Esophagus Quick-Review Notes

Anatomy

• Muscular tube, $25\,\text{cm}$ long (approx. $10$ in).
• Extent: starts opposite $C6$ (continuation of pharynx) → perforates diaphragm at $T10$ → joins stomach at $T11$.
• Four physiologic constrictions (from incisors): cricopharyngeal ($15\,\text{cm}$), aortic/bronchial ($25\,\text{cm}$), diaphragmatic ($40\,\text{cm}$), cardio-esophageal.

Blood Supply & Lymphatics

• Cervical: inferior thyroid a./v. → lower deep cervical LN.
• Thoracic: branches of descending thoracic aorta; veins → azygos; LN → broncho-mediastinal.
• Abdominal: left gastric a./v. (portal) ⇒ porto-systemic site (varices); LN → left gastric & celiac.

Histology (layers)

1. Mucosa: stratified squamous.
2. Submucosa: vessels, lymphatics.
3. Muscularis: upper $1/3$ striated, lower $2/3$ smooth.
4. Serosa only in short abdominal segment; rest has adventitia.

Dysphagia (difficulty swallowing)

• Intraluminal: foreign body.
• Intramural: atresia, corrosive/trauma, carcinoma, webs, achalasia, reflux stricture.
• Extrinsic: thyroid/bronchial CA, retrosternal goitre, aortic aneurysm, LNs, rolling hernia, vascular ring (dysphagia lusoria).
• General & functional: oral/pharyngeal sepsis, bulbar palsy, myasthenia, tetanus, diffuse spasm.
• Benign: fluids > solids; Malignant: solids > fluids, rapid in elderly.

Plummer–Vinson Syndrome

• Triad: dysphagia + iron-deficiency anemia + esophageal web (post-cricoid).
• Middle-aged women; koilonychia, smooth tongue, splenomegaly.
• Precancerous (post-cricoid CA).
• Treat iron; dilate web; long-term follow-up.

Zenker (Pharyngeal) Diverticulum

• Pulsion mucosal pouch through Killian’s dehiscence (between thyro- & cricopharyngeus).
• Elderly men: dysphagia, regurgitation of stale food, gurgling neck swelling, halitosis.
• Risks: aspiration pneumonia, perforation, <$1\%$ CA.
• Dx: barium swallow; Rx: excision + cricopharyngeal myotomy.

Congenital Esophageal Atresia

• Incidence $1:4000$.
• Commonest type $\approx 85\%$: proximal blind pouch + distal tracheo-esophageal fistula.
• Presents neonate with frothy saliva, choking, cyanosis; NG tube stops at $10\,\text{cm}$.
• Associated VACTERL anomalies.
• Investigations: X-ray with Lipiodol, endoscopy.
• Rx: early ligation of fistula + primary anastomosis; long-gap → staged (gastrostomy then delay repair).

Esophageal Injury / Corrosive Burn

• Iatrogenic (scopes/dilatation) most common; others: foreign body, penetrating, Boerhaave (vomiting).
• Corrosives: alkali → liquefactive necrosis (deep); acid → coagulative (superficial) → fibrosis/stricture.
• Complications: perforation, mediastinitis, stricture, carcinoma.
• Management: ABC, dilute/neutralize if early, no emesis; antibiotics ± steroids; scope after $24$ h; later bougie dilatation; surgery (resection/bypass) if refractory.

Achalasia

• Primary neuromuscular failure of LES relaxation (Auerbach plexus degeneration).
• Young adults, F > M.
• S/S: progressive dysphagia fluids > solids, nocturnal regurgitation, chest discomfort, aspiration.
• Barium: “bird’s beak”, dilated sigmoid esophagus, absent gastric air bubble.
• Endoscopy to exclude malignancy.
• Rx: pneumatic/balloon dilation (80 % success); Heller myotomy ± fundoplication; botulinum toxin/CCB if unfit.

Reflux Esophagitis (GERD)

• Incompetent LES, often with sliding hiatus hernia.
• Symptoms: heartburn, regurgitation, dysphagia; worse supine.
• Complications: ulcer, stricture, Barrett’s (intestinal metaplasia ⇒ adenocarcinoma).
• Investigations: endoscopy (grading I–IV), $24\,\text{h}$ pH <$4$, manometry, barium.
• Management: lifestyle, PPI/H2 blockers; surgery (Nissen $360^{\circ}$ wrap, Belsey $270^{\circ}$) if refractory/complicated.

Hiatus Hernia

• Sliding ($90\%$): GE junction + proximal stomach above diaphragm; causes reflux. Treat as GERD.
• Rolling (para-esophageal, $10\%$): fundus herniates; risk of volvulus/strangulation; surgical repair + closure of hiatus.

Carcinoma of Esophagus

• Incidence >$50$ yr; M:F ≈ $3:1$.
• Types: squamous (mid $2/3$; alcohol, smoking, hot liquids, achalasia, Plummer-Vinson, caustic), adenocarcinoma (distal $1/3$; Barrett, GERD, obesity).
• Spread: early submucosal lymphatics ⇒ regional LN; local to trachea, aorta; hematogenous liver, lung, bone.
• Presentation: short-history progressive dysphagia solids → liquids, weight loss, regurgitation, pain, hoarseness.
• Diagnosis: barium “rat-tail/shouldering”, endoscopy + biopsy, EUS (best staging), CT chest/abdomen.
• Treatment
  • Early (T1 N0): esophagectomy + lymphadenectomy.
  • Locally advanced: neoadjuvant chemoradiation ± surgery.
  • Metastatic/inoperable: stent, laser, palliative chemo/radiation, gastrostomy.
• Prognosis: overall <10\% 3-yr survival.

Diffuse Esophageal Spasm (DES)

• Uncoordinated simultaneous contractions; presents with chest pain > dysphagia.
• Barium: “corkscrew”.
• Rx: long myotomy (aortic arch → LES), medical (nitrates, CCB).

Key Numbers for Quick Recall

• Length $25\,\text{cm}$; starts $C6$, ends $T11$.
• Constrictions at $15, 25, 40\,\text{cm}$ from incisors.
• Achalasia → cancer risk $\approx 5\%$.
• Corrosive strictures dilate >$3$ weeks post-injury.
• Neonatal atresia: suspect with polyhydramnios & frothy saliva.