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4. Introduction:
The esophagus serves as a
conduit between the
pharynx and the stomach .
It begins at the
cricopharyngeus (c5-C6)
passes through the
diaphragm to join the
cardia of stomach (D10)
Length 23-37 cms
correlates with
individual's height and it is
usually longer in men than
in women.
5. Normal wall Thickness:
adequately distended: 3mm
incompletely distended:5mm
A-P diameter <16mm
Lateral diameter <24mm
New born :
length: 8-10cms
starts at c4-c5 up to T9
6. Anatomically divided
into three parts
Cervical(jn to notch)
4-5cms
Thoracic(notch to
hiatus)
abdominal
Functionally divided
into
upper esophageal
sphincter
esophageal body
lower esophageal
sphincter
7. UES
3 cm long zone of increased pressure at upper end
of esophagus
Relaxes with swallowing – normally remains
closed (prevents swallowing of air with
inspiration)
Located at the C5-C6 level
same as criopharyngeus muscle
8. LES (functional sphincter)
3-5 cm zone of increased pressure at lower end of
esophagus
Relaxes with swallowing
Contracts thereafter in sequence with transmitted
pressure increases – prevents reflux
Sphincter tone provided by intrinsic myogenic
activity
Sphincter relaxation due to neural activity
9. Esophagogastric Junction Definitions
The mucosal junction is marked by irregular
interdigitations, hence the term ‘Z line’. (ora serrata
or Z line) – most clinically practical
Point at which tubular esophagus joins gastric pouch
Junction of esophageal circular muscle layer with
oblique sling fibers of stomach (loop of Willis or
collar of Helvetius)
The gastro-oesophageal junction is found
constantly 40 cm distance from the incisor teeth.
11. primitive foregut endoderm is the origin for both the
future esophageal epithelium and submucosal glands.
smooth muscle ,- mesenchyme of the somites
surrounding the foregut.
striated muscle-mesenchyme of the branchial arches
4, 5, and 6. vagus 5th
RLN 6th
.
12. Histology:
The wall of the oesophagus comprises four layers
1. The outer fibrous coat(Adventitia)
2. Muscle layer with outer longitudinal and inner circular
fibers
3. Sub mucosa
4. Mucosa.
The mucosal lining of the oesophagus is stratified
squamous epithelium throughout its length, changing to
columnar epithelium only at the gastro-oesophageal
junction
Unlike the remainder of the GI tract, the esophagus does
not have a serosal layer, thus permitting rapid
dissemination of infection and tumor
13. Striated muscle predominates in the upper
esophagus, with smooth muscle in the lower two
thirds of the esophagus.
The transition from striated to smooth muscle varies
but usually occurs at the level of the aortic arch.
17. Course & Relations
At the thoracic inlet,- it
lies slightly to the left of
midline
At the mid chest -
closely apposes the left
mainstem bronchus and
the pericardium of the
left atrium
Distally lies anterior to
the descending aorta to
the left of midline as it
enters its diaphragmatic
hiatus.
18. Course & Relations
The esophagus abuts the pleura on the right but is
relatively protected from the left pleural space by the
intervening aorta.
As a result, processes involving the mid-thoracic
esophagus tend to spread into the right pleural space.
On CT, there may be small collections of air in the
esophageal lumen, but the presence of fluid or a
luminal caliber greater than 10 mm is abnormal and
suggests obstruction or a motility disorder
22. Anatomy – Lymphatic Drainage
Vessels run
longitudinally, then
penetrate wall to enter
regional nodes
Cervical – lt
supraclavicular
Thoracic – tracheal,
tracheobronchial,
posterior mediastinal,
diaphragmatic
Abdominal – celiac axis
23. Esophagus Innervation
. A rich network of intrinsic neurons capable of
producing secondary peristalsis is found in the
submucosa and between the circular and
longitudinal muscle layers.
This network communicates to the central
nervous system via the vagi(parasympathetic) and
sympathetic
Cervical: from superior and inferior cervical
sympathetic ganglia
Thorax: from upper thoracic and splanchnic
nerves
Abdominal: from celiac ganglion
24. Physiology of Swallowing
Primary peristalsis – progressive, triggered by
voluntary swallowing
Secondary peristalsis – progressive, generated by
distention or irritation usually from bolus not
traversing through the esophagus.propels
remaining bolus distally.
Tertiary peristalsis – nonprogressive
(simultaneous) and uncoordinated, after
voluntary or spontaneously between swallows –
responsible for “corkscrew” appearance of spasm
of Barium Swallow
26. Plain Radiography:
Per se plain chest xray
is not modality for
imaging Normal
oesophagus
A chest radiograph
may give clue regarding
perforation ,foreign
bodies, achalasia etc.
27. Contrast swallow
Contrast medium::
Single contrast
1. Barium sulphate 80% suspension
2. Gastrografin
3. Gastromiro (Iopamidol) non ionic water
soluble
Gastrografin should NOT be used for the investigation of a tracheo-
oesophageal fistula or when aspiration is a possibility.
