2. Anatomy of The EsophagusAnatomy of The Esophagus
The esophagus is a hollow muscularThe esophagus is a hollow muscular
organ, approximately 25cm in length thatorgan, approximately 25cm in length that
extend from the pharynx to the stomachextend from the pharynx to the stomach
3. Anatomy of The EsophagusAnatomy of The Esophagus
Cervical Esophagus:Cervical Esophagus: Just lies to the left ofJust lies to the left of
midline behind the larynx and the trachea. Themidline behind the larynx and the trachea. The
entry to esophagus called upper esophagealentry to esophagus called upper esophageal
sphincter (UES).sphincter (UES).
Thoracic Esophagus:Thoracic Esophagus: The upper part passesThe upper part passes
behind the carina & Lt. main stem bronchus. Thebehind the carina & Lt. main stem bronchus. The
lower part passes behind the left atrium.lower part passes behind the left atrium.
4. Abdominal Esophagus:Abdominal Esophagus: Is the smallestIs the smallest
portion of the esophagus (2-4cm length). Itportion of the esophagus (2-4cm length). It
has lower esophageal sphincter (LES)-has lower esophageal sphincter (LES)-
non anatomical with normal restingnon anatomical with normal resting
pressure 10-20mmHg.pressure 10-20mmHg.
5. Anatomy of The EsophagusAnatomy of The Esophagus
Normal esophagealNormal esophageal narrowingnarrowing::
• UES at the level of cricoid cartilage 14mmUES at the level of cricoid cartilage 14mm
in diameter.in diameter.
• Broncho-aortic constriction 17mm inBroncho-aortic constriction 17mm in
diameter.diameter.
• LES (19mm) as it travels the diaphragm &LES (19mm) as it travels the diaphragm &
located 3-5cm at distal part of thelocated 3-5cm at distal part of the
esophagus.esophagus.
6.
7. Clinical Importance of normal esophagealClinical Importance of normal esophageal
narrowing:narrowing:
•Potential for development of diverticulum'sPotential for development of diverticulum's
(Zenker) in the neck.(Zenker) in the neck.
•Potential for perforation duringPotential for perforation during
esophagoscopyesophagoscopy
8. Anatomy of The EsophagusAnatomy of The Esophagus
The esophageal wall:The esophageal wall:
• The proximal esophagus is predominantlyThe proximal esophagus is predominantly
striated muscle.striated muscle.
• The distal esophagus is predominantly smoothThe distal esophagus is predominantly smooth
muscle.muscle.
• The mid esophagus contained a gradedThe mid esophagus contained a graded
transition of striated and smooth muscle.transition of striated and smooth muscle.
9.
10. Physiology of The EsophagusPhysiology of The Esophagus
The function of the esophagus is toThe function of the esophagus is to
transport the ingested material from thetransport the ingested material from the
pharynx to the stomach by peristalticpharynx to the stomach by peristaltic
waves.waves.
Primary peristalsis:Primary peristalsis: Triggered by theTriggered by the
swallowing center in the brain stem andswallowing center in the brain stem and
the contraction wave travel at speedthe contraction wave travel at speed
2cm/s.2cm/s.
11. Secondary peristalsis:Secondary peristalsis: Induced byInduced by
esophageal distensionesophageal distension from retainedfrom retained
bolus, refluxed material. Its role is to clearbolus, refluxed material. Its role is to clear
the esophagus form retained bolus.the esophagus form retained bolus.
12. Tertiary peristalsis:Tertiary peristalsis:
Tertiary contractions are non-propulsive and
uncoordinated and their non-peristaltic nature means they
move the bolus up as well as down the oesophagus.
They are seen as intermittent ripples along the wall of the
oesophagus lasting only a few seconds, as multiple
simultaneous contraction rings or as a segmented barium
column producing a corkscrew appearance.
