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Esophageal Disorders


Overview :

The main function of the esophagus is to move food from the back of the mouth to the stomach. The adult esophagus is about 10 in (25 cm) long. It is consists of a layer of cells that secretes mucus and two layers of muscle, one circular and one longitudinal. This combination of muscles allows the esophagus to contract and propel food from the mouth the stomach. This rhythmic contraction is called peristalsis. At the end of the esophagus nearest the mouth is a ring of muscle called the upper esophageal sphincter (UES). A similar muscular ring called the lower esophageal sphincter (LES) is found 1-1.5 in (2-4 cm) above the point where the esophagus enters the stomach. The LES contracts to prevent the contents of the stomach from backflowing into the lower end of the esophagus.

Structural abnormalities

Structural abnormalities of the esophagus can be either congenital or acquired. Congenital abnormalities occur in about 1 of every 3,000-5,000 births. The two most common congenital esophageal abnormalities are esophageal atresia (EA) and tracheoesophageal fistula (TEF).

EA is a condition in which the esophagus is interrupted and the portion of the tube near the mouth is not connected to the portion that goes into the stomach. Usually the upper part of the tube ends in a blind pouch. This creates a life-threatening condition for the newborn who is unable to eat.

TEF is a condition in which the esophagus is connected to the trachea (windpipe). The trachea and the esophagus lie parallel to each other in the neck. Sometimes during fetal development, a connection called a fistula develops between these two tubes. This allows food to enter the trachea and be inhaled into the lungs causing a life-threatening condition called aspiration pneumonia. Often TEF and EA are present in the same infant. Both these conditions must be surgically corrected for the infant to survive.

Other, less common congenital structural abnormalities include webs, stenosis, cysts, and diverticula. Webs are thin membranes that lie across the esophagus and cause a partial obstruction. Stenosis is the abnormal reduction in the diameter of the esophagus due to thickening of the esophageal wall Diverticula are pouches of tissue that extend off the esophagus. Both diverticula and stenosis can be either congenital or acquired later in life.

Acquired structural abnormalities of the esophagus include Schatzki ring and hiatal hernia. Schatzki ring, sometimes called a lower esophageal ring, is a circular band of tissue located where the esophagus empties into the stomach. This ring is found in 6-14% of individuals, and for most people the presence of this ring does not create symptoms. Schatzki ring is found equally in all races and in both men and women. Schatzki rings that cause symptoms usually occur in middle age individuals. The ring can cause intermittent problems swallowing food or food impaction where the esophagus enters the stomach.

The esophagus passes a gap in the diaphragm called the diaphragmatic hiatus in order to reach the stomach. Hiatal hernia (also called hiatus hernia) is a condition that occurs when a portion of the stomach pushes up through this gap next to the esophagus. Although a hiatus hernia is not a direct structural abnormality of the esophagus, it is associated with gastroesophageal reflux disease (GERD) or heartburn in which the acidic stomach contents backflow into the lower part of the esophagus and erode the cell lining. Hiatal hernia is very common and often causes no symptoms. It is treated as a separate entry.

Lacerations, tears and ruptures of the esophagus, known as Mallory-Weiss syndrome and Boerhaave syndrome, are life-threatening disorders. Mallory-Weiss syndrome usually occurs in alcoholics. In both conditions, tears result from vomiting and retching. The resulting bleeding creates a medical emergency that can be fatal.

Motility abnormalities

Motility abnormalities create difficulty in swallowing, called dysphagia. Dysphagia is a symptom of several esophageal motility disorders as well as several obstructive disorders such as esophageal webs or Schatzki ring.

Achalasia is an esophageal motility disorder caused by uncoordinated contractions of the two muscular layers that make up the esophagus. Because muscular contractions are disorganized, peristalsis and the orderly movement of food down the esophagus does not occur. In addition, with achalasia the lower esophageal sphincter remains contracted when food is present in the esophagus which prevents the food from entering the stomach. This causes the esophagus to bulge above the LES, a condition called megaesophagus.

Achalasia is caused by destruction of some of the nerve cells that control muscular contraction of the esophagus. This disorder generally begins in young adults and becomes progressively worse as the individual ages. Individuals with achalasia also have a higher risk of developing esophageal cancer at an earlier than usual age.

Individuals can also develop esophageal motility disorders secondary to other muscle diseases. Scleroderma is a disorder in which smooth muscle begins to atrophy. The smooth muscle in the esophagus can be affected just like other smooth muscle in the body, making swallowing difficult. Scleroderma esophagus is also associated with GERD and increased risk of cancer of the esophagus. Other conditions such as diabetes mellitus, alcoholism, and some psychiatric disorders can also produce secondary esophageal motility disorders.

Inflammatory disorders

Inflammatory esophageal disorders fall under the general name of esophagitis. Esophagitis causes the esophagus to become swollen and the lining of the esophagus becomes eroded and sore. It is present in about 5% of the population in the United States. There are four main types of esophagitis: reflux, infection, corrosive, and radiation. Reflux esophagitis is caused by GERD when the lower esophageal sphincter does not close tightly and the acidic contents of the stomach enter esophagus. GERD is common and is treated in depth in a separate entry. Infectious esophagitis can be caused fungal, viral, or bacterial infections. Infectious esophagitis occurs frequently in individuals with compromised immune systems, such as those with AIDS or leukemia. Corrosive esophagitis occurs when an individual either intentionally or accidentally swallows harsh chemicals such as lye. Radiation esophagitis is a complication of radiation treatments for cancer of the esophagus or lung.

Malignancies

Barrett's esophagus is a pre-cancerous condition which has a high risk of developing into esophageal cancer. It is found most commonly in white males in their 50s and 60s and is usually associated with years of chronic GERD.

Cancers of the esophagus tend to be aggressive and have poor outcomes. Adenocarcinoma is the primary cancer of the esophagus. Esophageal cancers are treated in detail in a separate entry.




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