Download Esophageal Motility Disorders

Esophageal Motility Disorders
Iskander Al-Githmi, MD, FRCSC, FRCSC (Ts & CDS), FACS, FCCP
Consultant & Asst. Professor of Cardiothoracic Surgery
King Abdulaziz University College of Medicine
Anatomy of The Esophagus
The esophagus is a hollow muscular
organ, approximately 25cm in length that
extend from the pharynx to the stomach
The pharynx is a muscular tube,
approximately 12cm in length that serve
as entry to the esophagus and respiratory
tract.
Anatomy of The Esophagus
Cervical Esophagus: Just lies to the left of
midline behind the larynx and the trachea. The
entry to esophagus called upper esophageal
sphincter (UES).
Thoracic Esophagus: The upper part passes
behind the carina & Lt. main stem bronchus. The
lower part passes behind the left atrium.
Abdominal Esophagus: Is the smallest portion of
the esophagus (2-4cm length). It has lower
esophageal sphincter (LES)- non anatomical
with normal resting pressure 10-20mmHg.
Anatomy of The Esophagus
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Normal esophageal narrowing:
UES at the level of cricoid cartilage 14mm in
diameter.
Broncho-aortic constriction 17mm in diameter.
LES (19mm) as it travels the diaphragm &
located 3-5cm at distal part of the esophagus.
Clinical Importance of normal esoph. narrowing:
Potential for development of diverticulum's
(Zenker) in the neck.
Potential for perforation during esophagoscopy
Pills-induced stricture.
Anatomy of The Esophagus
The esophageal wall:
• The proximal esophagus is predominantly
striated muscle.
• The distal esophagus is predominantly smooth
muscle.
• The mid esophagus contained a graded
transition of striated and smooth muscle.
Anatomy of The Esophagus
The esophageal wall:
• The muscle oriented in two perpendicular opposing
layers an inner circular layer and outer longitudinal
layers both called muscularis propria.
• The outermost layer of the esophagus called adventitia
(fibro-areolar layer), but no serosa. This may contribute
for cancer spread.
• Underneath the adventitia there is a longitudinal muscle
layer and beneath there is circular layer.
• Between the two muscle layers there are network of
sympathetic and parasympathetic fibers (myentric
plexus)
Anatomy of The Esophagus
The esophageal wall:
• Beneath the muscle layers lies the submucosa
which contain mucus gland, blood and lymphatic
vessels and network works of nerve fibers
(meissners).
• Beneath the submucosa is the mucosa which
consist of squamous epithelium except the distal
2cm at G-E junction (Z-line) or transition to
columnar epithelium.
Anatomy of The Esophagus
Blood supply & venous drainage
• Cervical esophagus received its arterial blood
from inferior thyroid artery.
• Thoracic esophagus received its arterial blood
from bronchial, aorta, left gastric artery and from
inferior phrenic artery.
• The esophageal veins drain to periesophageal
venous network & to inferior thyroid vein in the
neck and to azygos and hemiazygos veins in the
thorax.
Anatomy of The Esophagus
Lymphatic drainage:
• The lymphatic plexus are located in the mucosa and the
muscular layers drained to mediastinal lymph nodes.
Clinical facts about the esophagus
• Cervical esophagus is 5 cm in length and 15cm distance
from upper incisors
• Thoracic esophagus is 12cm in length and 25cm
distance from upper incisors
• Lower esophagus is 2cm in length & 38cm from upper
incisors
Physiology of The Esophagus
The function of the esophagus is to transport the
ingested material from the pharynx to the
stomach by peristaltic waves.
Primary peristalsis: Triggered by the swallowing
center in the brain stem and the contraction
wave travel at speed 2cm/s.
Secondary peristalsis: Induced by esophageal
distension from retained bolus, refluxed material.
Its role is to clear the esophagus form retained
bolus.
Physiology of The Esophagus
Tertiary peristalsis: Are non peristaltic
contraction and play no known physiological
role. Frequently observed in elderly people
called (presbyesophagus), also seen in motility
disorders.
Physiology of The Esophagus
Mechanism of swallowing
• During the pharyngeal phase of swallowing, a
primary peristalsis is created, that relax the UES
and forces the food bolus through it. The UES
remain constricted and has resting pressure of
20-60 mmHg. The peristaltic waves travel at the
speed 2cm/s and reach the stomach in 5-10
second
Physiology of The Esophagus
• Secondary peristalsis get initiated if the primary
peristalsis failed to get food to the stomach and
the esophagus became distended.
