esophageal diseases DR CHALA A 2016.pptx

Esophageal diseases PowerPoint

2024

1. Esophageal Diseases Moderator : Dr. Obsa (MD, Assistant Professor Of G.Surgery ) Prest : D r. Chala A (MD , GSR ) 6/17/2024

2. OUTLINE Review Of Anatomy And Physiology Functional assessment Of Esophagus Motility Disorders Diverticular Diseases Hiatal Hernia GERD & Its Complications Benign &Malignant Esophageal Tumors Caustic Injury Of Esophagus References 6/17/2024

3. Introduction :Clinical Anatomy Esophagus is a muscular tube Begins at inferior border of cricoid cartilage(C6)as continuation of the pharynx Ends at the cardiac opening of the diaphragm(T11)… 25 to 30 cm long Descends on the anterior aspect of the vertebral bodies and longus colli muscles, posterior to the trachea, and adjacent to the descending aorta 6/17/2024

4. Normal Areas Of Esophageal Narrowing Junction with pharynx(cervical constriction) caused by the cricopharyngeus muscle average luminal diameter of 1.5 cm is the most common site of iatrogenic perforation When crossed by arch of aorta and left main bronchus ( Bronchoaortic constriction) average luminal diameter of 1.6 cm. At the esophageal opening of the diaphragm (Diaphragmatic constriction) average luminal diameter 1.6 to 1.9cm second most common site of iatrogenic esophageal perforation during rigid endoscopy 6/17/2024

5. Introduction: Clinical Anatomy 6/17/2024 A . Topographic relationships of the cervical esophagus: (a) hyoid bone, (b) thyroid cartilage, (c) cricoid cartilage, (d) thyroid gland, (e) sternoclavicular. B. Lateral radio-graphic appearance with landmarks identified as labeled in A. The location of C6 is also included (f).

6. Arterial Supply The cervical portion: inferior thyroid artery Thoracic portion: bronchial arteries and aortic esophageal arteries The abdominal portion: ascending branch of the left gastric artery and inferior phrenic arteries 6/17/2024

7. Venous Drainage Cervical region- inferior and superior thyroid veins, Thoracic region- bronchial, azygos and hemiazygos Abdominal region left gastric (coronary), phrenic vein 6/17/2024

8. Lymphatic Drainage Run longitudinally before they exit through the muscle wall Lymphatics of the upper two thirds tends to be upward Internal jugular , deep cervical, paratracheal and subcarinal nodes Distal third tends to be downward Paraesophageal , inferior pulmonary ligament, perigastric , and left gastric artery lymph nodes True direction of flow in disease states is difficult to estimate due to lymphatic obstruction 6/17/2024

9. Innervations Complete parasympathetic innervation is provided by the vagus nerves Sympathetic fibers take origin from the fourth to the sixth spinal cord segments and terminate in the cervical and thoracic sympathetic ganglia Distal esophageal segments receive direct sympathetic fibers from the celiac ganglion 6/17/2024

10. Histology Upper third :striated muscle Lower two third : smooth muscle predominates Mucosa consists of squamous cell epithelium except for the distal 1-2 cm, which is columnar epithelium Two layers of muscle : an inner circular and outer longitudinal layer The esophagus, unlike the rest of GIT , lacks a serosal covering . 6/17/2024

11. Physiology Three functional structures UES Cricopharyngeus muscle High pressure zone 100 mm Hg in the anteroposterior position and 30 mm Hg in the lateral orientation In tonic contraction Relaxation occur with swallowing and belching 6/17/2024 Prevents Esophagopharyngeal regurgitation Entry of air into the esophagus regurgitation of gastric contents into the pharynx

12. Physiology Of Swallowing 6/17/2024

13. Physiology 2. Body No motor activity in resting state(not tonically contracted) Not all peristaltic waves are complete in normal subjects Type of food : sold or liquid to dry swallows, complete waves occur on only approximately two-thirds of occasions posture and age decrease in amplitude is seen when the subject is supine and in men >80 years of age rate of swallowing Swallows at 5-second intervals or less tend to inhibit peristalsis completely; completely normal sequences occur only when swallows are taken at >20-second intervals…..(8cm/sec) 6/17/2024

