageal sphincter (LOS) = functional zone of high
pressure above the gastro-oesophageal junction. Relaxants include pressure above the gastro-oesophageal junction. Relaxants include
alcohol.alcohol.
Swallowing requires intact and coordinated innervation from vagus Swallowing requires intact and coordinated innervation from vagus
(UOS, oesophagus, LOS) and intramural myenteric plexus.(UOS, oesophagus, LOS) and intramural myenteric plexus.
Esophageal diseasesEsophageal diseases
I: Neuro-muscularI: Neuro-muscular
Inadequate LES relaxationInadequate LES relaxation
•AchalasiaAchalasia
•Epiphrenic diverticulumEpiphrenic diverticulum
Uncoordinated esophageal contractionUncoordinated esophageal contraction
•Diffuse esophageal spasm (DES)Diffuse esophageal spasm (DES)
Hypo-contarctionHypo-contarction
•Ineffective esophageal motility (IEM)Ineffective esophageal motility (IEM)
I: Neuro-muscularI: Neuro-muscular
Inadequate LES relaxationInadequate LES relaxation
•AchalasiaAchalasia
•Epiphrenic diverticulumEpiphrenic diverticulum
Uncoordinated esophageal contractionUncoordinated esophageal contraction
•Diffuse esophageal spasm (DES)Diffuse esophageal spasm (DES)
Hypo-contarctionHypo-contarction
•Ineffective esophageal motility (IEM)Ineffective esophageal motility (IEM)
Esophageal diseasesEsophageal diseases
Hyper-contractionHyper-contraction
High-amplitude peristaltic contraction (HAPC, High-amplitude peristaltic contraction (HAPC,
“nutcracker esophagus”), “nutcracker esophagus”),
Hypertensive lower esophageal sphincter (HLES)Hypertensive lower esophageal sphincter (HLES)
II. InflammatoryII. Inflammatory
Reflux esophagitisReflux esophagitis
Caustic esophagitisCaustic esophagitis
Infectious esophagitisInfectious esophagitis
Foreign bodyForeign body
Hyper-contractionHyper-contraction
High-amplitude peristaltic contraction (HAPC, High-amplitude peristaltic contraction (HAPC,
“nutcracker esophagus”), “nutcracker esophagus”),
Hypertensive lower esophageal sphincter (HLES)Hypertensive lower esophageal sphincter (HLES)
II. InflammatoryII. Inflammatory
Reflux esophagitisReflux esophagitis
Caustic esophagitisCaustic esophagitis
Infectious esophagitisInfectious esophagitis
Foreign bodyForeign body
Esophageal diseasesEsophageal diseases
III: Anatomic:III: Anatomic:
Sliding hiatus herniaSliding hiatus hernia
Rolling (Para-esophageal) hiatus herniaRolling (Para-esophageal) hiatus hernia
Mixed hiatus herniaMixed hiatus hernia
Esophageal diverticular diseasesEsophageal diverticular diseases
IV: NeoplasticIV: Neoplastic
Esophageal carcinomaEsophageal carcinoma
Benign tumorsBenign tumors
III: Anatomic:III: Anatomic:
Sliding hiatus herniaSliding hiatus hernia
Rolling (Para-esophageal) hiatus herniaRolling (Para-esophageal) hiatus hernia
Mixed hiatus herniaMixed hiatus hernia
Esophageal diverticular diseasesEsophageal diverticular diseases
IV: NeoplasticIV: Neoplastic
Esophageal carcinomaEsophageal carcinoma
Benign tumorsBenign tumors
Dysphagia and achalasia
Causes of dysphagia
•Extrinsic mechanical
•Carcinoma of the bronchus
•Thoracic aortic aneurysm
•Goitre
•Intrinsic mechanical
•Benign stricture
•Oesophageal carcinoma
•Bolus obstruction
•Primary neuromuscular
•Achalasia
•Diffuse oesophageal spasm
•Nutcracker oesophagus
•Secondary neuromuscular
•Multiple sclerosis
•Systemic sclerosis
•Chagas' disease
•Autonomic neuropathy
Dysphagia and achalasia
Causes of dysphagia
•Extrinsic mechanical
•Carcinoma of the bronchus
•Thoracic aortic aneurysm
•Goitre
•Intrinsic mechanical
•Benign stricture
•Oesophageal carcinoma
•Bolus obstruction
•Primary neuromuscular
•Achalasia
•Diffuse oesophageal spasm
•Nutcracker oesophagus
•Secondary neuromuscular
•Multiple sclerosis
•Systemic sclerosis
•Chagas' disease
•Autonomic neuropathy
Dysphagia and achalasia
SymptomsSymptoms
DysphagiaDysphagia
OdynophagiaOdynophagia
RegurgitationRegurgitation
HematemesisHematemesis
Aspiration/coughAspiration/cough
Recurrent chest infectionRecurrent chest infection
DysphagiaDysphagia
OdynophagiaOdynophagia
RegurgitationRegurgitation
HematemesisHematemesis
Aspiration/coughAspiration/cough
Recurrent chest infectionRecurrent chest infection
HistoryHistory
Onset.Onset.
DurationDuration
ProgressionProgression
Severity of symptomsSeverity of symptoms
Types of food intake that causes problemsTypes of food intake that causes problems
Alleviating factorsAlleviating factors
Onset.Onset.
DurationDuration
ProgressionProgression
Severity of symptomsSeverity of symptoms
Types of food intake that causes problemsTypes of food intake that causes problems
Alleviating factorsAlleviating factors
Dysphagia (from the Greek Dysphagia (from the Greek dys,dys, meaning with meaning with
difficulty, and difficulty, and phagia,phagia, meaning to eat) arises meaning to eat) arises
when transport of liquid or a bolus of food along when transport of liquid or a bolus of food along
the pharyngoesophageal conduit is impaired by the pharyngoesophageal conduit is impaired by
mechanical obstruction or neuromuscularmechanical obstruction or neuromuscular failure failure
that disrupts peristalsis. that disrupts peristalsis.
Patients with dysphagia often complain of Patients with dysphagia often complain of
difficulty in initiating a swallow or the sensation difficulty in initiating a swallow or the sensation
of food sticking or stopping in transit to the of food sticking or stopping in transit to the
stomach. The cause is almost always organic stomach. The cause is almost always organic
rather than functional.rather than functional.
It is important to differentiate oropharyngeal It is important to differentiate oropharyngeal
("transfer") dysphagia from esophageal ("transfer") dysphagia from esophageal
dysphagiadysphagia
difficulty, and difficulty, and phagia,phagia, meaning to eat) arises meaning to eat) arises
when transport of liquid or a bolus of food along when transport of liquid or a bolus of food along
the pharyngoesophageal conduit is impaired by the pharyngoesophageal conduit is impaired by
mechanical obstruction or neuromuscularmechanical obstruction or neuromuscular failure failure
that disrupts peristalsis. that disrupts peristalsis.
Patients with dysphagia often complain of Patients with dysphagia often complain of
difficulty in initiating a swallow or the sensation difficulty in initiating a swallow or the sensation
of food sticking or stopping in transit to the of food sticking or stopping in transit to the
stomach. The cause is almost always organic stomach. The cause is almost always organic
rather than functional.rather than functional.
It is important to differentiate oropharyngeal It is important to differentiate oropharyngeal
("transfer") dysphagia from esophageal ("transfer") dysphagia from esophageal
dysphagiadysphagia
Oropharyngeal vs.Oesophageal DysphagiaOropharyngeal vs.Oesophageal Dysphagia
In Oropharyngeal dysphagia, there is difficulty In Oropharyngeal dysphagia, there is difficulty
in preparing and transporting the food bolus in preparing and transporting the food bolus
through the oral cavity as well as initiating the through the oral cavity as well as initiating the
swallow. This may be associated with swallow. This may be associated with
aspiration or nasopharyngeal regurgitation.aspiration or nasopharyngeal regurgitation.
In Oesophageal dysphagia, patients complain In Oesophageal dysphagia, patients complain
of food sticking in their lower throat, neck, of food sticking in their lower throat, neck,
retro-sternal discomfort or epigastrium.retro-sternal discomfort or epigastrium.
In Oropharyngeal dysphagia, there is difficulty In Oropharyngeal dysphagia, there is difficulty
in preparing and transporting the food bolus in preparing and transporting the food bolus
through the oral cavity as well as initiating the through the oral cavity as well as initiating the
swallow. This may be associated with swallow. This may be associated with
aspiration or nasopharyngeal regurgitation.aspiration or nasopharyngeal regurgitation.
In Oesophageal dysphagia, patients complain In Oesophageal dysphagia, patients complain
of food sticking in their lower throat, neck, of food sticking in their lower throat, neck,
retro-sternal discomfort or epigastrium.retro-sternal discomfort or epigastrium.
The HistoryThe History
The history can also be used to help differentiate The history can also be used to help differentiate
structural from functional (i.e., motility disorders) structural from functional (i.e., motility disorders)
causes of dysphagia. causes of dysphagia.
