This document summarizes the anatomy, histology, common abnormalities and disorders of the esophagus. It discusses congenital anomalies like tracheoesophageal fistulas. It also covers acquired conditions such as esophageal diverticula, motor disorders like achalasia, inflammatory disorders including different types of esophagitis, Barrett's esophagus and esophageal cancer. Esophageal adenocarcinoma arises from Barrett's esophagus while squamous cell carcinoma is more common in other parts of the esophagus. Both types usually present at late stages with poor prognosis.

1. - BY SURAJ DHARA
(MMCH)

2. Anatomy/Histology of the Esophagus
The esophagus is lined by
non-keratinized stratified
squamous epithelium
It can withstand abrasion
from foods but is
sensitive to acid
The lower esophageal
sphincter protect the
lower esophagus from
gastric acid

3. Tracheoesophageal Fistulas
Most common congenital esophageal anomaly,
communication between trachea and esophagus
Often associated with atresia (incomplete esophageal
development)

4. Tracheoesophageal Fistulas
Most common presentation is regurgitation during
feeding
Aspiration, suffocation, pneumonia, and severe fluid
and electrolyte imbalances can occur
Esophageal atresia is associated with congenital heart
defects, genitourinary malformations, and neurologic
disease

5. Esophageal Diverticula
Outpouchings of the wall that contain all layers of the
esophagus
Zenker Diverticulum (pharyngoesophageal
diverticulum) is located immediately above the upper
esophageal sphincter
Traction Diverticula occurs in the mid esophagus
Epiphrenic diverticula are located immediately above
the diaphragm

6. Esophageal Diverticula
Diverticula occur in areas
of weakened esophageal
wall
Zenker diverticula can
accumulate large amounts
of food causing
regurgitation and
aspiration pneumonia
Epiphrenic diverticula are
often seen in association
with reflux esophagitis

7. Motor Disorders of the Esophagus
Dysphagia: difficulty swallowing
Odynophagia: pain on swallowing
Achalasia: absence of peristalsis in the body of the
esophagus and failure of the LES to relax in response to
swallowing
Primary/Idiopathic: failure of distal esophageal
inhibitory neurons
Secondary: Chagas disease, Trypanosoma cruzi infection
destroys myenteric plexus causing aperistalsis and
esophageal dilatation. Also caused by infiltrative
disorders such as malignancy, amyloidosis, sarcoidosis

8. Inflammatory Disorders of the
Esophagus
Chemical Esophagitis
Infectious Esphagitis
Candida
Herpes
Cytomegalovirus
Reflux Esophagitis (GERD)
Reflux and Barrett’s esophagus

9. Chemical Esophagitis
Corrosive acids or alkalis, alcohol, and heavy
smoking are common irritants
Medications can cause esophageal injury when pills
get stuck in the esophagus instead of dissolving in
the stomach (pill esophagitis)
Chemotherapy and radiation therapy are important
causes of iatrogenic esophagitis
Chemical injury causes self-limited pain and
dysphagia but in more severe cases hemorrhage or
perforation may occur

10. Infectious Esophagitis
Mostly affect immunocompromised
Candida esophagitis:
Candidiasis presents as small white
plaques with hyperemic borders, in
severe cases grayish
pseudomembranes are seen
Histologically, the candidal
psuedomembrane contains fungal
hyphae, necroinflammatory debris
and fibrin

11. Infectious Esophagitis
Herpes Esophagitis:
Early lesions show plaques that may
resemble candidiasis. Asl lesions
evolve, large punched-out ulcers
develop
Histologically, epithelium shows
nuclear viral inclusions within a rim of
degenerating epithelial cells at the
margin of the ulcer
CMV Esophagitis:
Grossly similar to Herpes infeciton
Microscopically, shallower ulcers show
characteristic nuclear and cytoplasmic
inclusions in endothelial and stromal

12. Viral Esophagitis
Herpes
CMV

13. Reflux Esophagitis
Most common type of esophagitis
The lower esophageal spinchter (LES) is
the most important barrier against reflux
In the absence of proper LES tone the
gastric contents (which are under positive
pressure) enter and damage the
epithelium of lower esophagus
In addition, bile from the duodenum may
exacerbate injury
Lower LES tone and higher abdominal
pressure may be see in :
alcohol and tobacco use, obesity, central
nervous system depressants, pregnancy,
hiatal hernia, delayed gastric emptying
From A.D.A.M.com
LES

14. Reflux Esophagitis
If reflux persists, the
squamous epithelium
becomes thickened,
hyperemic and ulcerated
Microscopically, the
epithelial basal layer is
hyperplastic and
intaepithelial eosinophils
and neutrophils are seen

15. Reflux Esophagitis
Clinically, reflux esophagitis is called
gastroesophageal reflux disease (GERD)
Most common in adults >40 ys
symptoms include dysphagia and heartburn
Regurgitation or even severe chest pain in severe
cases
Treatment with proton pump inhibitors or H2
histamine receptor antagonists are usually effective
Complications are related to duration of symptoms
and include ulceration, bleeding and Barrett
esophagus

16. Barrett Esophagus
Replacement of the squamous
esophageal epithelium by columnar
epithelium (intestinal metaplasia) as
a reaction to GERD injury
Affects the lower esophagus, may
extend higher
Most common in men (40-60 yo),
Caucasian
Dysplasia is detected in about 2% of
Barrett’s cases/year and it is
associated with persistent GERD

17. Barrett Esophagus Morphology
 Endoscopically, it appears as
“tongues” of red, velvety
mucosa above the GE junction
Histologically, intestinal
metaplasia is composed of
goblet cells wit cytoplasmic
mucus vacuoles
The diagnosis of Barrett
esophagus requires both:
Abnormal endoscopic findings
and histology of intestinal
metaplasia
Normal gastroesophageal junction Barrett esophagus

18. Barrett and Dysplasia
Dysplasia is identified by increased
N/C ratio, atypical mitoses,
hyperchromasia , cellular crowding
(stratification) and abnormal
architecture
Based on the degree of cytologic
and architectural atypia, dysplasia is
categorized as low or high grade
Invasion of neoplastic cells into the
lamina propria results intramucosal
carcinoma

19. Esophageal Carcinoma
Esophageal Adenocarcinoma
Squamous Cell Carcinoma

20. Esophageal Adenocarcinoma
Arises from preexisting
Barret esophagus and
involves the lower 1/3
Risk is increased by
smoking, obesity, and prior
radiation
Most common in men
(M:F=7:1), Caucasians
Most common type in US

21. Squamous Cell Carcinoma
Usually arises in the upper or middle
1/3 esophagus
Major risk factors include
Alcohol and tobacco
Consumption of hot beverages
Achalasia
Esophageal web (Plummer Vinson
Syndrome)
Chemical injury (lye ingestion)
Most common in men (M:F=4:1),
African-Americans
Most common type of esophageal
carcinoma worldwide

22. Esophageal Carcinoma
Patients usually present late, predicting a poor prognosis
Symptoms include:
Progressive dysphagia (solids liquids)
Weight loss
Hematemisis
Hoarseness (recurrent laryngeal nerve involvement) and
cough (tracheal involvement) are seen in SqCC
Lymph node involvement:
Upper 1/3= cervical
Middle 1/3= mediastinal/ tracheal
Lower 1/3= celiac/gastric
Overall 5-year survival is low; <20% in Adeno and <10%
SqCC