14. Physiology Three types of contractions Primary peristalsis Progressive Triggered by voluntary swallowing at UES Propels food to stomach B . Secondary peristalsis Progressive In response to distension or irritation “house-keeper” role in clearing refluxed material begin in the smooth muscle (near the level of the aortic arch) 6/17/2024

15. Physiology C. Tertiary peristalsis Non progressive contractions Occur during swallowing or spontaneously Seen in elderly, EMD and emotional states of patients during recording No physiologic function 6/17/2024

16. Physiology . LES High pressure zone 3-5 cm long Protects esophagus against reflux of acid Has 2 components Intrinsic Formed by smooth ms Resting tone of 15-25 mm Hg Relaxes for 5-10 sec to allow food bolus & gas in gastric distension 6/17/2024 B. Extrinsic Compression by diaphragmatic ms Most important during strainin g

17. Assessment of Esophageal Function Thorough understanding of the patient’s underlying anatomic and functional deficits before making therapeutic decisions is fundamental to the successful treatment of esophageal disease. The diagnostic tests may be divided into four Tests to detect structural abnormalities of the esophagus; tests to detect functional abnormalities of the esophagus; tests to detect increased esophageal exposure to gastric juice; Tests of duodenogastric function as they relate to esophageal disease 6/17/2024

18. Assessment of Esophageal Function A. Tests To Detect Structural Abnormalities Of The Esophagus 1.Endoscopic(UGED) evaluation : The first diagnostic test in patients with suspected esoph . Dss (dysphagia) assessment and biopsy of the mucosa of UGIT diagnosis and assessment of obstructing lesions in the UGIT. 6/17/2024

19. Assessment of Esophageal Function Endoscopic(UGED) evaluation: When GERD is the suspected_esophagitis and Barrett’s columnar-lined esophagus (CLE ). Severity and the length of esophagitis involved are recorded based on Los Angeles (LA) grading system . LA Grading Mild Esophagitis : LA grade A or B—one or more erosions limited to the mucosal fold(s) and either less than or greater than 5 mm in longitudinal extent respectively Severe Esophagitis _ LA grade C or D 6/17/2024

20. Assessment of Esophageal Function 2. Radiographic Evaluation Barium swallow -selectively to assess anatomy and motility. Assess large hiatal hernias- better than endoscopy Coordinated esophageal peristalsis can be determined by observing several individual swallows of barium traversing the entire length of the organ,with the patient in the horizontal position. Hiatal hernias are best demonstrated with the patient prone 6/17/2024

21. Assessment of Esophageal Function B . Tests to Detect Functional Abnormalities 1.Esophageal Motility Study (EMS): performed using electronic, pressure-sensitive transducers located within the catheter, or water-perfused catheters with lateral side holes attached to transducers outside the body . 6/17/2024

22. Assessment of Esophageal Function 2. High-Resolution Manometry 3. Esophageal Impedance . 4.Esophageal Transit Scintigraphy . 6/17/2024

23. Assessment of Esophageal Function C. Tests to Detect Increased Exposure to Gastric Juice Twenty-Four-Hour Ambulatory pH Monitoring . Radiographic Detection of Gastroesophageal Reflux . D . Tests of Duodenogastric Function: gastric emptying studies , Gastric acid analysis, and cholescintigraphy 6/17/2024

24. Esophageal Diseases Classes of esophageal diseases I: Neuro-muscular Inadequate LES relaxation Achalasia Epiphrenic diverticulum Uncoordinated esophageal contraction Diffuse esophageal spasm (DES) Hypo- contarction Ineffective esophageal motility (IEM) Hyper-contraction High-amplitude peristaltic contraction (HAPC, “nutcracker esophagus”), Hypertensive lower esophageal sphincter (HLES ) II. Inflammatory Reflux esophagitis Caustic esophagitis Infectious esophagitis Foreign body 6/17/2024