Dysphagia that is episodic and occurs with both Dysphagia that is episodic and occurs with both
liquids and solids from the outset (Equal liquids and solids from the outset (Equal
dysphagia) suggests a motor disorder, whereas dysphagia) suggests a motor disorder, whereas
when the dysphagia is initially for solids, and when the dysphagia is initially for solids, and
then progresses with time to semisolids and then progresses with time to semisolids and
liquids, one should suspect a structural cause liquids, one should suspect a structural cause
(e.g., stricture). (e.g., stricture).
If such a progression is rapid and associated with If such a progression is rapid and associated with
significant weight loss, a malignant stricture is significant weight loss, a malignant stricture is
suspected suspected
The history can also be used to help differentiate The history can also be used to help differentiate
structural from functional (i.e., motility disorders) structural from functional (i.e., motility disorders)
causes of dysphagia. causes of dysphagia.
Dysphagia that is episodic and occurs with both Dysphagia that is episodic and occurs with both
liquids and solids from the outset (Equal liquids and solids from the outset (Equal
dysphagia) suggests a motor disorder, whereas dysphagia) suggests a motor disorder, whereas
when the dysphagia is initially for solids, and when the dysphagia is initially for solids, and
then progresses with time to semisolids and then progresses with time to semisolids and
liquids, one should suspect a structural cause liquids, one should suspect a structural cause
(e.g., stricture). (e.g., stricture).
If such a progression is rapid and associated with If such a progression is rapid and associated with
significant weight loss, a malignant stricture is significant weight loss, a malignant stricture is
suspected suspected
Symptom onset and progressionSymptom onset and progression
Sudden onsetSudden onset of symptoms may result from a of symptoms may result from a strokestroke
(OPD) or food impaction (OD). (OPD) or food impaction (OD).
Intermittent non progressive or slowly progressiveIntermittent non progressive or slowly progressive
dysphagia suggests a benign cause, such as a motility dysphagia suggests a benign cause, such as a motility
disorder or a stable peptic esophageal stricture. disorder or a stable peptic esophageal stricture.
A history of prolonged heartburnA history of prolonged heartburn may suggest peptic may suggest peptic
esophageal stricture, neoplasm, or esophageal ring. esophageal stricture, neoplasm, or esophageal ring.
Sudden onsetSudden onset of symptoms may result from a of symptoms may result from a strokestroke
(OPD) or food impaction (OD). (OPD) or food impaction (OD).
Intermittent non progressive or slowly progressiveIntermittent non progressive or slowly progressive
dysphagia suggests a benign cause, such as a motility dysphagia suggests a benign cause, such as a motility
disorder or a stable peptic esophageal stricture. disorder or a stable peptic esophageal stricture.
A history of prolonged heartburnA history of prolonged heartburn may suggest peptic may suggest peptic
esophageal stricture, neoplasm, or esophageal ring. esophageal stricture, neoplasm, or esophageal ring.
Key PointsKey Points
Age suggests most likely cause of dysphagiaAge suggests most likely cause of dysphagia
Globus pharyngeus rarely associated with any Globus pharyngeus rarely associated with any
serious diseaseserious disease
Dysphagia of short duration in elderly patient Dysphagia of short duration in elderly patient
who smoke or drink and which progress from who smoke or drink and which progress from
solids to liquids is a classic case of malignancysolids to liquids is a classic case of malignancy
Referred otalgia with dysphagia is a sinister Referred otalgia with dysphagia is a sinister
symptom and poor prognostic signsymptom and poor prognostic sign
Age suggests most likely cause of dysphagiaAge suggests most likely cause of dysphagia
Globus pharyngeus rarely associated with any Globus pharyngeus rarely associated with any
serious diseaseserious disease
Dysphagia of short duration in elderly patient Dysphagia of short duration in elderly patient
who smoke or drink and which progress from who smoke or drink and which progress from
solids to liquids is a classic case of malignancysolids to liquids is a classic case of malignancy
Referred otalgia with dysphagia is a sinister Referred otalgia with dysphagia is a sinister
symptom and poor prognostic signsymptom and poor prognostic sign
Key Points (2)Key Points (2)
Neurological causes of dysphagia mostly affect Neurological causes of dysphagia mostly affect
orpharyngeal phaseorpharyngeal phase
Ingested foreign bodies tend to lodge at sites of Ingested foreign bodies tend to lodge at sites of
constrictionconstriction
Barium study is contraindicated in patients with Barium study is contraindicated in patients with
suspected perforation of oesophagussuspected perforation of oesophagus
Neurological causes of dysphagia mostly affect Neurological causes of dysphagia mostly affect
orpharyngeal phaseorpharyngeal phase
Ingested foreign bodies tend to lodge at sites of Ingested foreign bodies tend to lodge at sites of
constrictionconstriction
Barium study is contraindicated in patients with Barium study is contraindicated in patients with
suspected perforation of oesophagussuspected perforation of oesophagus
Physical examinationPhysical examination
General factors such as body habitus, General factors such as body habitus, droolingdrooling, and , and
mental status should be noted.mental status should be noted.
Voice qualityVoice quality (e.g. a wet sounding voice suggesting (e.g. a wet sounding voice suggesting
pooling of secretions), Wheezing or labored pooling of secretions), Wheezing or labored
breathing, and any cranial nerve weakness should be breathing, and any cranial nerve weakness should be
noted.noted.
Gurgling noise in the neckGurgling noise in the neck or crepitus in the neck or crepitus in the neck
may indicate the presence of Zenker’s diverticulum. may indicate the presence of Zenker’s diverticulum.
Inspection or palpation of the tongueInspection or palpation of the tongue and tongue and tongue
strength may unmask fibrillation or fasciculation of strength may unmask fibrillation or fasciculation of
one or both sides.one or both sides.
General factors such as body habitus, General factors such as body habitus, droolingdrooling, and , and
mental status should be noted.mental status should be noted.
Voice qualityVoice quality (e.g. a wet sounding voice suggesting (e.g. a wet sounding voice suggesting
pooling of secretions), Wheezing or labored pooling of secretions), Wheezing or labored
breathing, and any cranial nerve weakness should be breathing, and any cranial nerve weakness should be
noted.noted.
Gurgling noise in the neckGurgling noise in the neck or crepitus in the neck or crepitus in the neck
may indicate the presence of Zenker’s diverticulum. may indicate the presence of Zenker’s diverticulum.
Inspection or palpation of the tongueInspection or palpation of the tongue and tongue and tongue
strength may unmask fibrillation or fasciculation of strength may unmask fibrillation or fasciculation of
one or both sides.one or both sides.
InvestigationInvestigation
Barium swallowBarium swallow
EndoscopyEndoscopy
Esophageal manometryEsophageal manometry
Chest x-rayChest x-ray
EUSEUS
PH StudyPH Study
ThoracoscopyThoracoscopy
Barium swallowBarium swallow
EndoscopyEndoscopy
Esophageal manometryEsophageal manometry
Chest x-rayChest x-ray
EUSEUS
PH StudyPH Study
ThoracoscopyThoracoscopy
Investigations for Dysphagia:
Plain Films
Inflammatory (epiglottitis, Retro-Pharyngeal
abscess), radio-opaque foreign bodies.
Barium
Esophagram
Indicated in patients in whom structural disorders
are suspected (e.g. dysphagia to solid foods)
Manometry Rarely used except in cases where elevated
intraluminal pressures must be followed (e.g.
achalasia).
Bolus
Scintigraphy
Indicated to follow improvement in a patient with
h/O aspiration or to follow esophageal emptying
in achalasia.
Video
fluoroscopic
examination or
modified
barium
swallow
"Gold standard", integrity of the oral and
pharyngeal stages of the swallowing process.
Plain Films
Inflammatory (epiglottitis, Retro-Pharyngeal
abscess), radio-opaque foreign bodies.
Barium
Esophagram
Indicated in patients in whom structural disorders
are suspected (e.g. dysphagia to solid foods)
Manometry Rarely used except in cases where elevated
intraluminal pressures must be followed (e.g.
achalasia).
Bolus
Scintigraphy
Indicated to follow improvement in a patient with
h/O aspiration or to follow esophageal emptying
in achalasia.
Video
fluoroscopic
examination or
modified
barium
swallow
"Gold standard", integrity of the oral and
pharyngeal stages of the swallowing process.
Achalasia
Achalasia (“failure to relax"): loss of peristalsis in the
distal esophagus and a failure of LES relaxation.
The etiology of achalasia is not known
Autoimmune disorder - associated with HLA-DQw1
antibodies to enteric neurons
Chronic infections with herpes zoster or measles
viruses.
Chaga’s disease
Achalasia (“failure to relax"): loss of peristalsis in the
distal esophagus and a failure of LES relaxation.
The etiology of achalasia is not known
Autoimmune disorder - associated with HLA-DQw1
antibodies to enteric neurons
Chronic infections with herpes zoster or measles
viruses.
