- Epithelium: Squamous
- Inner layer: Circular
- Outer layer: Longitudinal
- No serosa
- Mucosa is strongest layer (in small bowel, submucosa is strongest)
- Central input initiates swallow which elicits primary peristalsis
- Distention then elicits secondary peristalsis.
Swallowing order of events:
- Soft palate closes nasopharynx,
- Larynx up,
- Larynx closes,
- UES relaxes,
- Pharyngeal contraction
Sphincters: are contracted at rest.
- UES (cricopharyngeous muscle): tone 50-70 mmHg
- LES tone: 10-25 mmHg (length 4cm)
- Cripharyngeus muscle
- Mainstem broncus, aortic arch
Zencker's diverticulum: (false diverticulum)
- Occurs in Killian's triangle (region b/t oblique pharyngeal constrictors and transverse cricopharyngeous fibers)
- Due to increase pressure (pulsion tic)
- Dx: Barium swallow studies
- Tx: myotomy, diverticulectomy/pexy to spinous process.
- Approach via left cervical incision
- Decrease ganglion cells (neuronal degeneration) in Auerbach's plexus
- Absence of peristalsis and esophageal relaxation
- Bird's beak on Ba swallow
- No peristalsis
- é LES pressure
- Incomplete LES relaxation
- Ca channel blockers, Dilation (effective 60%)
- Laparoscopic or thoracoscopic Heller myotomy
Diffuse esophageal spasm:
- Normal LES tone
- Strong unorganized contractions
- Medical treatment (Ca++ channel blockers)
- Type I: (most common) Sliding hernia GE junction sliding above diaphragm.
- Type II:(Paraesophageal hole in diafragm) GE junction in abdomen, fundus of stomach above the diaphragm; Associated with Gastric Volvulus
- Type III: Combined
- Type IV: Entire stomach in chest + another organ
- Paraesophageal hernia: always operate since risk of incarceration, strangulation
- Metaplasia from squamous to columnar cells.
- 1-2% get adenocarcinoma (30-100 x risk)
- P53 associated (tumor suppressor gene)
- Severe Barrett’s dysplasia = esophagectomy
- Uncomplicated Barrett’s needs careful follow up despite medical or surgical therapy.
Assessing T staging:
- EUS is more accurate than CT
AdenoCA #1 esophageal cancer over squamous (also true for lung CA)
Rigth gastroepiploic artery: primary blood supply to stomach after replacing esophagus
Achalasia and chemical ingestion also increase risk of esophageal CA
- Most common benign tumor of the esophagus
- Do not biopsy on EGD.
- If symptomatic or > 5cm excise by enucleation via thoracotomy (R if middle, L if lower esophagus).
Caustic esophageal injury:
- No NGT
- No not induce vomiting
- Nothing to drink
Esophageal rupture (Boerhaave's):
- Key to survival is early Dx (85% mortality if > 36 hours)