25. Esophageal Disease Cont … III: Anatomic: Sliding hiatus hernia Rolling (Para-esophageal) hiatus hernia Mixed hiatus hernia Esophageal diverticular diseases IV: Neoplastic Esophageal carcinoma Benign tumors 6/17/2024

26. Gastroesophageal Reflux Disease Retrograde flow of gastric material back into the esophageal lumen Accounts for approximately 75% of esophageal pathology GER is a physiologically normal occurrence in humans …TRESR Determinants of Undesirable Changes volume of refluxed contents, the time interval between reflux episodes, the duration that refluxed agents remain in contact with the esophageal mucosa , and constituents of refluxate 6/17/2024

27. Gastroesophageal Reflux Disease Despite the common prevalence of GERD, it can be one of the most challenging diagnostic and therapeutic problems in clinical medicine. A contributing factor to this is the lack of a universally accepted definition of the disease . The most simplistic approach is to define the disease by its symptoms Endoscopy- documented esophagitis Study of esophageal exposure to gastric juice 6/17/2024

28. GERD: Pathophysiology The Human Antireflux Mechanism and the Pathophysiology of GERD There is a high-pressure zone located at the esophagogastric junction in humans(LES). Three basic defense systems exist to prevent pathologic GER: Anatomic reflux barriers( les)-valve effect Esophageal luminal clearance mechanisms(pump effect), and Intrinsic tissue resistance to esophageal mucasal damage 6/17/2024

29. The Lower Esophageal Sphincter: There are three characteristics of the LES that work in unison to maintain its barrier function. These characteristics include: The resting LES pressure, Its overall length , and The intra-abdominal length 6/17/2024

30. GERD: Pathophysiology GERD-inherent alterations to (a) attenuated LES tone, (b)increase in intra-abdominal pressure (stress reflux) (c) increased transient LES relaxations 6/17/2024

31. GERD: Pathophysiology Therefore, a permanently defective sphincter is defined by one or more of the following characteristics: any LES with a, mean resting pressure of less than 6 mmHg, an overall sphincter length of <2 cm, an intra-abdominal sphincter length of <1 cm . The most common cause of a defective sphincter is an inadequate abdominal length. It is believed that GERD has its origins within the stomach 6/17/2024

32. Hiatal Hernia vs Gastroesophageal Reflux Disease Attenuation of collar sling musculature and clasp fibers with repeated gastric distention---- the EGJ begins to assume an “upside down funnel” appearance, with progressive opening of the acute angle of His. Attenuation and stretching of the phrenoesophageal ligament, subsequent enlargement of the hiatal opening and axial herniation. There is a high degree of correlation between reflux threshold and the degree of hiatal herniation 6/17/2024

33. GERD:Clinical presentation 6/17/2024

34. GERD :Investigations 24hr PH recording….Gold “standard” Esophageal manometry….decrease in LES Endoscopy…R/o ca, BE, stricture Grading of esophagitis Grade1: small circular,nonconfluent erosions Grade2:linear erosions with granulations which bleeds easily when touched Grade3:cobblestone esophagus Grade4:stricture Barium swallow….to see G-E anatomy 6/17/2024

35. GERD Complications 1.Barrett’s Esophagus Definition and Histologic Features Definition : Any length of endoscopically identifiable columnar mucosa that proves on biopsy to show intestinal metaplasia . Three different types of columnar epithelia can be found in BE 6/17/2024

36. BE:Histologic Features cont 1 ) specialized intestinal metaplasia is the most common, and dysplasia and carcinoma in BE are almost invariably associated with it Its hallmark is the presence of intestinal goblet cells (2 ) gastric fundic - type epithelium indicated by the presence of parietal and chief cells 3 ) cardiac-type epithelium . indicated by the absence of parietal and chief cells Combinations of these subtypes are not uncommon 6/17/2024