Chaga’s disease
Achalasia: Pathology
Ineffective relaxation of the LES
loss of esophageal peristalsis → impaired
esophageal emptying and gradual dilatation
Decrease or loss of myenteric ganglion cells
Slight increase risk of esophageal carcinoma
Ineffective relaxation of the LES
loss of esophageal peristalsis → impaired
esophageal emptying and gradual dilatation
Decrease or loss of myenteric ganglion cells
Slight increase risk of esophageal carcinoma
Achalasia is a disease of unknown etiology that is Achalasia is a disease of unknown etiology that is
characterized by the degeneration of neural elements in the characterized by the degeneration of neural elements in the
wall of the esophagus. Degenerative changes also can be wall of the esophagus. Degenerative changes also can be
found in ganglion cells of the dorsal motor nucleus of the found in ganglion cells of the dorsal motor nucleus of the
vagus in the brainstem, and Wallerian degeneration has vagus in the brainstem, and Wallerian degeneration has
been observed in vagal fibers that supply the esophagus. been observed in vagal fibers that supply the esophagus.
The disordered esophageal motility of achalasia appears to The disordered esophageal motility of achalasia appears to
be due primarily to the degeneration and loss of ganglion be due primarily to the degeneration and loss of ganglion
cells within the esophageal wall, a process that cells within the esophageal wall, a process that
preferentially affects inhibitory neurons. preferentially affects inhibitory neurons.
Loss of inhibitory neurons in the LES causes basal sphincter Loss of inhibitory neurons in the LES causes basal sphincter
pressures to rise, and renders the sphincter incapable of pressures to rise, and renders the sphincter incapable of
normal relaxation. In the smooth muscle portion of the body normal relaxation. In the smooth muscle portion of the body
of the esophagus, the loss of intramural neurons results in of the esophagus, the loss of intramural neurons results in
aperistalsis. aperistalsis.
Achalasia is a disease of unknown etiology that is Achalasia is a disease of unknown etiology that is
characterized by the degeneration of neural elements in the characterized by the degeneration of neural elements in the
wall of the esophagus. Degenerative changes also can be wall of the esophagus. Degenerative changes also can be
found in ganglion cells of the dorsal motor nucleus of the found in ganglion cells of the dorsal motor nucleus of the
vagus in the brainstem, and Wallerian degeneration has vagus in the brainstem, and Wallerian degeneration has
been observed in vagal fibers that supply the esophagus. been observed in vagal fibers that supply the esophagus.
The disordered esophageal motility of achalasia appears to The disordered esophageal motility of achalasia appears to
be due primarily to the degeneration and loss of ganglion be due primarily to the degeneration and loss of ganglion
cells within the esophageal wall, a process that cells within the esophageal wall, a process that
preferentially affects inhibitory neurons. preferentially affects inhibitory neurons.
Loss of inhibitory neurons in the LES causes basal sphincter Loss of inhibitory neurons in the LES causes basal sphincter
pressures to rise, and renders the sphincter incapable of pressures to rise, and renders the sphincter incapable of
normal relaxation. In the smooth muscle portion of the body normal relaxation. In the smooth muscle portion of the body
of the esophagus, the loss of intramural neurons results in of the esophagus, the loss of intramural neurons results in
aperistalsis. aperistalsis.
Achalasia
•LES pressure and relaxation are regulated by
excitatory (eg, acetylcholine, substance P)
and inhibitory (eg, nitric oxide, vasoactive
intestinal peptide) neurotransmitters.
• Persons with achalasia lack nonadrenergic,
noncholinergic, inhibitory ganglion cells,
causing an imbalance in excitatory and
inhibitory neurotransmission.
•The result is a hypertensive nonrelaxed
esophageal sphincter.
•LES pressure and relaxation are regulated by
excitatory (eg, acetylcholine, substance P)
and inhibitory (eg, nitric oxide, vasoactive
intestinal peptide) neurotransmitters.
• Persons with achalasia lack nonadrenergic,
noncholinergic, inhibitory ganglion cells,
causing an imbalance in excitatory and
inhibitory neurotransmission.
•The result is a hypertensive nonrelaxed
esophageal sphincter.
Incidence
Annual incidence of approximately 1 case per 100,000.
Men and women are affected with equal frequency.
Usually diagnosed between the ages of 25 and 60 years.
Seen and reported from Ethiopia.
Beware of pseudo-achalasia
Annual incidence of approximately 1 case per 100,000.
Men and women are affected with equal frequency.
Usually diagnosed between the ages of 25 and 60 years.
Seen and reported from Ethiopia.
Beware of pseudo-achalasia
Symptomatology
Dysphagia: delayed (about 2 years) and progressive,
worse for fluid than solid,
Weight loss
Regurgitation of undigested food
Regurgitation associated pulmonary complication
Chest pain
Dysphagia: delayed (about 2 years) and progressive,
worse for fluid than solid,
Weight loss
Regurgitation of undigested food
Regurgitation associated pulmonary complication
Chest pain
Achalasia: Investigations
CXR: Esophageal air fluid levels
Barium swallow: Dilated esophagus with Bird's beak
deformity.
Manometry: gold standard
Elevated LES pressure (> 35mmHg)
Incomplete sphincter relaxation
Complete absence of peristalsis
Endoscopy: dilated esophagus with tightly closed LES
→ gentle pressure will admit the scope with a "pop“.
CXR: Esophageal air fluid levels
Barium swallow: Dilated esophagus with Bird's beak
deformity.
Manometry: gold standard
Elevated LES pressure (> 35mmHg)
Incomplete sphincter relaxation
Complete absence of peristalsis
Endoscopy: dilated esophagus with tightly closed LES
→ gentle pressure will admit the scope with a "pop“.
Approach ConsiderationsApproach Considerations
Recommendations for the proper diagnosis of the disorder Recommendations for the proper diagnosis of the disorder
include the following:include the following:
Performing an esophageal motility test on all patients suspected of Performing an esophageal motility test on all patients suspected of
having achalasiahaving achalasia
Using esophagram findings to support a diagnosisUsing esophagram findings to support a diagnosis
Using barium esophagram, as recommended for patients with Using barium esophagram, as recommended for patients with
equivocal motility testingequivocal motility testing
Endoscopic assessment of the gastroesophageal junction and gastric Endoscopic assessment of the gastroesophageal junction and gastric
cardia, as recommended, to rule out pseudoachalasiacardia, as recommended, to rule out pseudoachalasia
Perform an esophagogastroduodenoscopy (EGD) to rule out cancer Perform an esophagogastroduodenoscopy (EGD) to rule out cancer
of the gastroesophageal junction or fundus. If a tumor is suspected, of the gastroesophageal junction or fundus. If a tumor is suspected,
perform an endoscopic ultrasound at the same time.perform an endoscopic ultrasound at the same time.
Recommendations for the proper diagnosis of the disorder Recommendations for the proper diagnosis of the disorder
include the following:include the following:
Performing an esophageal motility test on all patients suspected of Performing an esophageal motility test on all patients suspected of
having achalasiahaving achalasia
Using esophagram findings to support a diagnosisUsing esophagram findings to support a diagnosis
Using barium esophagram, as recommended for patients with Using barium esophagram, as recommended for patients with
equivocal motility testingequivocal motility testing
Endoscopic assessment of the gastroesophageal junction and gastric Endoscopic assessment of the gastroesophageal junction and gastric
cardia, as recommended, to rule out pseudoachalasiacardia, as recommended, to rule out pseudoachalasia
Perform an esophagogastroduodenoscopy (EGD) to rule out cancer Perform an esophagogastroduodenoscopy (EGD) to rule out cancer
of the gastroesophageal junction or fundus. If a tumor is suspected, of the gastroesophageal junction or fundus. If a tumor is suspected,
perform an endoscopic ultrasound at the same time.perform an endoscopic ultrasound at the same time.
Achlasia work upAchlasia work up
The radiologic examination of choice in the diagnosis of The radiologic examination of choice in the diagnosis of
achalasia is a barium swallow study performed under achalasia is a barium swallow study performed under
fluoroscopic guidance.fluoroscopic guidance.
A diagnosis of achalasia supported by the results of A diagnosis of achalasia supported by the results of
radiologic studies must always be confirmed by radiologic studies must always be confirmed by
performing upper gastrointestinal endoscopy and performing upper gastrointestinal endoscopy and
esophageal manometry.esophageal manometry.
24 Hour pH measurement: 24 Hour pH measurement: important for the following important for the following
reasons;reasons;
To rule out gastroesophageal reflux disease (GERD)To rule out gastroesophageal reflux disease (GERD)
To determine if abnormal reflux is being caused by treatment.To determine if abnormal reflux is being caused by treatment.
The radiologic examination of choice in the diagnosis of The radiologic examination of choice in the diagnosis of
achalasia is a barium swallow study performed under achalasia is a barium swallow study performed under
fluoroscopic guidance.fluoroscopic guidance.
A diagnosis of achalasia supported by the results of A diagnosis of achalasia supported by the results of
radiologic studies must always be confirmed by radiologic studies must always be confirmed by
performing upper gastrointestinal endoscopy and performing upper gastrointestinal endoscopy and
esophageal manometry.esophageal manometry.
24 Hour pH measurement: 24 Hour pH measurement: important for the following important for the following
reasons;reasons;
To rule out gastroesophageal reflux disease (GERD)To rule out gastroesophageal reflux disease (GERD)
To determine if abnormal reflux is being caused by treatment.To determine if abnormal reflux is being caused by treatment.