Esophageal Motility Disorders
Achalasia
Spastic esophageal motility disorders such as
diffuse esophageal spasm, nutcracker
esophagus and hypertensive LES
Secondary esophageal motility disorders related
to scleroderma, diabetes, alcohol consumption ..
Esophageal Motility Disorders
Achalasia (failure to relax)
• Is the only esophageal motility disorder with an
established pathology.
• The predominant pathophysiology of achalasia
is the loss of Auerbach ganglion cells from the
wall of the esophagus ,starting at LES and
progress proximally.
• Incidence is 1-3 / 100,000 population / year.
Esophageal Motility Disorders
Achalasia (failure to relax)
• Characterized by failure of LES to relax
completely during swallowing
• The loss of nerve ganglion along the esophageal
wall cause a peristalsis leading to stasis of food
and subsequent dilatation.
• Manometry may reveal elevated LES pressure >
40 mmHg in 60% of patients.
Esophageal Motility Disorders
Spastic esophageal motility disorders
• Diffuse esoph.spasm (DES): This is probably
related to fragmental degeneration of vagal
nerve fibers.
• Characterized by simultaneous, repetitive high
pressure muscular contraction within the
esophagus.
• The muscular wall is thickened, hypertrophied
and is hypersensitive to stretching.
Esophageal Motility Disorders
Scleroderma esophagus
• Collagen vascular disease.
• Characterized by smooth muscle hypertrophy
and mainly involve the distal 2/3 of esophagus
gradually lead to loss of peristalsis and
weakening of LES causing GERD.
• Involve the esophagus in 80% of patient with
scleroderma.
Esophageal Motility Disorders
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Clinical History
Achalasia:
The hall mark is dysphagia to both solid and
liquid.
Regurgitation commonly occur at night
Retrosternal chest pain.
Heartburn occur in 30% of patients which may
be related to food fermentation and lactic acid.
Esophageal Motility Disorders
Clinical History
 Spastic motility disorders
• Chest pain is the hall mark which may mimic
angina due to esophageal distension.
• Dysphagia to both solid and liquid.
 Scleroderma
• Involve the esophagus in 80% of patients.
• Symptoms are related to GERD [dysphagia,
heartburn and regurgitation].
Esophageal Motility Disorders
Problems to be considered
 Coronary Artery Disease (CAD).
 Mechanical obstruction (tumor).
 Achalaisa and scleroderma increase risk of
esophageal cancer.
Esophageal Motility Disorders
Diagnosis
 History
 Physical examination-unremarkable
 Barium Swallow
Bird peak appearance- classic for
achalasia
Rosary beads or corkscrewclassic for DES
Esophageal Motility Disorders
Diagnosis
 Esophagoscopy to rule out tumor or
inflammatory lesion but not to diagnose
esophageal dysmotility.
 Manometry study is to evaluate the esophageal
motor pattern, contraction amplitude and LES
pressure.
Flexible Gastro-Esophagoscope
Esophageal Manometry Cath.
Esophageal Manometry
Esophageal Manometry
Achalasia
Esophageal Motility Disorders
Treatment
 The primary goal is symptomatic relief directed
at relieving the physiologic obstruction at the
level of LES by surgical or balloon dilatation.
 Nitrate and Ca channel & B blockers are
currently used in all patients with esophageal
motility disorders.
 Antireflux therapy e.g proton pump inhibitors
(esomeprazol) + prokinetic such as motilium or
erythromycin.
Esophageal Motility Disorders
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Treatment
Botulinum toxin injection (Botox): Injected edoscopically
in 4 quadrants into LES in treating patient with achalasia.
Botox is a potential inhibitor of acetylcholine release
from nerve terminals. It is indicated in those pt. not
candidate for surgery or refuse surgery.
Endoscopic balloon dilatation: This is the standard
therapy for patients with achalasia.
The mechanism based on disruption of circular muscle.
Balloon dilatation response rate is 70%
Esophageal Motility Disorders
Treatment
 Surgery (Heller Myotomy): surgical treatment
targets to disrupt the LES.
 This can be performed thoracoscopic or
laparascopic.
 Outcome is excellent 80-100% response rate.
Normal Esophagus
Barrett Esophagus
Definition: Intestinal metaplasia
Risk factors
Age
Male
GERD
Smoking
Treatment:
Antireflux therapy
Medical: Pump inhibitors (esomeprazole)
Prokinetic meds (Motilium)
Annual Surveillance (esophagoscopy)
Surgical: Fundoplication + Annual Surveillance
Complications:
Dysplasia
Adenocarcinoma <1%/Yr