37. Pathophysiology Increased acid exposures, decreased LES muscle tone, and impaired esophageal acid clearance Chronic distal esophageal acid inflammation leads to loss of disaccharidase activity, low mucosal glutaminase levels, altered levels of mucosal protein synthesis MAP kinase activation and upregulation of COX-2 expression regenerative processes in response to chronic injury result in the development of BE(animal study 6/17/2024

38. Barrett Esophagus Complication of long standing GERD( >5-year history of reflux symptoms) reflux of both acid and bile have a major role in the development of BE Average Age At Diagnosis Is 55 Years Prevalence increases with age up to 70 years Occurs in 10 % to 15%of pts with symptomatic GERD( end stage ) More common in white males 6/17/2024

39. Barrett Esophagus Obesity and smoking history increases risk of BE 30- to 100-fold greater risk of developing esophageal AC than do normal populations Single most important risk for AC with life time risk of 10% risk of a patient developing esophageal AC has been estimated to be 0.5% per year 6/17/2024

40. Diagnosis H igh index of suspicion must be there Long-standing history of heartburn and/or regurgitation Endoscopy revealing abnormal salmon-colored columnar epithelium extending proximally within the esophagus Biopsy …intestinal metaplasia with goblet cell s 24hr PH recording Esophageal manometry….decrease in LES antireflux surgery results in long-lasting relief and prevention of high-grade dysplasia and AC 6/17/2024

41. GERD : Management Principle MEDICAL MNG PPI antacids, alginic acid metoclopramide or domperidone (Early on) LSM SURGICAL MNGT Antireflux surgery indications: (a) objectively proven GERD ( b) typical symptoms of GERD despite adequate medical management , (c) a younger patient unwilling to take lifelong medication 6/17/2024

42. Esophageal Motility Disorders Functional disorders that interfere with swallowing or produce dysphagia without mechanical obsn Result from abnormalities in the propulsive pump action of the esophageal body or the relaxation of the LES. These disorders result from either primary, or secondary. Standard manometric technique is the key in the diagnosis . 6/17/2024

43. Primary Esophageal Motility Disorders   Achalasia, "vigorous" achalasia Diffuse and segmental esophageal spasm Nutcracker esophagus Hypertensive lower esophageal sphincter Nonspecific esophageal motility disorders 6/17/2024

44. Secondary esophageal motility disorders   Collagen vascular diseases: progressive systemic sclerosis, polymyositis and dermatomyositis, mixed connective tissue disease, systemic lupus erythematosus Chronic idiopathic intestinal pseudo-obstruction Neuromuscular diseases Endocrine and metastatic disorders 6/17/2024

45. Manometric Characteristics of the Primary Esophageal Motility Disorders Achalasia   Incomplete lower esophageal sphincter (LES) relaxation (<75% relaxation) Aperistalsis in the esophageal body Elevated LES pressure ≤26 mmHg Increased intraesophageal baseline pressures relative to gastric baseline Diffuse esophageal spasm (DES )   Simultaneous ( nonperistaltic contractions) (>20% of wet swallows ) Repetitive and multipeaked contractions Spontaneous contractions Intermittent normal peristalsis Contractions may be of increased amplitude and duration Nutcracker esophagus   Mean peristaltic amplitude (10 wet swallows) in distal esophagus Š180 mmHg Increased mean duration of contractions (>7.0 s) Normal peristaltic sequence 6/17/2024

46. Manometric Characterstics … Hypertensive lower esophageal sphincter   Elevated LES pressure (≥26 mmHg) Normal LES relaxation Normal peristalsis in the esophageal body Ineffective esophageal motility disorders   Decreased or absent amplitude of esophageal peristalsis (<30 mmHg) Increased number of nontransmitted contractions 6/17/2024