Achalasia: Pseudo-
achalasia
achalasia
Achalasia: Treatment
Palliation of dysphagia is the key:
→ relieve functional obstruction of distal esophagus
Options of treatment
Pharmacotherapy
Botulinum toxin
Esophageal dilation
Operative myotomy (Heller’s cardiomyotomy)
Palliation of dysphagia is the key:
→ relieve functional obstruction of distal esophagus
Options of treatment
Pharmacotherapy
Botulinum toxin
Esophageal dilation
Operative myotomy (Heller’s cardiomyotomy)
Achalasia: Pharmacotherapy
Nitrates
Ca++ channel blockers
Anticholinergics
Opiods
Nitrates
Ca++ channel blockers
Anticholinergics
Opiods
Botulinum Toxin injection
Baloon dilatation
Modified Heller’s cardiomyotomy
Treatment recommendations Treatment recommendations
Initial therapy should be either graded pneumatic dilation (PD) or Initial therapy should be either graded pneumatic dilation (PD) or
laparoscopic surgical myotomy with a partial fundoplication in laparoscopic surgical myotomy with a partial fundoplication in
patients fit to undergo surgerypatients fit to undergo surgery
Initial therapy choice should be based on patient age, sex, Initial therapy choice should be based on patient age, sex,
preference, and local institutional expertisepreference, and local institutional expertise
Botulinum toxin therapy is recommended for patients not suited to Botulinum toxin therapy is recommended for patients not suited to
PD or surgeryPD or surgery
Pharmacologic therapy can be used for patients not undergoing Pharmacologic therapy can be used for patients not undergoing
PD or myotomy and who have failed botulinum toxin therapy PD or myotomy and who have failed botulinum toxin therapy
Initial therapy should be either graded pneumatic dilation (PD) or Initial therapy should be either graded pneumatic dilation (PD) or
laparoscopic surgical myotomy with a partial fundoplication in laparoscopic surgical myotomy with a partial fundoplication in
patients fit to undergo surgerypatients fit to undergo surgery
Initial therapy choice should be based on patient age, sex, Initial therapy choice should be based on patient age, sex,
preference, and local institutional expertisepreference, and local institutional expertise
Botulinum toxin therapy is recommended for patients not suited to Botulinum toxin therapy is recommended for patients not suited to
PD or surgeryPD or surgery
Pharmacologic therapy can be used for patients not undergoing Pharmacologic therapy can be used for patients not undergoing
PD or myotomy and who have failed botulinum toxin therapy PD or myotomy and who have failed botulinum toxin therapy
DES & Nutcracker EsophagusDES & Nutcracker Esophagus
Characterized by Characterized by severe chest painsevere chest pain and and
dysphagiadysphagia
Primarily involvement of lower 1/3, muscle Primarily involvement of lower 1/3, muscle
hypertrophy and high pressure contractionshypertrophy and high pressure contractions
Symptoms intermittent so ambulatory Symptoms intermittent so ambulatory
manometry is requiredmanometry is required
Treat with calcium channel blockers or balloon Treat with calcium channel blockers or balloon
dilatationdilatation
Results disappointingResults disappointing
Characterized by Characterized by severe chest painsevere chest pain and and
dysphagiadysphagia
Primarily involvement of lower 1/3, muscle Primarily involvement of lower 1/3, muscle
hypertrophy and high pressure contractionshypertrophy and high pressure contractions
Symptoms intermittent so ambulatory Symptoms intermittent so ambulatory
manometry is requiredmanometry is required
Treat with calcium channel blockers or balloon Treat with calcium channel blockers or balloon
dilatationdilatation
Results disappointingResults disappointing
Nutcracker EsophagusNutcracker Esophagus
The major difference between esophageal spasm and The major difference between esophageal spasm and
nutcracker esophagus is that in a nutcracker esophagus there nutcracker esophagus is that in a nutcracker esophagus there
are very high amplitude contractions in the distal esophagus are very high amplitude contractions in the distal esophagus
and no simultaneous contractions as seen in esophageal spasm and no simultaneous contractions as seen in esophageal spasm
and only occasionally does impairment of esophageal function and only occasionally does impairment of esophageal function
lead to dysphagia. lead to dysphagia.
““nutcracker” is often used to represent a variant of diffuse nutcracker” is often used to represent a variant of diffuse
esophageal spasm.esophageal spasm.
The major difference between esophageal spasm and The major difference between esophageal spasm and
nutcracker esophagus is that in a nutcracker esophagus there nutcracker esophagus is that in a nutcracker esophagus there
are very high amplitude contractions in the distal esophagus are very high amplitude contractions in the distal esophagus
and no simultaneous contractions as seen in esophageal spasm and no simultaneous contractions as seen in esophageal spasm
and only occasionally does impairment of esophageal function and only occasionally does impairment of esophageal function
lead to dysphagia. lead to dysphagia.
““nutcracker” is often used to represent a variant of diffuse nutcracker” is often used to represent a variant of diffuse
esophageal spasm.esophageal spasm.
Esophageal DiverticulumEsophageal Diverticulum
I. Upper Esophageal Diverticula (Zenker's) I. Upper Esophageal Diverticula (Zenker's)
Uncommon Esophageal Diverticula/Pulsion or traction forcesUncommon Esophageal Diverticula/Pulsion or traction forces
II. Midesophageal II. Midesophageal
-Usually small and asymptomatic.-Usually small and asymptomatic.
III. Epiphrenic III. Epiphrenic
-Usually symptomatic and on the right-Usually symptomatic and on the right
I. Upper Esophageal Diverticula (Zenker's) I. Upper Esophageal Diverticula (Zenker's)
Uncommon Esophageal Diverticula/Pulsion or traction forcesUncommon Esophageal Diverticula/Pulsion or traction forces
II. Midesophageal II. Midesophageal
-Usually small and asymptomatic.-Usually small and asymptomatic.
III. Epiphrenic III. Epiphrenic
-Usually symptomatic and on the right-Usually symptomatic and on the right
Zenker's diverticulumZenker's diverticulum
Key factsKey facts
Associated with lower cranial nerve Associated with lower cranial nerve
dysfunction (e.g. motor neuron disease, dysfunction (e.g. motor neuron disease,
previous CVA).previous CVA).
Pathological featuresPathological features
Acquired diverticulum: fibrous tissue and Acquired diverticulum: fibrous tissue and
serosa without muscle fibres in most of the serosa without muscle fibres in most of the
wall.wall.
Tends to lie to one side of the midline due to Tends to lie to one side of the midline due to
the cervical spine directly behind.the cervical spine directly behind.
Key factsKey facts
Associated with lower cranial nerve Associated with lower cranial nerve
dysfunction (e.g. motor neuron disease, dysfunction (e.g. motor neuron disease,
previous CVA).previous CVA).
Pathological featuresPathological features
Acquired diverticulum: fibrous tissue and Acquired diverticulum: fibrous tissue and
serosa without muscle fibres in most of the serosa without muscle fibres in most of the
wall.wall.
Tends to lie to one side of the midline due to Tends to lie to one side of the midline due to
the cervical spine directly behind.the cervical spine directly behind.
Pharyngeal pouchPharyngeal pouch – –
Zenker's diverticulumZenker's diverticulum
Key factsKey facts
An acquired An acquired pulsionpulsion diverticulum arising in the diverticulum arising in the
relatively fibrous tissue between the inferior constrictor relatively fibrous tissue between the inferior constrictor
and cricopharyngeus muscle: ˜Killian's dehiscence.and cricopharyngeus muscle: ˜Killian's dehiscence.
Arises primarily as a result of failure of appropriate Arises primarily as a result of failure of appropriate
coordinated relaxation of the cricopharyngeus causing coordinated relaxation of the cricopharyngeus causing
increased pressure on the tissues directly above during increased pressure on the tissues directly above during
swallowing.swallowing.
Typically occurs in the elderly.Typically occurs in the elderly.
Zenker's diverticulumZenker's diverticulum
Key factsKey facts
An acquired An acquired pulsionpulsion diverticulum arising in the diverticulum arising in the
relatively fibrous tissue between the inferior constrictor relatively fibrous tissue between the inferior constrictor
and cricopharyngeus muscle: ˜Killian's dehiscence.and cricopharyngeus muscle: ˜Killian's dehiscence.
Arises primarily as a result of failure of appropriate Arises primarily as a result of failure of appropriate
coordinated relaxation of the cricopharyngeus causing coordinated relaxation of the cricopharyngeus causing
increased pressure on the tissues directly above during increased pressure on the tissues directly above during
swallowing.swallowing.
Typically occurs in the elderly.Typically occurs in the elderly.
Zenker's diverticulumZenker's diverticulum
Clinical featuresClinical features
Upper cervical dysphagia.Upper cervical dysphagia.
Intermittent ˜lump appearing to the side Intermittent ˜lump appearing to the side
of the neck on swallowing.of the neck on swallowing.
Regurgitation of foodRegurgitation of food undigested.undigested.
Clinical featuresClinical features
Upper cervical dysphagia.Upper cervical dysphagia.
Intermittent ˜lump appearing to the side Intermittent ˜lump appearing to the side
of the neck on swallowing.of the neck on swallowing.
Regurgitation of foodRegurgitation of food undigested.undigested.
Zenker´s diverticulumZenker´s diverticulum
Diagnosis and investigationsDiagnosis and investigations
Diagnosis may be made on observed Diagnosis may be made on observed
swallowing with a transient neck swelling swallowing with a transient neck swelling
appearing.appearing.
