Problems in Ingestion MEDIUM

• The esophagus is a mucus-lined, muscular tube that transports food from the mouth to the stomach.
• It starts at the base of the pharynx and ends about 4 cm below the diaphragm.
• The upper esophageal sphincter (hypopharyngeal sphincter) is at the pharynx-esophagus junction.
• The lower esophageal sphincter (gastroesophageal or cardiac sphincter) is at the esophagus-stomach junction.
• An incompetent lower esophageal sphincter causes gastric content reflux.
• Esophageal surgery is difficult because the esophagus lacks a serosal layer.
• Esophageal disorders include motility issues, hernias, diverticula, perforations, foreign bodies, burns, GERD, Barrett's esophagus, tumors, and carcinoma.
• Dysphagia is a common symptom, ranging from food sticking to painful swallowing (odynophagia).

Achalasia

• Achalasia involves absent or ineffective peristalsis in the distal esophagus with failure of the esophageal sphincter to relax.
• It leads to narrowing above the stomach and dilation of the upper esophagus.
• It is rare, progresses slowly, and commonly affects individuals in their 20s-40s and 60s-70s.
• The main symptom is dysphagia, mainly with solid foods.
• Patients feel food sticking in the lower esophagus.
• Regurgitation occurs to relieve discomfort from esophageal distention.
• Noncardiac chest pain, epigastric pain, and heartburn may also occur.
• X-ray shows esophageal dilation above the narrowed lower gastroesophageal sphincter. This is called a "bird's beak" deformity.
• Diagnosis involves barium swallow, CT scan, endoscopy, and high-resolution manometry.
• Management includes eating slowly, drinking fluids with meals, and botulinum toxin injections to inhibit smooth muscle contraction, but its effects fade over time.
• Pneumatic dilation stretches the narrowed area. Typically two dilations are required.
• Esophagomyotomy (Heller myotomy) involves cutting the esophageal muscle fibers, often done laparoscopically with or without fundoplication.
• Per-oral endoscopic myotomy (POEM) is a newer alternative technique.

Esophageal Spasm

• Three forms exist: jackhammer esophagus, diffuse esophageal spasm (DES), and type III achalasia
• Jackhammer esophagus involves high-amplitude, long-duration spasms in >20% of swallows.
• DES has normal-amplitude but uncoordinated spasms that move quickly throughout the esophagus.
• Type III achalasia involves lower esophageal sphincter obstruction with spasms.
• All three types cause dysphagia, heartburn, regurgitation, and chest pain (similar to coronary artery spasm).
• Esophageal manometry is the standard diagnostic test.
• Treatment involves smooth muscle relaxants (calcium channel blockers, nitrates) to reduce pressure and contraction amplitude.
• Botulinum toxin may be used for specific frail patients.
• Proton pump inhibitors (PPIs) are indicated, especially if GERD symptoms are present.
• Small, frequent meals and a soft diet reduce esophageal pressure and irritation.
• Heller myotomy or POEM may be tried if conservative therapies fail.

Hiatal Hernia

• The esophageal opening in the diaphragm enlarges, allowing the upper stomach to move into the thorax.
• It is more common in women.
• Sliding (Type I): The upper stomach and gastroesophageal junction displace upward and slide in and out of the thorax, accounting for 90-95% of cases.
• Paraesophageal: Part or all of the stomach pushes through the diaphragm beside the esophagus.
• Type IV paraesophageal hernias involve other abdominal viscera (colon, omentum, small bowel) in the hernia sac.
• Sliding hernias may cause heartburn, regurgitation, and dysphagia; many patients are asymptomatic.
• Large hernias can cause food intolerance, nausea, and vomiting.
• Sliding hernias are often associated with GERD.
• Hemorrhage, obstruction, volvulus, and strangulation are more common with paraesophageal hernias.
• Diagnosis includes x-ray studies, barium swallow, EGD, esophageal manometry, or chest CT scan.
• Management: small, frequent feedings; avoid reclining 1 hour after eating; elevate the head of the bed.
• Surgical repair is indicated for symptomatic patients, primarily to relieve GERD symptoms.
• Laparoscopic approach (Toupet or Nissen fundoplication) is generally recommended.
• Open approaches are reserved for complications.
• Up to 50% of patients experience early postoperative dysphagia; advance diet slowly, manage nausea/vomiting, track nutritional intake, and monitor weight.
• Monitor for postoperative belching, vomiting, gagging, abdominal distention, and epigastric chest pain, which may indicate surgical revision.