Barium should NOT be used if perforation is suspected.
28. Double contrast study: 200-250% high density , low
viscocity 15-20ml . Effervescent powder(or NG Tube)
is given with another mouth full of barium.
Erect>prone>supine
Medications: Buscopan or glucagon for hypotonia for
longer retention (not for assessment of motility
disorders)
Positions: RAO ,LAO, Frontal,Lateral in erect
Motility disorders(prone swallow)
Severe dysphagia?? 5ml diluted barium initially further filming n
contrast based on abnormality observed
29. Barium has superior contrast qualities and unless
there are specific contraindications, its use (rather
than water-soluble agents) is preferred.
Rapid serial radiography (2 frames per s) or video
recording may be required for assessment of the
laryngopharynx and upper oesophagus during
deglutition
30. The patient is in the erect RAO position to throw the
oesophagus clear of the spine.
An ample mouthful of barium is swallowed, and spot
films of the upper and lower oesophagus are taken.
.
If rapid serial radiography is required, it may be
performed in the right lateral, RAO and PA positions
31. AP or PA Projection
Pt. supine or prone
Center midsagittal
plane to cassette
Bottom of cassette
should be placed just
below tip of xyphoid
Pt. drinks contrast
before exposure and
continues drinking
during exposure
32. Structures Shown/Film Evaluation
Entire barium filled
esophagus from lower
neck to stomach
Barium should be
sufficiently penetrated
Surrounding structures
should be visible, not
overpenetrated
No rotation on AP, PA, or
lateral projections
Esophagus should be
displayed between heart
and spine on oblique
projections
33. Lateral Projection
Place pt in lateral
position
Center midcoronal
plane to cassette
Bottom of cassette
below xyphoid process
Pt must drink
continuously before
and during exposure
37. Bulbous distention of
the distal esophagus is
called the vestibule and
corresponds to the
manometrically-defined
lower esophageal
sphincter.
This distention is best
demonstrated by breath
holding in inspiration or
a Valsalva maneuver.
Do not mistake this for a
hiatal hernia.
40. Endoscopic USG:
Evolved as the imaging
modality of choice for
entire oesophagus.
Helps in visualising wall
layers of oesophagus
thus in perfect T-
staging( superior to CT)
Helps in taking needle
biopsy of suspected
growth and suspicious
surrounding
lymphnodes.
45. S-EUS- 5layered wall
Inner(1)-outer(5)
1st layer -bright (hyper-echoic)
- superficial mucosa.
2nd (dark, hypoechoic)- deep
mucosa.
3r d (hyperechoic)-
submucosa and the acoustic
interface between the
submucosa and the muscularis
propria.
4th (hypoechoic) – muscularis
propria
5th layer corresponds to the
adventitia
48. CT-Protocol
Patient position: supine with arms elevated above
level of head
Topogram position: AP 1 inch below chin to
umbilicus
Mode : Helical CT with single breath hold, thus
reducing breathing and cardiac artifact
Scan orientation: caudocranial.
starting point: Imaginary line joining both cp angles
end point: 1cm above apex of lung
High-density or positive oral contrast material
swallowed directly before CT is helpful in delineating
the esophageal lumen.
49. Scanning is performed during the portal venous
phase and intravenous contrast administered at a rate
of 2 to 4 mL/sec.
Slice thickness should be no more than 5 mm
throughout the chest.
In patients with suspected esophageal varices, water
is used as a negative contrast agent combined with
intravenous contrast.
50. A positive oral contrast agent combined with
intravenous contrast can obscure submucosal
vascular structures.
Multiplanar reformatted images may also be helpful,
particularly in the staging of esophageal cancer.
CT has advantage over mri in detecting lymohnodes
with more accuracy
51.
52.
53.
54.
55.
56.
57. MRI
The advent of fast, breath-hold MR sequences has
increased the utility of MR in evaluation of the GI
tract.
But there is still role for MR imaging in evaluation of
the esophagus is limited.
Cardiac gating must be incorporated, and coverage of
the entire esophagus in a single breath-hold sequence
remains problematic .
62. PET-CT: For picking metastasis and extent of spread
of malignancy with in the esophagus
Nuclear medicine: Prime role for assessing
oesophageal motility disorders and reflux disease
especially in young children.
Endoscopy : Is now the investigation of choice for
evaluating as well as obtaining biopsy at the same
setting. However lack of spatial resolution and in
ability to look out side the lumen are the limitations.
63.
64. conclusion
Chest xray - no/limited role in evaluating oesophagus.
Ba. Swallow is most useful modality in evaluating
oesophageal disorders
Normal variants in barium swallow should not
be misinterpreted
Endoscopic Usg is imaging modality of choice for T-
staging of oesophageal cancer and to check
extraluminal contiguous extension
CT scan is THE imaging modality for evaluating
extraluminal disease and nodal disease in carcinoma.
MRI has limited role in evaluating oesophageal
disease
Radionucleotide scans are useful in motility disorders