Video barium swallow will show filling of Video barium swallow will show filling of
pouch.pouch.
Gastroscopy should be avoided unless there is a Gastroscopy should be avoided unless there is a
question of associated pathology since the question of associated pathology since the
pouch is easily missed and easily damaged or pouch is easily missed and easily damaged or
perforated by inadvertent intubation.perforated by inadvertent intubation.
Diagnosis and investigationsDiagnosis and investigations
Diagnosis may be made on observed Diagnosis may be made on observed
swallowing with a transient neck swelling swallowing with a transient neck swelling
appearing.appearing.
Video barium swallow will show filling of Video barium swallow will show filling of
pouch.pouch.
Gastroscopy should be avoided unless there is a Gastroscopy should be avoided unless there is a
question of associated pathology since the question of associated pathology since the
pouch is easily missed and easily damaged or pouch is easily missed and easily damaged or
perforated by inadvertent intubation.perforated by inadvertent intubation.
Zenker´s diverticulumZenker´s diverticulum
TreatmentTreatment
Endoscopic stapled pharyngoplasty: side Endoscopic stapled pharyngoplasty: side
to side stapling of pouch to the upper to side stapling of pouch to the upper
oesophagus, which also divides the oesophagus, which also divides the
cricopharyngeus musclecricopharyngeus muscle
TreatmentTreatment
Endoscopic stapled pharyngoplasty: side Endoscopic stapled pharyngoplasty: side
to side stapling of pouch to the upper to side stapling of pouch to the upper
oesophagus, which also divides the oesophagus, which also divides the
cricopharyngeus musclecricopharyngeus muscle
Hiatus herniaHiatus hernia
Key factsKey facts
The presence of part or all of the stomach The presence of part or all of the stomach
within the thoracic cavity, usually by protrusion within the thoracic cavity, usually by protrusion
through the oesophageal hiatus in the through the oesophageal hiatus in the
diaphragmdiaphragm
Very common; majority are asymptomatic.Very common; majority are asymptomatic.
May or may not be associated with gastro-May or may not be associated with gastro-
oesophageal reflux disease.oesophageal reflux disease.
Predisposing factors: obesity, previous surgery.Predisposing factors: obesity, previous surgery.
Key factsKey facts
The presence of part or all of the stomach The presence of part or all of the stomach
within the thoracic cavity, usually by protrusion within the thoracic cavity, usually by protrusion
through the oesophageal hiatus in the through the oesophageal hiatus in the
diaphragmdiaphragm
Very common; majority are asymptomatic.Very common; majority are asymptomatic.
May or may not be associated with gastro-May or may not be associated with gastro-
oesophageal reflux disease.oesophageal reflux disease.
Predisposing factors: obesity, previous surgery.Predisposing factors: obesity, previous surgery.
Hiatus herniaHiatus hernia
Clinico-pathological featuresClinico-pathological features
Sliding herniaSliding hernia
Results from axial displacement of upper Results from axial displacement of upper
stomach through the oesophageal hiatus, stomach through the oesophageal hiatus,
usually with stretching of the phrenico-usually with stretching of the phrenico-
oesophageal membrane.oesophageal membrane.
By far the commonest form. May result By far the commonest form. May result
in GORD.in GORD.
Clinico-pathological featuresClinico-pathological features
Sliding herniaSliding hernia
Results from axial displacement of upper Results from axial displacement of upper
stomach through the oesophageal hiatus, stomach through the oesophageal hiatus,
usually with stretching of the phrenico-usually with stretching of the phrenico-
oesophageal membrane.oesophageal membrane.
By far the commonest form. May result By far the commonest form. May result
in GORD.in GORD.
Hiatus herniaHiatus hernia
Clinico-pathological featuresClinico-pathological features
Rolling (paraoesophageal) herniaRolling (paraoesophageal) hernia
Results from the displacement of part or all of the Results from the displacement of part or all of the
fundus and body of the stomach through a defect in the fundus and body of the stomach through a defect in the
phrenico-oesophageal membrane such that it comes to phrenico-oesophageal membrane such that it comes to
lie alongside the normal oesophagus.lie alongside the normal oesophagus.
Much less common.Much less common.
Symptoms include hiccough, ˜pressure in the chest, Symptoms include hiccough, ˜pressure in the chest,
odynophagia.odynophagia.
May result in volvulus or becomMay result in volvulus or become e incarcerated and incarcerated and
cause obstructioncause obstruction..
Clinico-pathological featuresClinico-pathological features
Rolling (paraoesophageal) herniaRolling (paraoesophageal) hernia
Results from the displacement of part or all of the Results from the displacement of part or all of the
fundus and body of the stomach through a defect in the fundus and body of the stomach through a defect in the
phrenico-oesophageal membrane such that it comes to phrenico-oesophageal membrane such that it comes to
lie alongside the normal oesophagus.lie alongside the normal oesophagus.
Much less common.Much less common.
Symptoms include hiccough, ˜pressure in the chest, Symptoms include hiccough, ˜pressure in the chest,
odynophagia.odynophagia.
May result in volvulus or becomMay result in volvulus or become e incarcerated and incarcerated and
cause obstructioncause obstruction..
Diagnosis and investigationsDiagnosis and investigations
Video barium swallow usually identifies Video barium swallow usually identifies
the type and extent.the type and extent.
CT scanning of the thorax is the CT scanning of the thorax is the
investigation of choice in acute investigation of choice in acute
presentations.presentations.
Video barium swallow usually identifies Video barium swallow usually identifies
the type and extent.the type and extent.
CT scanning of the thorax is the CT scanning of the thorax is the
investigation of choice in acute investigation of choice in acute
presentations.presentations.
TreatmentTreatment
Medical (mainly for GORD symptoms)Medical (mainly for GORD symptoms)
Reduce acid production. Stop smoking, Reduce acid production. Stop smoking,
lose weight, reduce alcohol consumption.lose weight, reduce alcohol consumption.
Counteract acid secretion: proton pump Counteract acid secretion: proton pump
inhibitors, symptomatic relief with inhibitors, symptomatic relief with
antacids.antacids.
Promote oesophageal emptying : Promote oesophageal emptying :
promotilants, e.g. metoclopramide.promotilants, e.g. metoclopramide.
Medical (mainly for GORD symptoms)Medical (mainly for GORD symptoms)
Reduce acid production. Stop smoking, Reduce acid production. Stop smoking,
lose weight, reduce alcohol consumption.lose weight, reduce alcohol consumption.
Counteract acid secretion: proton pump Counteract acid secretion: proton pump
inhibitors, symptomatic relief with inhibitors, symptomatic relief with
antacids.antacids.
Promote oesophageal emptying : Promote oesophageal emptying :
promotilants, e.g. metoclopramide.promotilants, e.g. metoclopramide.
SurgicalSurgical
Rarely required. Indicated forRarely required. Indicated for::
persistent symptoms despite maximal medical therapy;persistent symptoms despite maximal medical therapy;
established complications of rolling hernia such as established complications of rolling hernia such as
volvulus or obstruction.volvulus or obstruction.
Elective procedure of choice is open or laparoscopic Elective procedure of choice is open or laparoscopic
reduction of the hernia and fixation (gastropexy), usually reduction of the hernia and fixation (gastropexy), usually
with plication of the oesophageal opening with plication of the oesophageal opening (cural plication), (cural plication),
occasionally with a fundoplication (e.g. Nissen's operation) if occasionally with a fundoplication (e.g. Nissen's operation) if
GORD symptoms predominate. Acute presentations may require a GORD symptoms predominate. Acute presentations may require a
partial gastrectomy.partial gastrectomy.
SurgicalSurgical
Rarely required. Indicated forRarely required. Indicated for::
persistent symptoms despite maximal medical therapy;persistent symptoms despite maximal medical therapy;
established complications of rolling hernia such as established complications of rolling hernia such as
volvulus or obstruction.volvulus or obstruction.
Elective procedure of choice is open or laparoscopic Elective procedure of choice is open or laparoscopic
reduction of the hernia and fixation (gastropexy), usually reduction of the hernia and fixation (gastropexy), usually
with plication of the oesophageal opening with plication of the oesophageal opening (cural plication), (cural plication),
occasionally with a fundoplication (e.g. Nissen's operation) if occasionally with a fundoplication (e.g. Nissen's operation) if
GORD symptoms predominate. Acute presentations may require a GORD symptoms predominate. Acute presentations may require a
partial gastrectomy.partial gastrectomy.
Gastro-oesophageal reflux disease Gastro-oesophageal reflux disease
GORDGORD
Key factsKey facts
Pathologically excessive entry of gastric contents into the Pathologically excessive entry of gastric contents into the
oesophagus.oesophagus.
Reflux occurs ˜normally up to 5% of the time.Reflux occurs ˜normally up to 5% of the time.
Commonest in middle-aged adults.Commonest in middle-aged adults.
Usually due to gastric acid but also due to bile reflux.Usually due to gastric acid but also due to bile reflux.