47. Achalasia Primary disorder of LES. Incidence 6 in 100,000 per year. 5% life time risk to develop esophageal ca Usually occurring during middle age. Equal incidence for either sex. Classic triad of presenting symptoms: dysphagia, regurgitation, and weight loss 6/17/2024

48. Achalasia Vigorous Achlasia Repetitive simultaneous contractions in body of esophagus (as with DES). partial or absent LES relaxation (as with achalasia). Pts present with dysphagia and chest pain . 6/17/2024

49. Achalasia Pathogenesis :Central vagal dysfunction and destruction of the peripheral myenteric plexus are the two hypothesis Diagnosis Barium swallow distal tapering (“bird’s beak appearance ”) Manometry : failure of the LES to relax lack of progressive peristalsis Esophagoscopy esophagitis, associated carcinoma, stricture 6/17/2024

50. Diffuse Esophageal Spasm Defined as >20% simultaneous contractions intermixed with normal peristalsis. Multiphasic, repetitive, often high-amplitude contractions that occur after a swallow and spontaneously LES usually has normal resting pressure and relaxation A criterion of 30% or more peristaltic waveforms out of 10 wet swallows has been used to differentiate DES from vigorous achalasia. 6/17/2024

51. Diffuse Esophageal Spasm Pathophysiology Etiology is unknown Recent studies implicate decreased available nitric oxide . Clinical feature Mean age of occurrence 50 years Common in women Intermittent chest pain and dysphagia are the common presenting symptoms Has less effect on the patient's general condition 6/17/2024

52. DES: Diagnosis Manometer Barium swallow corkscrew esophagus epiphrenic or midesophageal diverticulum Esophagoscopy should be performed to rule out an infiltrating tumor, esophageal fibrosis, or esophagitis 6/17/2024

53. Nutcracker esophagus Is characterized by: extremely high-amplitude (as high as 225 to 430 mm Hg) progressive peristaltic contractions, often of prolonged duration. Normal peristaltic sequences Symptoms : chest pain, dysphagia, and odynophagia 6/17/2024

54. Hypertensive LES LES pressures > 26 mm Hg but with normal relaxation  Normal esophageal peristalsis About half of these patients, however, have associated motility disorders of the esophageal body, particularly hypertensive peristalsis. Myotomy of the LES may be indicated in patients not responding to medical therapy or dilation. 6/17/2024

55. Nonspecific Esophageal Motility Disorders No or decreased amplitude(<30 mm Hg )of perstalsis Normal or low LES pressure Normal LES relaxation Most pts have GERD with heartburn and regurgitation Surgery plays no role in the treatment of these disorders unless there is an associated diverticulum 6/17/2024

56. Disorders LES pressure LES relaxation Wave progression Wave amplitude Achalasia Usually high Incomplete No peristalsis Usually low DES Usually normal Normal Simultaneous, >20% swallows Usually normal Nutcracker esophagus Usually normal Normal Normal High Hypertensive LES High Normal Normal Normal Ineffective esophageal motility Usually normal Normal Usually disordered Low, >30% swallows 6/17/2024

57. Diverticula of the Esophagus Epithelial-lined mucosal pouches that protrude from the esophageal lumen Cause: Motility disorders,Traction , Congenital Classification depending on the site of occurrence: 1.Pharyngoesophageal ( Zenker’s ) diverticula occur at the junction of the pharynx and esophagus 2. Parabronchial ( midesophageal ) diverticula occur near the tracheal bifurcation 3. Epiphrenic ( supradiaphragmatic ) diverticula arise from the distal 10 cm of esophagus 6/17/2024

58. Pharyngoesophageal (Zenker’s) Diverticula Definition :Is a pulsion diverticulum resulting from a transient incomplete opening in the UES also referred to as cricopharyngeal achalasia Clinical Features : usually asymptomatic initially vague sensation or sticking in the throat intermittent cough, 6/17/2024