14. A series of indentations
resembling a corkscrew
(hence the description
'corkscrew oesophagus')
15. Mechanism of swallowingMechanism of swallowing
During the pharyngeal phase of swallowing, aDuring the pharyngeal phase of swallowing, a
primary peristalsis is created, that relax the UESprimary peristalsis is created, that relax the UES
and forces the food bolus through it. The UESand forces the food bolus through it. The UES
remain constricted and has resting pressure ofremain constricted and has resting pressure of
20-60 mmHg. The peristaltic waves travel at the20-60 mmHg. The peristaltic waves travel at the
speed 2cm/s and reach the stomach in 5-10speed 2cm/s and reach the stomach in 5-10
secondsecond
16. Secondary peristalsis get initiated if the primarySecondary peristalsis get initiated if the primary
peristalsis failed to get food to the stomach and theperistalsis failed to get food to the stomach and the
esophagus became distended.esophagus became distended.
18. Secondary esophageal motility disordersSecondary esophageal motility disorders
related to , diabetes, alcoholrelated to , diabetes, alcohol
consumption,collagen,endocrine andconsumption,collagen,endocrine and
neuromuscular diseases.neuromuscular diseases.
19. Esophageal Motility DisordersEsophageal Motility Disorders
Achalasia (failure to relax)Achalasia (failure to relax)
• Is the only esophageal motility disorder with anIs the only esophageal motility disorder with an
established pathology.established pathology.
• The predominant pathophysiology of achalasiaThe predominant pathophysiology of achalasia
is theis the loss of Auerbachloss of Auerbach ganglion cells from theganglion cells from the
wall of the esophagus ,starting at LES andwall of the esophagus ,starting at LES and
progress proximally.progress proximally.
• Incidence is 1-3 / 100,000 population / year.Incidence is 1-3 / 100,000 population / year.
20. Esophageal Motility DisordersEsophageal Motility Disorders
Achalasia (failure to relax)Achalasia (failure to relax)
• Characterized by failure of LES to relaxCharacterized by failure of LES to relax
completely during swallowingcompletely during swallowing
Primary and secondary peristalsis initially fails,
tertiary contractions develops ,leading to stasiss ,leading to stasis
of food and subsequent dilatation.of food and subsequent dilatation.
• Manometry may reveal elevated LES pressure >Manometry may reveal elevated LES pressure >
40 mmHg in 60% of patients.40 mmHg in 60% of patients.
21. A barium swallow will show the gastro-
oesophageal junction failing to open fully and
tapering to a rat tail or bird beak appearance.
Intact mucosal folds can be traced through this
narrowed segment which at times opens briefly
to allow a little barium to spurt into the stomach.
22. Achalasia. The oesophagus is
distended. Intact
oesophageal folds pass
through the tapered
narrowing, which corresponds
to the site of the lower
oesophageal sphincter
23. Esophageal Motility DisordersEsophageal Motility Disorders
SPASTIC ESOPHAGEAL MOTILITY DISORDERSSPASTIC ESOPHAGEAL MOTILITY DISORDERS
1)Diffuse esophageal spasm (DES):1)Diffuse esophageal spasm (DES):
This is probably related to fragmentalThis is probably related to fragmental
degeneration of vagal nerve fibers.degeneration of vagal nerve fibers.
• Characterized by simultaneous, repetitive highCharacterized by simultaneous, repetitive high
pressure muscular contraction within thepressure muscular contraction within the
esophagus.esophagus.
• May be associated with severe intermittent chest
pain, dysphagia and even food impaction.
25. 2)Nutcracker esophagus2)Nutcracker esophagus
This is a manometric diagnosis in which patients
with non-cardiac chest pain have primary
peristaltic waves with pressures in excess of 180
mmHg (normally 100 mmHg).
The barium swallow and oesophageal scintigram
show normal peristalsis and cannot therefore be
used to diagnose this condition.
26. 3)Hypertensive /hypertrophic LES,Non-3)Hypertensive /hypertrophic LES,Non-
specific.specific.