Contributory factors include:Contributory factors include:
reduced tone in the lower oesophageal sphincter: idiopathic, reduced tone in the lower oesophageal sphincter: idiopathic,
alcohol, drugs, previous surgery, secondary to existing peptic alcohol, drugs, previous surgery, secondary to existing peptic
stricture.stricture.
increased intragastric pressure: coughing, delayed gastric increased intragastric pressure: coughing, delayed gastric
emptying, large meal.emptying, large meal.
GORDGORD
Key factsKey facts
Pathologically excessive entry of gastric contents into the Pathologically excessive entry of gastric contents into the
oesophagus.oesophagus.
Reflux occurs ˜normally up to 5% of the time.Reflux occurs ˜normally up to 5% of the time.
Commonest in middle-aged adults.Commonest in middle-aged adults.
Usually due to gastric acid but also due to bile reflux.Usually due to gastric acid but also due to bile reflux.
Contributory factors include:Contributory factors include:
reduced tone in the lower oesophageal sphincter: idiopathic, reduced tone in the lower oesophageal sphincter: idiopathic,
alcohol, drugs, previous surgery, secondary to existing peptic alcohol, drugs, previous surgery, secondary to existing peptic
stricture.stricture.
increased intragastric pressure: coughing, delayed gastric increased intragastric pressure: coughing, delayed gastric
emptying, large meal.emptying, large meal.
Gastro-oesophageal reflux Gastro-oesophageal reflux
disease GORDdisease GORD
Pathological featuresPathological features
EsophagitisEsophagitis
Results in inflammatory changes in the Results in inflammatory changes in the
squamous lined oesophagus.squamous lined oesophagus.
Varies in severity from minor mucosal Varies in severity from minor mucosal
erythema and erosions to extensive erythema and erosions to extensive
circumferential ulceration and stricture. circumferential ulceration and stricture.
disease GORDdisease GORD
Pathological featuresPathological features
EsophagitisEsophagitis
Results in inflammatory changes in the Results in inflammatory changes in the
squamous lined oesophagus.squamous lined oesophagus.
Varies in severity from minor mucosal Varies in severity from minor mucosal
erythema and erosions to extensive erythema and erosions to extensive
circumferential ulceration and stricture. circumferential ulceration and stricture.
Gastro-oesophageal reflux Gastro-oesophageal reflux
disease GORDdisease GORD
Pathological featuresPathological features
StrictureStricture
Chronic fibrosis and epithelial destruction Chronic fibrosis and epithelial destruction
may result in stricture.may result in stricture.
Eventually shortening and narrowing of Eventually shortening and narrowing of
the lower esophagus.the lower esophagus.
May lead to fixation and susceptibility to May lead to fixation and susceptibility to
further reflux.further reflux.
disease GORDdisease GORD
Pathological featuresPathological features
StrictureStricture
Chronic fibrosis and epithelial destruction Chronic fibrosis and epithelial destruction
may result in stricture.may result in stricture.
Eventually shortening and narrowing of Eventually shortening and narrowing of
the lower esophagus.the lower esophagus.
May lead to fixation and susceptibility to May lead to fixation and susceptibility to
further reflux.further reflux.
Gastro-oesophageal reflux Gastro-oesophageal reflux
disease GORDdisease GORD
Clinical featuresClinical features
Dyspepsia may be the only feature; may Dyspepsia may be the only feature; may
radiate to back and left neck.radiate to back and left neck.
True reflux may occur with acid in the True reflux may occur with acid in the
pharynx.pharynx.
Commonly worse at night, after large Commonly worse at night, after large
meals, and when recumbent.meals, and when recumbent.
Dysphagia may occur if there is associated Dysphagia may occur if there is associated
ulceration or a stricture.ulceration or a stricture.
disease GORDdisease GORD
Clinical featuresClinical features
Dyspepsia may be the only feature; may Dyspepsia may be the only feature; may
radiate to back and left neck.radiate to back and left neck.
True reflux may occur with acid in the True reflux may occur with acid in the
pharynx.pharynx.
Commonly worse at night, after large Commonly worse at night, after large
meals, and when recumbent.meals, and when recumbent.
Dysphagia may occur if there is associated Dysphagia may occur if there is associated
ulceration or a stricture.ulceration or a stricture.
Gastro-oesophageal reflux Gastro-oesophageal reflux
disease GORDdisease GORD
Pathological featuresPathological features
Oesophageal metaplasia ˜Barrett's oesophagusOesophageal metaplasia ˜Barrett's oesophagus
May developMay developee as a result of gastro-oesophageal reflux; as a result of gastro-oesophageal reflux;
possibly more commonly in biliary reflux.possibly more commonly in biliary reflux.
Normal squamous epithelium is replaced by columnar Normal squamous epithelium is replaced by columnar
epithelium.epithelium.
Dysplasia and premalignant change (metaplasia) may Dysplasia and premalignant change (metaplasia) may
occur in the columnar epithelium.occur in the columnar epithelium.
disease GORDdisease GORD
Pathological featuresPathological features
Oesophageal metaplasia ˜Barrett's oesophagusOesophageal metaplasia ˜Barrett's oesophagus
May developMay developee as a result of gastro-oesophageal reflux; as a result of gastro-oesophageal reflux;
possibly more commonly in biliary reflux.possibly more commonly in biliary reflux.
Normal squamous epithelium is replaced by columnar Normal squamous epithelium is replaced by columnar
epithelium.epithelium.
Dysplasia and premalignant change (metaplasia) may Dysplasia and premalignant change (metaplasia) may
occur in the columnar epithelium.occur in the columnar epithelium.
Gastro-oesophageal reflux Gastro-oesophageal reflux
disease GORDdisease GORD
Diagnosis and investigationsDiagnosis and investigations
Under the age of 45Under the age of 45
Symptoms are relatively common and can be treated Symptoms are relatively common and can be treated
empirically. Investigation is only required if symptoms empirically. Investigation is only required if symptoms
fail to respond to treatment.fail to respond to treatment.
Over the age of 45Over the age of 45
Reflux can be confirmed by 24h continuous pH Reflux can be confirmed by 24h continuous pH
monitoring. Peaks of pH change must correspond to monitoring. Peaks of pH change must correspond to
symptoms. symptoms.
EndoscopyEndoscopy should be performed in all new cases over should be performed in all new cases over
the age of 45 to exclude oesophageal malignancy.the age of 45 to exclude oesophageal malignancy.
disease GORDdisease GORD
Diagnosis and investigationsDiagnosis and investigations
Under the age of 45Under the age of 45
Symptoms are relatively common and can be treated Symptoms are relatively common and can be treated
empirically. Investigation is only required if symptoms empirically. Investigation is only required if symptoms
fail to respond to treatment.fail to respond to treatment.
Over the age of 45Over the age of 45
Reflux can be confirmed by 24h continuous pH Reflux can be confirmed by 24h continuous pH
monitoring. Peaks of pH change must correspond to monitoring. Peaks of pH change must correspond to
symptoms. symptoms.
EndoscopyEndoscopy should be performed in all new cases over should be performed in all new cases over
the age of 45 to exclude oesophageal malignancy.the age of 45 to exclude oesophageal malignancy.
Gastro-oesophageal reflux Gastro-oesophageal reflux
disease GORDdisease GORD
TreatmentTreatment
MedicalMedical
Reduce acid production: smoking, weight, Reduce acid production: smoking, weight,
alcohol consumption.alcohol consumption.
Counteract acid secretion: proton pump Counteract acid secretion: proton pump
inhibitors (e.g. omeprazole 20mg od), inhibitors (e.g. omeprazole 20mg od),
symptomatic relief with antacids (e.g. Gaviscon symptomatic relief with antacids (e.g. Gaviscon
10mL PO od).10mL PO od).
oesophageal emptying: promotilants, e.g. oesophageal emptying: promotilants, e.g.
metoclopramide 10mg tds PO.metoclopramide 10mg tds PO.
disease GORDdisease GORD
TreatmentTreatment
MedicalMedical
Reduce acid production: smoking, weight, Reduce acid production: smoking, weight,
alcohol consumption.alcohol consumption.
Counteract acid secretion: proton pump Counteract acid secretion: proton pump
inhibitors (e.g. omeprazole 20mg od), inhibitors (e.g. omeprazole 20mg od),
symptomatic relief with antacids (e.g. Gaviscon symptomatic relief with antacids (e.g. Gaviscon
10mL PO od).10mL PO od).
oesophageal emptying: promotilants, e.g. oesophageal emptying: promotilants, e.g.
metoclopramide 10mg tds PO.metoclopramide 10mg tds PO.
Gastro-oesophageal reflux Gastro-oesophageal reflux
disease GORDdisease GORD
SurgicalSurgical
Procedure of choice is laparoscopic Procedure of choice is laparoscopic
fundoplication, ˜Nissen's operation fundoplication, ˜Nissen's operation
(wrapping fundus of the stomach around (wrapping fundus of the stomach around
the intraabdominal oesophagus to the intraabdominal oesophagus to
augment high pressure zone).augment high pressure zone).
disease GORDdisease GORD
SurgicalSurgical
Procedure of choice is laparoscopic Procedure of choice is laparoscopic
fundoplication, ˜Nissen's operation fundoplication, ˜Nissen's operation
(wrapping fundus of the stomach around (wrapping fundus of the stomach around
the intraabdominal oesophagus to the intraabdominal oesophagus to
augment high pressure zone).augment high pressure zone).
