Esophagus Anatomy and Constrictions Quiz

Esophageal Anatomy and Constrictions

• Cricopharynx is located approximately 25 cm from the upper incisor.
• Left bronchus constriction occurs at 25 cm from the upper incisor.
• Esophagus also constricts at 25 cm due to the Arch of Aorta.
• Diaphragm constriction of the esophagus is found at 40 cm from the upper incisor.

Achalasia Overview

• Achalasia results from the lower esophageal sphincter's inability to relax.
• Most prevalent in males aged 30-60 years.
• Significant risk factors include Chagas disease and Allgrove syndrome.
• Primarily affects individuals aged 30-60 years.

Pathophysiology of Achalasia

• Decreased peristalsis and sphincter relaxation stem from impaired parasympathetic function.
• Distal parasympathetic nerves diminish, leading to ineffective peristalsis.
• Absence of nerves in the lower esophageal sphincter results in failure to relax.

Esophagitis and Complications

• Stagnant esophagitis can occur due to Achalasia.
• Potential complications include squamous cell carcinoma due to stagnant esophagitis.
• Zenker's diverticuli may develop as a complication of Achalasia.
• Aspiration pneumonitis is a potential respiratory complication.

Clinical Presentation and Diagnosis

• Late findings of Achalasia include mega-esophagus and a sigmoid appearance of the esophagus.
• Classic triad of symptoms: dysphagia, regurgitation, and significant weight loss.
• Eckhardt's score assesses severity based on dysphagia, regurgitation, weight loss, and retrosternal pain.
• Most common motility disorder of the esophagus is Achalasia.

Differential Diagnosis and Investigations

• Pseudo-achalasia can mimic symptoms of Achalasia in esophageal cancer patients.
• Initial investigation for Achalasia is upper GI endoscopy.
• Upper GI endoscopy helps detect distal narrowing and rules out malignancy.
• Diagnosis confirmation is achieved through esophageal manometry.

Achalasia and the Chicago Classification

• Achalasia types characterized by elevated Integrated Relaxation Pressure (IRP) at Lower Esophageal Sphincter (LES) across all forms.

Type 1 Achalasia

• Defined by complete absence of peristalsis with 100% failure of contractions.

Type 2 Achalasia

• Notable for complete lack of peristalsis with "Pan-Esophageal Pressurization" in more than 20% of swallows.

Type 3 Achalasia

• Characterized by complete lack of peristalsis and spasms or contractions present in over 20% of swallows.

Radiological Features of Achalasia

• Bird Beak Appearance is a signature characteristic of Achalasia observed through imaging.

Zenker's Diverticulum

• Also known as Pharyngeal Pouch.
• Considered a false (mucosal) pulsion diverticulum arising from the inferior constrictor muscle.
• Forms through a weak area called Killian's Dehiscence.

Symptoms and Diagnosis of Zenker's Diverticulum

• Symptoms include food regurgitation when lying down, halitosis, and risk of aspiration.
• Diagnosed through barium swallow or CT with oral contrast.

Treatment Options for Zenker's Diverticulum

• Options include endoscopic diverticulopexy or stapled diverticulopexy; previously diverticulectomy combined with cricopharyngeal myotomy was used.

Medical Management of Achalasia

• Treated with calcium channel blockers or nitrates to relax the LES.

Minimally Invasive Procedures for Achalasia

• Botox injections or endoscopic dilation are commonly employed.
• Preferred treatment is Heller's cardiomyotomy, where muscle is cut over a length of 6 to 7 cm while preserving the mucosa.

Type III Achalasia Treatment Approach

• POEM (Per Oral Endoscopic Myotomy) is the preferred approach for managing Type III Achalasia.

Nutcracker Esophagus

• Characterized by high amplitude contractions occurring with pain during swallowing.

Corkscrew Esophagus

• Another term for Diffuse Esophageal Spasm, characterized by irregular contractions.

Reflux Prevention Mechanisms

• Diaphragmatic crura, phrenico-esophageal ligament, lower esophageal sphincter tone, and the Angle of His support the lower esophagus against reflux.
• The Angle of His is the angle formed between the esophagus and stomach, preventing backward flow of contents, thereby protecting against acid reflux.
• The intra-abdominal segment of the esophagus maintains low pressure during digestion, crucial for effective reflux prevention.

Role of Ligaments and Sphincters

• The phrenico-esophageal ligament stabilizes the esophagus within the diaphragm, enhancing lower esophageal sphincter tone, and helps prevent hiatus hernia formation.
• The tone of the lower esophageal sphincter is critical in preventing reflux, while the upper esophageal sphincter, diaphragmatic crura, and phrenico-esophageal ligament tones also contribute.

Reflux Consequences

• Reflux can lead to columnar metaplasia, which is associated with Barrett's esophagus, increasing the risk of adenocarcinoma.
• Repeated esophagitis may result in shortening of the esophagus, potentially leading to a Type I hiatus hernia.

Symptoms and Diagnosis

• Heartburn typically manifests as burning pain located retrosternally.
• Epigastric pain is a common additional indicator of stomach discomfort.
• Volume reflux or regurgitation usually suggests more severe reflux issues.

Investigative Procedures

• The first-line investigation for reflux is upper GI endoscopy, while 24-hour pH monitoring serves as the gold standard for atypical reflux symptoms.
• The Los Angeles classification system evaluates the severity of gastroesophageal reflux disease (GERD).
• The Demeester score above 14.7 indicates a strong correlation between symptoms and pH drops.

Treatment Approaches

• Primary treatment for reflux involves medical management with Proton Pump Inhibitors (PPIs), typically prescribed for a duration of 2 to 8 weeks.
• Further intervention may be necessary if reflux persists despite medication or if severe symptoms, such as regurgitation, occur.
• Anti-reflux surgery may be indicated if complications, such as Barrett's esophagus, develop or if persistent symptoms are present.