59. Midesophageal or traction diverticula Frequently noted in patients who had mediastinal lymph node involvement with tuberculosis may also be caused by motility abnormalities Is true diverticula Asymptomatic and incidentally discovered most of the time Dysphagia, regurgitation, chest pain, or aspiration 6/17/2024

60. Epiphrenic Diverticula Within 10 cm of patients the gastroesophageal junction common on the right side. are more have a motility disorder. about half of the cases in achalasia present with dysphagia, regurgitation, vomiting, chest and epigastric pain 6/17/2024

61. Benign and Malignant Esophageal Tumours Benign Tumors Of Esophagus Relatively uncommon. Mostly mesenchymal origin. Divided into intramural and intraluminal. Intramural: Majority are lieomyoma other histological type include cyts , lipoma,neurofibroma,heamangioma … Intraluminal : Polyploid or pedanculated growth that orginate in the submucosa and develop into the lumen. Includes the likes of myxoma , myxofibroma , fibroma, fibrolipoma 6/17/2024

62. Benign Esophageal Tumors Leiomyoma Fibrovascular polyp Squamous cell papilloma Granular cell tumor Hemangioma Congenital esophageal cyst 6/17/2024 Bronchogenic cyst Inflammatory fibroid polyp (eosinophilic granuloma) Lymphangioma Lipoma Neurofibroma

63. Leiomyoma 50 % of benign tumors. Average age is 38. M:F 2:1 90 % in lower two third. Usually solitary. Size ranges from 0.5cm to 30cm. Dysphagia and pain most common symptoms. Microscopically Benign appearing spindle cells without atypia Mitoses are sparse or absent Necrosis virtually never occurs 6/17/2024

64. Diagnosis Hx Barium swallow is the most useful method: smooth, semilunar, or crescent-shaped filling defect that moves with swallowing Esophagoscopy to exclude coexistence with carcinoma Treatment: Simple Enucleation 6/17/2024

65. Esophageal Cancer :Introduction Epidemiology 1-2 % of all cancers. 4% all GI malignancy 6 th leading cause of cancer death world wide. 8 th most common cancer world wide Age distribution • Occur most commonly at 6 th and 7 th decade . • BLH study (22-88) Ĉ mean age of 54 years . Sex • 3-5x common in men • BLH study men are commonly affected Causes death due to- starvation and dehydration 6/17/2024

66. Esophageal Cancer: Risks And Causes Chronic alcohol consumption Chronic smoking and tobacco chewing Diets high in nitrites or nitrosamines Spicy foods with spirits Frequent very hot diet 6/17/2024

67. Precancerous conditions Achalasia Barrett’s esophagus Caustic Injury 1,000-fold greater than that of the general population lumen is less distensible, dysphagia present earlier damage to submucosal lymphatic and the presence of dense scar tissue limit lymphatic spread Genetic Factors Mutant p53 overexpression (57%) Tylosis , an autosomal dominant disorder characterized by hyperkeratosis of the palms and soles (95% chance of developing cancer during their lifetimes) Miscellaneous radiation, head and neck cancer, Plummer–Vinson syndrome, celiac disease, and thyroid disease 6/17/2024

68. Esophageal Cancer: Sites 6/17/2024

69. Esophageal Cancer : Histopathology 6/17/2024

70. Esophageal Cancer : Histopathology Histologically SCC and AC are the commonest type. • In western countries : Until 1970 SCC : 92-95%, AC : 2.5-5% Since 1970 the incidence of AC has been  ing by 5-10% per year . increasing obesity and decreasing H. pylori infections increased recognition and frequency of GERD and detection of Barrett's esophagus adenocarcinoma account 50% of eso ca . • In the BLH study: SCC -93%,AC- 6%,and leiomyosarcoma -0.7% 6/17/2024

71. Esophageal cancer : SCC Pathology Arises from the mucosa of the esophagus Common in the upper & middle third esophagus (mainly thoracic esophagus) Four types of gross pathologic presentations 1. Fungiating type - 60 % of SCC lesions project into the lumen and appear as filling defects on barium swallow. These lesions may also present as flat plaques 6/17/2024