Gastro-oesophageal reflux Gastro-oesophageal reflux
disease GORDdisease GORD
SurgicalSurgical
Rarely required. Indicated for:Rarely required. Indicated for:
persistent symptoms despite maximal medical therapy;persistent symptoms despite maximal medical therapy;
large volume reflux with risk of aspiration pneumonia;large volume reflux with risk of aspiration pneumonia;
complications of reflux including stricture and severe complications of reflux including stricture and severe
ulceration.ulceration.
Uncertain role in the prevention of progressive Uncertain role in the prevention of progressive
dysplasia in Barrett's oesophageal metaplasia in the dysplasia in Barrett's oesophageal metaplasia in the
absence of symptoms.absence of symptoms.
disease GORDdisease GORD
SurgicalSurgical
Rarely required. Indicated for:Rarely required. Indicated for:
persistent symptoms despite maximal medical therapy;persistent symptoms despite maximal medical therapy;
large volume reflux with risk of aspiration pneumonia;large volume reflux with risk of aspiration pneumonia;
complications of reflux including stricture and severe complications of reflux including stricture and severe
ulceration.ulceration.
Uncertain role in the prevention of progressive Uncertain role in the prevention of progressive
dysplasia in Barrett's oesophageal metaplasia in the dysplasia in Barrett's oesophageal metaplasia in the
absence of symptoms.absence of symptoms.
Oesophageal tumoursOesophageal tumours
Key facts and pathological featuresKey facts and pathological features
There are several types of oesophageal tumours.There are several types of oesophageal tumours.
AdenocarcinomaAdenocarcinoma
Rapidly increasing incidence in Western world: 5:1 (M:F)Rapidly increasing incidence in Western world: 5:1 (M:F)
Commonest in Japan, northern China, and South Africa,Commonest in Japan, northern China, and South Africa,
Associated with dietary nitrosamines, GORD, and Barrett's Associated with dietary nitrosamines, GORD, and Barrett's
metaplasia.metaplasia.
Typically occurs in the lower half of the oesophagus.Typically occurs in the lower half of the oesophagus.
Key facts and pathological featuresKey facts and pathological features
There are several types of oesophageal tumours.There are several types of oesophageal tumours.
AdenocarcinomaAdenocarcinoma
Rapidly increasing incidence in Western world: 5:1 (M:F)Rapidly increasing incidence in Western world: 5:1 (M:F)
Commonest in Japan, northern China, and South Africa,Commonest in Japan, northern China, and South Africa,
Associated with dietary nitrosamines, GORD, and Barrett's Associated with dietary nitrosamines, GORD, and Barrett's
metaplasia.metaplasia.
Typically occurs in the lower half of the oesophagus.Typically occurs in the lower half of the oesophagus.
Oesophageal tumoursOesophageal tumours
Key facts and pathological featuresKey facts and pathological features
Squamous carcinomaSquamous carcinoma
Incidence slightly reducing in Western Incidence slightly reducing in Western
world: 3:1 (M:F) world: 3:1 (M:F)
Associated with smoking, alcohol intake, Associated with smoking, alcohol intake,
diet poor in fresh fruit and vegetables, diet poor in fresh fruit and vegetables,
chronic achalasia, chronic caustic strictures.chronic achalasia, chronic caustic strictures.
May occur anywhere in the oesophagus.May occur anywhere in the oesophagus.
Key facts and pathological featuresKey facts and pathological features
Squamous carcinomaSquamous carcinoma
Incidence slightly reducing in Western Incidence slightly reducing in Western
world: 3:1 (M:F) world: 3:1 (M:F)
Associated with smoking, alcohol intake, Associated with smoking, alcohol intake,
diet poor in fresh fruit and vegetables, diet poor in fresh fruit and vegetables,
chronic achalasia, chronic caustic strictures.chronic achalasia, chronic caustic strictures.
May occur anywhere in the oesophagus.May occur anywhere in the oesophagus.
Oesophageal tumoursOesophageal tumours
Key facts and pathological featuresKey facts and pathological features
Rhabdomyo(sarco)maRhabdomyo(sarco)ma
Malignant tumour of skeletal muscle wall Malignant tumour of skeletal muscle wall
of the oesophagus. Very rare.of the oesophagus. Very rare.
Lipoma and gastrointestinal stromal Lipoma and gastrointestinal stromal
tumourstumours
GIST are rare.GIST are rare.
Key facts and pathological featuresKey facts and pathological features
Rhabdomyo(sarco)maRhabdomyo(sarco)ma
Malignant tumour of skeletal muscle wall Malignant tumour of skeletal muscle wall
of the oesophagus. Very rare.of the oesophagus. Very rare.
Lipoma and gastrointestinal stromal Lipoma and gastrointestinal stromal
tumourstumours
GIST are rare.GIST are rare.
Esophageal CarcinomaEsophageal Carcinoma
EC is increasing in faster in incidence than any other EC is increasing in faster in incidence than any other
malignancy in developed world with a ten fold rise in malignancy in developed world with a ten fold rise in
the last 20 yearsthe last 20 years
This increase is not squamous cell carcinoma but in This increase is not squamous cell carcinoma but in
the incidence of adenocarcinomathe incidence of adenocarcinoma
Classification of ACClassification of AC
Type 1: Lower 1/3 of esophagusType 1: Lower 1/3 of esophagus
Type 2: At oesophago-gastric junctionType 2: At oesophago-gastric junction
Type 3: In gastric cardia with 5cm of GE JunctionType 3: In gastric cardia with 5cm of GE Junction
Related to damaging effects of GE Reflux. Related to damaging effects of GE Reflux.
H pylori eradication distal vs. proximal diseaseH pylori eradication distal vs. proximal disease
EC is increasing in faster in incidence than any other EC is increasing in faster in incidence than any other
malignancy in developed world with a ten fold rise in malignancy in developed world with a ten fold rise in
the last 20 yearsthe last 20 years
This increase is not squamous cell carcinoma but in This increase is not squamous cell carcinoma but in
the incidence of adenocarcinomathe incidence of adenocarcinoma
Classification of ACClassification of AC
Type 1: Lower 1/3 of esophagusType 1: Lower 1/3 of esophagus
Type 2: At oesophago-gastric junctionType 2: At oesophago-gastric junction
Type 3: In gastric cardia with 5cm of GE JunctionType 3: In gastric cardia with 5cm of GE Junction
Related to damaging effects of GE Reflux. Related to damaging effects of GE Reflux.
H pylori eradication distal vs. proximal diseaseH pylori eradication distal vs. proximal disease
Esophageal Cancer: IntroductionEsophageal Cancer: Introduction
Causes 1-2% of all cancer related deathsCauses 1-2% of all cancer related deaths
Most occur above 50 years of ageMost occur above 50 years of age
M:F = 3:1M:F = 3:1
Common in EthiopiaCommon in Ethiopia
Causes death due to starvation and dehydrationCauses death due to starvation and dehydration
Causes 1-2% of all cancer related deathsCauses 1-2% of all cancer related deaths
Most occur above 50 years of ageMost occur above 50 years of age
M:F = 3:1M:F = 3:1
Common in EthiopiaCommon in Ethiopia
Causes death due to starvation and dehydrationCauses death due to starvation and dehydration
Esophageal Cancer: Risks and causesEsophageal Cancer: Risks and causes
1.1.Chronic alcohol consumptionChronic alcohol consumption
2.2.Chronic smoking and tobacco chewingChronic smoking and tobacco chewing
3.3.Diets high in nitrites or nitrosaminesDiets high in nitrites or nitrosamines
4.4.Spicy foods with spiritsSpicy foods with spirits
5.5.Frequent very hot dietFrequent very hot diet
1.1.Chronic alcohol consumptionChronic alcohol consumption
2.2.Chronic smoking and tobacco chewingChronic smoking and tobacco chewing
3.3.Diets high in nitrites or nitrosaminesDiets high in nitrites or nitrosamines
4.4.Spicy foods with spiritsSpicy foods with spirits
5.5.Frequent very hot dietFrequent very hot diet
Risk factorsRisk factors
AAlcohol / lcohol / AAchalasiachalasia
BBarrett’s esophagusarrett’s esophagus
CCigarettesigarettes
DDiverticuli [ Zenker’s]iverticuli [ Zenker’s]
EEsophageal web / sophageal web / EEsophagitissophagitis
FFamilialamilial
AAlcohol / lcohol / AAchalasiachalasia
BBarrett’s esophagusarrett’s esophagus
CCigarettesigarettes
DDiverticuli [ Zenker’s]iverticuli [ Zenker’s]
EEsophageal web / sophageal web / EEsophagitissophagitis
FFamilialamilial
Protective factorsProtective factors
Aspirin
Aspirin
NSAIDsNSAIDs
?
?
Helicobacter pyloriHelicobacter pylori
Dietary factors (fruits, Dietary factors (fruits,
vegetables, fiber)vegetables, fiber)
Aspirin
Aspirin
NSAIDsNSAIDs
?
?