This again is a manometric finding in
which the resting lower oesophageal
sphincter pressure is 40 mmHg or more
27. 4)Non-specific esophageal motility disorder4)Non-specific esophageal motility disorder
This term is used to describe the remaining
abnormalities of motility, such as
incomplete lower oesophageal relaxation and
loss of peristalsis
solitary abnormal contractions
28. 5) Presbyoesophagus5) Presbyoesophagus
Abnormal motility in the elderly is referred to
as presbyoesophagus,although an
underlying cause, for example diabetes,
can often be identified in such patients.
Elderly patients with severely disordered
motility may become symptomatic with
chest pain or dysphagia.
29. THE TRANSIT TESTTHE TRANSIT TEST
Scintigraphic tests have been shown to be
more sensitive than endoscopy
radiography and manometry in the
identification of patients with motility
problems.
30. Indications
patients with atypical chest pain (pain of cardiac
type with normal ECG and enzymes)
patients with dysphagia but normal endoscopy/
barium studies
patients with suspected muscular or
neuromuscular dysfunction
31. The transit test demonstrates oesophageal
function by visualising the passage of a
swallowed bolus into the stomach.
The labelled material may be prepared in either
liquid or solid form – for example, orange juice
labelled with 99mTc-DTPA, or scrambled egg
labelled with 99m Tc colloid.
32. Each swallow consists of one mouthful (8-10 ml)
of the labeled material and is swallowed in a
single gulp, the patient being asked not to
swallow again for the next 30 s, during which
time the image acquisition is made.(2-4 frames
per second).
33. The images can then be displayed as a
cine loop, and time-activity curves derived
for the upper third, middle third, lower third
and whole oesophagus.
34. A convenient way of displaying the entire
study is to use a functional image, with
distance on the vertical axis and time on
the horizontal axis.
35. Typically, three consecutive swallows may
be obtained in the supine position, and a
further three swallows in the sitting
position. Between each swallow the
oesophagus is rinsed with an unlabeled
drink in order to clear residual activity
36. The results can be expressed either
qualitatively, or by using a grading system,
or by measurement of the mean transit
time between mouth and stomach.
37. Transit through the upper third of the
oesophagus usually takes about I s,
through the middle third about 2 s, and
through the lower third about 6 s, giving a
transit time through the whole oesophagus
of 8-10 s.
38. Grading systems take into account the degree of
delay in transit time, the severity of disruption of
the transit pattern, and the frequency of the
abnormality in repeated swallows.
Qualitatively, several different patterns can be
recognised:
39. Normal. The bolus traverses the
oesophagus in a single wave of peristalsis
in 8-10 s or so, with no delay, no
fragmentation of the bolus, and no reflux
40. Condensed image of a
normal swallow.
Timescale (x axis) is 30 s,
y axis corresponds to the
length of the oesophagus
with the mouth at the top
and gastric fundus at the
bottom. M = mouth; D =
distance;S = stomach.
41. Transfer dysphagia. Once initiated, transit
shows a normal progression but there is
delay in initiating swallowing, and
sometimes fragmentation of the bolus in
the pharynx
42. Condensed image in a
patient with pharyngeal
incoordination leading to
transfer dysphagia,
showing fragmentation of
the initial swallowed bolus
but normal rate of transit
through the rest of the
oesophagus.
43. Step-delay' pattern. The initial peristaltic
wave dies out in the middle third of the
oesophagus and the bolus then remains
stationary until it is stripped down the
lower third by the next peristaltic wave.
Associated with reflux oesophagitis
44. Condensed image from a
patient with oesophagitis
showing a 'step-delay'
pattern with transient hold
up of the bolus in the
middle third of the
oesophagus.
45. Intraoesophageal reflux. The swallowed
bolus proceeds normally to the lower third,
then part or all of it refluxes back to the
middle third, before being cleared by
further peristalsis
Associated with reflux oesophagitis
46. Condensed image showing
intraoesophageal reflux
retrograde motion of part of the
swallowed bolus from the
lower end to the middle third,
with later clearing by a second
swallow. M = mouth;D =
distance; S = stomach.