72. Esophageal cancer : SCC Pathology 2.Ulcerative type - 25 % of SCC regular or irregular everted edges with a deep base 3. Diffuse infiltrative - 15 % of SCC extensive intramural spread. A desmoplastic response is usually present and can produce a tight stricture 6/17/2024

73. Esophageal cancer : SCC Pathology 4.Polypoidal type intraluminal polypoid growth with a smooth surface on a narrow stalk (fewer than 5% of cases) 6/17/2024

74. Esophageal Cancer: Adenocarcinoma Arises from the superficial and deep glands of the esophagus Limited to the lower 3 rd of esophagus.  Ed incidence most dramatically in white males Arise from premalignant condition (Barrett's Esoph .) in 59-86% Can be flat ,infiltrative , fungating 6/17/2024

75. Esophageal Cancer: Pathogenesis Of AC One hypothesis is that pluripotent stem cells in the basal layers undergo metaplasia after repeated stimulation from reflux GERD  metaplasia  low grade dysplasia  high grade dysplasia  adenocarcinoma (metaplasia–dysplasia–adenocarcinoma sequence) Other possible origins of columnar cells are the gastric cardia and propagation of columnar cells from the esophageal gland ducts 6/17/2024

76. Esophageal Cancer: Metastases Intraesophageal Spread Submucosal lymphatic spread Direct Extension upper and middle 3 rd tumors  TBT ,Aorta , RLN, pleura, thoracic duct , lung ,mediastinum . Lower3 rd tumors  Pericardium , Diaphragm ,Stomach , liver 6/17/2024

77. Esophageal Cancer: Metastases Lymphatic spread ---- 1 o longitudinal in normal conditions lymph above the carina flows into the thoracic duct or subclavian lymphatic trunks and lymph below the carina drains into the cisterna chyli in the abdomen, reversal of flow can occur when nodes are blocked by tumor Distant metastasis --- 25-30% liver (35 %), lungs (20%), bone (9%), brain or adrenal glands (2%), and pericardium, pancreas, spleen, or stomach (1%) no organ is spared 6/17/2024

78. Diagnosis of Esophageal Cancer: Clinical Presentations Gradual onset of dysphagia ( 87-95%) first for solids, then for both liquids and solids, then to saliva 6/17/2024

79. Diagnosis of Esophageal Cancer: Clinical Presentations Weight loss (42-71%) Non specific retrosternal discomfort or pain. Hoarseness (RLN inv.) Hematemesis (friability ,fistula to great vessels) Supraclavicular LN Stridor invasion to TBT Cough ,aspiration pneumonia (TEF) Hepatomegally 6/17/2024 Cachexia, dehydration and shock Cervical and supra-clavicular LAP---lately

80. Diagnosis of Esophageal Cancer : Investigations 1.Baseline Inx Laboratory tests CBC, Hgb , BG & Rh Serum electrolytes Serum albumin OFT Imaging Studies ECG,Ecocardiography,Pulmonary function test 6/17/2024

81. Diagnosis of Esophageal Cancer: Investigations 2.Diagnostic And Staging Studies 1.Barium swallow extent & location of tumor Irregular mucosal filling defect and asymmetric narrowing abrupt shelf edge, occasionally tapered narrowing Annular constriction 6/17/2024

82. Diagnosis of Esophageal Cancer: Investigations 2 . C XR-ray --- 47% advanced ca abnormal azygoesophageal recess (most common). posterior tracheal indentation medastinal widening pulmonary infiltrates , hilar LAP . 6/17/2024 3. Esophagoscopy direct visualization & biopsy Determine the longitudinal and circumferential extent degree of obstruction 4 . EUS to assess tumor depth (T staging ) & enlarged periesophageal LN (N staging ) better for celiac than for mediastinal disease 80% accurate.