Helicobacter pyloriHelicobacter pylori
Dietary factors (fruits, Dietary factors (fruits,
vegetables, fiber)vegetables, fiber)
Pre-cancerous conditionsPre-cancerous conditions
1.1.AchalasiaAchalasia
2.2.Corrosive stricture Corrosive stricture
3.3.Plummer-vinson syndrome with squamous metaplasiaPlummer-vinson syndrome with squamous metaplasia
4.4.Reflux esophagitis with barret’s esophagusReflux esophagitis with barret’s esophagus
1.1.AchalasiaAchalasia
2.2.Corrosive stricture Corrosive stricture
3.3.Plummer-vinson syndrome with squamous metaplasiaPlummer-vinson syndrome with squamous metaplasia
4.4.Reflux esophagitis with barret’s esophagusReflux esophagitis with barret’s esophagus
Esophageal cancer: SitesEsophageal cancer: Sites
Middle 1/3Middle 1/3: 50%: 50%
Lower 1/3Lower 1/3: 33%: 33%
Upper 1/3Upper 1/3: 17%: 17%
HistologyHistology
1.1.Squamous cell carcinoma: More common in Squamous cell carcinoma: More common in
EthiopiaEthiopia
2. Adenocarcinoma2. Adenocarcinoma
Middle 1/3Middle 1/3: 50%: 50%
Lower 1/3Lower 1/3: 33%: 33%
Upper 1/3Upper 1/3: 17%: 17%
HistologyHistology
1.1.Squamous cell carcinoma: More common in Squamous cell carcinoma: More common in
EthiopiaEthiopia
2. Adenocarcinoma2. Adenocarcinoma
Oesophageal tumoursOesophageal tumours
Clinical featuresClinical features
Dysphagia. Dysphagia. Any new symptoms of dysphagia, Any new symptoms of dysphagia,
especially over the age of 45, should be assumed to be especially over the age of 45, should be assumed to be
due to tumour until proven otherwise.due to tumour until proven otherwise.
Haematemesis. Haematemesis. Rarely the presenting symptom.Rarely the presenting symptom.
Incidental/screening. Occasionally identified as a result Incidental/screening. Occasionally identified as a result
of follow-up/screening for Barrett's metaplasia, of follow-up/screening for Barrett's metaplasia,
achalasia, or reflux disease. Presence of high grade achalasia, or reflux disease. Presence of high grade
dysplasia in Barrett's is associated with the presence of dysplasia in Barrett's is associated with the presence of
an occult adenocarcinoma in 30%.an occult adenocarcinoma in 30%.
Clinical featuresClinical features
Dysphagia. Dysphagia. Any new symptoms of dysphagia, Any new symptoms of dysphagia,
especially over the age of 45, should be assumed to be especially over the age of 45, should be assumed to be
due to tumour until proven otherwise.due to tumour until proven otherwise.
Haematemesis. Haematemesis. Rarely the presenting symptom.Rarely the presenting symptom.
Incidental/screening. Occasionally identified as a result Incidental/screening. Occasionally identified as a result
of follow-up/screening for Barrett's metaplasia, of follow-up/screening for Barrett's metaplasia,
achalasia, or reflux disease. Presence of high grade achalasia, or reflux disease. Presence of high grade
dysplasia in Barrett's is associated with the presence of dysplasia in Barrett's is associated with the presence of
an occult adenocarcinoma in 30%.an occult adenocarcinoma in 30%.
Esophageal Cancer: SymptomsEsophageal Cancer: Symptoms
Gradual onset of dysphagia first for solids, then for Gradual onset of dysphagia first for solids, then for
both liquids and solids, then to salivaboth liquids and solids, then to saliva
Anorexia and odenophagiaAnorexia and odenophagia
Profound weight loss, weaknessProfound weight loss, weakness
Rarely, features of metastasisRarely, features of metastasis
Gradual onset of dysphagia first for solids, then for Gradual onset of dysphagia first for solids, then for
both liquids and solids, then to salivaboth liquids and solids, then to saliva
Anorexia and odenophagiaAnorexia and odenophagia
Profound weight loss, weaknessProfound weight loss, weakness
Rarely, features of metastasisRarely, features of metastasis
Esophageal cancer: signsEsophageal cancer: signs
In early disease: may be entirely normalIn early disease: may be entirely normal
Cachexia, dehydration and shockCachexia, dehydration and shock
Cervical and supra-clavicular LAPCervical and supra-clavicular LAP
Rarely, features of metastasisRarely, features of metastasis
In early disease: may be entirely normalIn early disease: may be entirely normal
Cachexia, dehydration and shockCachexia, dehydration and shock
Cervical and supra-clavicular LAPCervical and supra-clavicular LAP
Rarely, features of metastasisRarely, features of metastasis
Esophageal Cancer: StagingEsophageal Cancer: Staging
StagingStaging
T1: invades lamina propria or sub mucosaT1: invades lamina propria or sub mucosa
T2: invades muscularis propriaT2: invades muscularis propria
T3: invades adventitiaT3: invades adventitia
T4: invades adjacent structuresT4: invades adjacent structures
N0: no lymph nodesN0: no lymph nodes
N1: regional lymph nodesN1: regional lymph nodes
M1: distant metastasis, including celiac or cervical nodesM1: distant metastasis, including celiac or cervical nodes
StagingStaging
T1: invades lamina propria or sub mucosaT1: invades lamina propria or sub mucosa
T2: invades muscularis propriaT2: invades muscularis propria
T3: invades adventitiaT3: invades adventitia
T4: invades adjacent structuresT4: invades adjacent structures
N0: no lymph nodesN0: no lymph nodes
N1: regional lymph nodesN1: regional lymph nodes
M1: distant metastasis, including celiac or cervical nodesM1: distant metastasis, including celiac or cervical nodes
Esophageal Cancer: StagingEsophageal Cancer: Staging
Stage IStage I: : T1 N0T1 N0
Stage 2AStage 2A::T2 N0 and T3 N0T2 N0 and T3 N0
Stage 2BStage 2B::T1 N1 and T2 N1T1 N1 and T2 N1
Stage 3Stage 3: : T3 N1 and T4 any NT3 N1 and T4 any N
Stage 4Stage 4: : M1M1
Stage IStage I: : T1 N0T1 N0
Stage 2AStage 2A::T2 N0 and T3 N0T2 N0 and T3 N0
Stage 2BStage 2B::T1 N1 and T2 N1T1 N1 and T2 N1
Stage 3Stage 3: : T3 N1 and T4 any NT3 N1 and T4 any N
Stage 4Stage 4: : M1M1
Esophageal Cancer: InvestigationEsophageal Cancer: Investigation
Esophagoscopy and biopsy: Gold standardEsophagoscopy and biopsy: Gold standard
Endo-esophageal ultra soundEndo-esophageal ultra sound
Barium swallowBarium swallow
CT- ScanCT- Scan
Abdominal ultrasoundAbdominal ultrasound
Esophagoscopy and biopsy: Gold standardEsophagoscopy and biopsy: Gold standard
Endo-esophageal ultra soundEndo-esophageal ultra sound
Barium swallowBarium swallow
CT- ScanCT- Scan
Abdominal ultrasoundAbdominal ultrasound
Oesophageal tumoursOesophageal tumours
Diagnosis and investigationsDiagnosis and investigations
Diagnosis usually by flexible Diagnosis usually by flexible
oesophagoscopy and biopsy.oesophagoscopy and biopsy.
Barium swallow only indicated for failed Barium swallow only indicated for failed
intubation or suspected post-cricoid intubation or suspected post-cricoid
carcinoma (often missed by endoscopy).carcinoma (often missed by endoscopy).
Diagnosis and investigationsDiagnosis and investigations
Diagnosis usually by flexible Diagnosis usually by flexible
oesophagoscopy and biopsy.oesophagoscopy and biopsy.
Barium swallow only indicated for failed Barium swallow only indicated for failed
intubation or suspected post-cricoid intubation or suspected post-cricoid
carcinoma (often missed by endoscopy).carcinoma (often missed by endoscopy).
Oesophageal tumoursOesophageal tumours
Staging investigationsStaging investigations
Local staging: endoluminal ultrasound scan to Local staging: endoluminal ultrasound scan to
assess depth of invasion.assess depth of invasion.
Regional staging: CT scanning to evaluate local Regional staging: CT scanning to evaluate local
invasion, locoregional lymphadenopathy, liver invasion, locoregional lymphadenopathy, liver
disease.disease.
Disseminated disease. PET scanning may be Disseminated disease. PET scanning may be
used to exclude occult disseminated disease in used to exclude occult disseminated disease in
patients otherwise considered for potentially patients otherwise considered for potentially
curative surgery.curative surgery.
Staging investigationsStaging investigations
Local staging: endoluminal ultrasound scan to Local staging: endoluminal ultrasound scan to
assess depth of invasion.assess depth of invasion.
Regional staging: CT scanning to evaluate local Regional staging: CT scanning to evaluate local
invasion, locoregional lymphadenopathy, liver invasion, locoregional lymphadenopathy, liver
disease.disease.
Disseminated disease. PET scanning may be Disseminated disease. PET scanning may be
used to exclude occult disseminated disease in used to exclude occult disseminated disease in
patients otherwise considered for potentially patients otherwise considered for potentially
curative surgery.curative surgery.
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