Disorders of the oesophagus

 

Normal oesophagus

A muscular tube lined mostly with squamous epithelium

Waves of peristalsis facilitate swallowing

 

Atresia

Congenital disorder with a blind end to the oesophagus, at first feed the infant coughs and may become cyanosed.

May be a fistula to the trachea

Aspiration bronchopheumonia often follows

 

Achalasis

A fairly uncommon disorder

 

Aetiology

A primary neurological disorder of unknown cause

Failure of the cardiac sphincter to relax

Faulty peristalsis of the oesophagus due to defective parasympatheric innerveation

 

Pathophysiology

Dilation of the oesophagus

 

Clinical features

Dysphagia

Food is retained in the oesophagus

Food stagnates in oesophagus and smells

Regurgitation of stagnant food

Episodic chest pain

Aspiration

Weight loss

 

Management

Dilation of the cardiac sphincter

Myotomy

These treatments will allow the emptying of the oesophagus by gravity but will lead to potentially severe reflux

 

Reflux

This is very common

Reflux of gastric contents in to the oesophagus

The oesophagus is lined by squamous epithelium which can not resist gastric juice

 

Aetiology Relative incompetence of the cardiac sphincter

 

Factors

Factors which increase intra- abdominal pressure

Lying down

Stooping

Lifting

Obesity Tight clothes

After large meals

Straining at stool

Factors which reduce cardiac sphincter tone - Smoking Anticholinergic drugs Dietary fat Pregnancy, (probably a hormonal effect)

 

Investigations

Endoscopy

Barium studies

Electrical 24 hour recordings of oesophageal acid

 

Features

Painful heartburn

Entry of gastric juices into the mouth

Inflammation of lining

Odynophagia

Bleeding

 

 

 

Complications

Oesophagitis

Over time fibrosis and stricture may develop

Barrett`s oesophagus --------- malignancy

Pulmonary aspiration

 

Management

Reduce reflux Use of cholinergic drugs Reduce acid burden

Protect oesophageal mucosa, eg. alginate preparations such as Gaviscon

Treat anaemia

 

Hiatus Hernia

Hiatus gap

Hernia - the protrusion of viscus outside it`s natural cavity

Most common mechanical disorder of the oesophagus

 

Factors

Increased intrabdominal pressure eg obesity, pregnancy

Protrusion of part of the fundus of the stomach into the chest via the oesophageal opening in the diaphragm.

Often older patients, over 50 years

 

Clinical features

May be asymptomatic

Those of reflux

 

 

Cancer

Two principle forms

 

i. Squamous cell carcinoma

Can effect any part of the oesophagus

 

Aetiological factors

Smoking

Strong alcoholic drinks

Tannic acid

Lack of riboflavin and vitamin A

Fungal contamination of food

Opium use

Thermal injury

Human Papillomavirus

 

ii Adinocarcinoma

Found in the lower third

Mostly associated with Barrett`s oesophagus which is oesophagus lined with metaplastic columnar cells

 

Investigations

Endoscopy

Histology

Cytology

 

Clinical features

Remorselessly progressive dysphagia for solids then liquids

Patient can often point to the level of obstruction

Regurgitation

Retrosternal discomfort

Pain

Weight loss

Anaemia - occult blood loss

Pressure on the trachea

Metastases my be palpable in liver or cervical glands

 

Complications

Aspiration

Inanition

Perforation in to mediastinum

Fistula in to trachea

Invasion of the aorta

 

Management

Surgery - oesophago-gastrostomy

Radiotherapy

Stents

Palliative

Laser photocoagulation

This disorder carries a very poor prognosis, about 10% survival at 5 years

Benign tumours of the oesophagus account for about 5% of neoplaysia

 

 

Varices

 

Dilated varicose veins of the lower oesophagus

 

Aetiology - Hepatic hypertension secondary to cirrhosis

 

Complications - Massive haemorrhage

 

Differential diagnosis - Other causes of chest and epigastric pain must always be considered

 

 

Infection

This may occur in immunocompramised patients and be caused by Candidiasis, herpes simplex or cytomegalovirus. All will cause oesophagitis

 

Diffuse oesophageal spasm

Episodic severe chest pain with dysphagia

Cause unknown

Treat by reducing oesophageal muscle tone with GTN or crushed Nifedipine

No obvious prognostic implications

Reassure pain is not cardiac

 

Other conditions

Foreign bodies

Perforating foreign bodies

Rupture

Mallory - Weiss