83. Diagnosis of Esophageal Cancer: Investigations 5.Abd.U/S liver metastasis 6. Bronchoscopy cancers of upper &middle 3 rd esophagus 7.CT scan –of the abdomen and chest local extent of the tumor, the relationship to adjacent structures, and distant metastases assessing the response to adjuvant therapy cannot define the layers of the esophagus 8.Thoracoscopy and Laparoscopy for staging regional nodes ---92% accuracy 9.Bone scan 10.PET Identify specific areas of  ed metabolic activity Important for detecting distant metastasis Has Dxtic accuracy of 88% in determining resectability 6/17/2024

84. Esophageal cancer : Staging Choosing the best therapy for an individual patient requires accurate staging. Staging starts with the HX/PE . LN disease remote from the tumor, particularly in the cervical region This is often referred to as M1a disease . Other metastatic LNs are rarely palpable but are equally ominous, especially the umbilical LN in GEJ cancer 6/17/2024

85. Esophageal cancer : Staging Clinical Staging . Clinical factors that indicate an advanced stage of ca. Recurrent nerve paralysis , Horner’s syndrome, Persistent spinal pain, Paralysis of the diaphragm, Fistula formation, and Malignant pleural effusion . 6/17/2024 Factors that make surgical cure unlikely A tumor >8 cm in length, Abnormal axis of the esophagus on a barium radiogram, > 4 enlarged lns on CT, Weight loss > 20%, and Loss of appetite

86. Esophageal cancer : Staging AJCC TNM Staging : Primary tumor[T] and regional node[N] 6/17/2024

87. Esophageal cancer : Staging AJCC TNM Staging :Distant metastasis[M] Mx - distant metastasis cant be assessed M0- no distant metastasis M1-distant metastasis M1a- non regional lymph node metastasis M1b- other distant metastasis 6/17/2024

88. 6/17/2024

89. TABLE 6/17/2024

90. Esophageal Cancer :Management Principles ALGORITHM S 6/17/2024

91. Esophageal Caustic Injury Caused by the ingestion of caustic agents. Mainly in children- accidental and small amount taken. In adults or teenagers, usually deliberate, and greater quantities are swallowed. Alkalis are more frequently swallowed accidentally than acids. Sites susceptible to injury are Normal areas of esophageal narrowing and striated muscle–smooth muscle interface because of a relative delay in transit time 6/17/2024

92. Caustic injury : pathology Lesions caused by lye injury occur in three phases. 1)Acute necrotic phase lasting 1 to 4 days after injury intense inflammatory reaction 2)Ulceration and granulation phase superficial necrotic tissue sloughs. starting 3 to 5 days after injury . lasts 10 to 12 days, and it is during this period that the esophagus is the weakest 3) Phase of cicatrization and scarring begins the third week following injury narrowing of the esophagus efforts must be made to reduce stricture formation 6/17/2024

93. Caustic injury : Clinical Features Oral pain, hematemesis, drooling, and inability or refusal to swallow, respiratory distress Hoarseness, stridor, and dyspnea Substernal, back, or abdominal pain Dysphagia During acute phase Strictures 6/17/2024

94. Diagnosis History & Physical Examination CXR or AXR to r/o perforation , aspiration pneumonitis, air in the esophageal wall. Esophagoscopy : 12 to 24 hours after injury. 6/17/2024

95. Perforation of t he Esophagus Potentially lethal complication due to mediastinitis and septic shock Numerous causes, but may be iatrogenic Surgical emphysema is virtually pathognomonic Treatment is urgent; it may be conservative or surgical, but requires specialised care 6/17/2024

96. Refernces Schwartz's Principles of Surgery, 11 th Edition Shields: General Thoracic Surgery, 8th Edition Sabiston Textbook of Surgery, 21 ed Robbins basic pathology 8 th edition A.Ali et al , Oesophageal Carcinoma In Tikur Anbessa Hospital, Addis Ababa , East African Medical Journal, Oct.’98. up-to-date Baily & love’s short practice of surgery,27 th edition 6/17/2024