47. Incoordinate. After swallowing, the bolus is
immediately fragmented by dystonic
contractions, and no peristaltic wave
develops
Patients with diffuse oesophageal spasm,
frequent tertiary contractions, or
presbyoesophagus typically show an
incoordinate pattern with delayed transit
48. Adynamic. Swallowing is initiated
normally, but peristalsis is weak or absent
and bolus remains in the middle third of
the oesophagus if the patient is supine, or
clears only very slowly from the lower
oesophagus if the patient is sitting
49. Patients with autonomic neuropathy
associated with diabetes, and those with
systemic sclerosis involving the
oesophagus, typically show delayed
clearance with adynamic patterns
50. Condensed image in a
patient with achalasia
showing stasis of the
swallowed bolus in the
middle third of the
oesophagus, with to-and
fro movement caused by
respiratory excursion.
51. Esophageal Motility DisordersEsophageal Motility Disorders
Scleroderma esophagusScleroderma esophagus
Collagen vascular disease.Collagen vascular disease.
Vasculitis damages the smooth muscle coat of
the bowel and mainly involve the distal 2/3 ofand mainly involve the distal 2/3 of
esophagus.esophagus.
Muscle damage results in a loss of primary and
secondary motility , development of tertiary
contractions and weakening of LES causingand weakening of LES causing
GERD.GERD.
52. Scleroderma: Incompetence
of the gastro-oesophageal
sphincter resulting in severe
reflux oesophagitis with
structuring, oedematous
mucosa (mosaic pattern)
and deep ulceration.
53. Esophageal Motility DisordersEsophageal Motility Disorders
Clinical HistoryClinical History
Achalasia:Achalasia:
• The hall mark is dysphagia to both solid andThe hall mark is dysphagia to both solid and
liquid.liquid.
• Regurgitation commonly occur at nightRegurgitation commonly occur at night
• Retrosternal chest pain.Retrosternal chest pain.
• Heartburn occur in 30% of patients which mayHeartburn occur in 30% of patients which may
be related to food fermentation and lactic acid.be related to food fermentation and lactic acid.
54. Esophageal Motility DisordersEsophageal Motility Disorders
Clinical HistoryClinical History
Spastic motility disordersSpastic motility disorders
• Chest pain is the hall mark which may mimicChest pain is the hall mark which may mimic
angina due to esophageal distension.angina due to esophageal distension.
• Dysphagia to both solid and liquid.Dysphagia to both solid and liquid.
SclerodermaScleroderma
• Involve the esophagus in 80% of patients.Involve the esophagus in 80% of patients.
• Symptoms are related to GERD [dysphagia,Symptoms are related to GERD [dysphagia,
heartburn and regurgitation].heartburn and regurgitation].
55. Esophageal Motility DisordersEsophageal Motility Disorders
Problems to be consideredProblems to be considered
Coronary Artery Disease (CAD).Coronary Artery Disease (CAD).
Mechanical obstruction (tumor).Mechanical obstruction (tumor).
Achalaisa and scleroderma increase risk ofAchalaisa and scleroderma increase risk of
esophageal cancer.esophageal cancer.
56. Esophageal Motility DisordersEsophageal Motility Disorders
DiagnosisDiagnosis
HistoryHistory
Physical examination-unremarkablePhysical examination-unremarkable
Barium SwallowBarium Swallow
Bird peak appearance- classic forBird peak appearance- classic for
achalasiaachalasia
Rosary beads or corkscrew-Rosary beads or corkscrew-
classic for DESclassic for DES
57. Bird peak appearance- classicBird peak appearance- classic
for achalasiaRosary beads orfor achalasiaRosary beads or
corkscrew-classic for DEScorkscrew-classic for DES