Diverticulum

• Esophageal diverticulum - an out-pouching of mucosa and submucosa through a weak part of esophageal musculature
• Pharyngoesophageal (upper), midesophageal (middle), or epiphrenic (lower) areas are all locations where diverticula can occur.
• Zenker diverticulum (ZD) in the pharyngoesophageal area is the most common.
• Caused by a dysfunctional sphincter that fails to open, leading to increased pressure.
• Increase in pressure forces the mucosa and submucosa to herniate through the esophageal musculature (pulsion diverticulum)
• Usually occurs in people older than 60 years of age.
• Midesophageal diverticula are uncommon, less acute, and usually do not require surgery.
• Epiphrenic diverticula are usually larger diverticula in the lower esophagus above the diaphragm.
• They may be related to improper functioning of the lower esophageal sphincter or motor disorders of the esophagus.
• Intramural diverticulosis - occurrence of numerous small diverticula associated with a stricture in the upper esophagus.
• Symptoms of pharyngoesophageal pulsion diverticulum include dysphagia, fullness in the neck, belching, regurgitation of undigested food, and gurgling noises after eating.
• Food or liquid fills the diverticulum/pouch.
• Regurgitation of undigested food and coughing when assuming a recumbent position, due to irritation of the trachea or aspiration.
• Halitosis and a sour taste in the mouth due to decomposition of food retained in the diverticulum.
• Dysphagia is the main symptom in the other types of diverticula, but less acute.
• Barium swallow determines the nature and location of a diverticulum.
• Manometric studies may be performed for patients with epiphrenic diverticula to rule out a motor disorder.
• Esophagoscopy is usually contraindicated due to the danger of perforation of the diverticulum, with resulting mediastinitis.
• Blind insertion of an NG tube should be avoided.
• ZD can be treated by endoscopy (rigid or flexible) or open surgery. Endoscopic septotomy treats ZD effectively, with recurrence rate of 11-30% of cases. POEM may be better, as it is associated with a decreased risk of symptom recurrence.
• During surgery, care is taken to avoid trauma to the common carotid artery and internal jugular veins.
• In addition to a diverticulectomy, a myotomy of the cricopharyngeal muscle is often performed to relieve spasticity of the musculature, which seems to contribute to a continuation of symptoms.
• An NG tube can be inserted at the time of surgery
• Postoperatively, observe the incision for leakage from the esophagus and a developing fistula.
• Withhold food and fluids until x-ray studies show no leakage at the surgical site. Begin with liquid diet and progress as tolerated.
• Surgery is indicated for epiphrenic and midesophageal diverticula only if the symptoms are troublesome and becoming worse.
• Treatment includes a diverticulectomy and long myotomy.
• Intramural diverticula usually regress after the esophageal stricture is dilated.

Gastroesophageal Reflux Disease (GERD)

• GERD is a disorder where gastric or duodenal contents backflow into the esophagus, causing symptoms and/or mucosal injury.
• Reflux can occur due to an incompetent lower esophageal sphincter, pyloric stenosis, hiatal hernia, or a motility disorder.
• GERD incidence increases with aging and is seen in patients with irritable bowel syndrome and obstructive airway disorder exacerbations (e.g., asthma, COPD, cystic fibrosis), peptic ulcer disease, and angina.
• Associated with tobacco use, coffee drinking, alcohol consumption, and gastric infection with Helicobacter pylori.
• Pyrosis (heartburn, a burning sensation in the esophagus), and regurgitation are the hallmark symptoms.
• Patients may experience dyspepsia (indigestion), dysphagia or odynophagia, hypersalivation, and esophagitis.
• GERD can cause dental erosion, ulcerations in the pharynx and esophagus, laryngeal damage, esophageal strictures, adenocarcinoma, and pulmonary complications.
• Diagnosis involves patient history, ambulatory pH monitoring (the gold standard), or a PPI trial.
• Ambulatory pH monitoring involves transnasal catheter placement or endoscopic wireless capsule placement for about 24 hours.
• Endoscopy or barium swallow assesses esophageal mucosa damage and rules out strictures and hernias.
• Management begins with educating the patient to avoid situations that decrease lower esophageal sphincter pressure or cause esophageal irritation.
• Lifestyle modifications include: tobacco cessation, limiting alcohol, weight loss, elevating the head of the bed, avoiding eating before bed, and altering the diet.
• Surgical management involves an open or laparoscopic Nissen fundoplication, where a portion of the gastric fundus is wrapped around the sphincter area of the esophagus.

Overview of the esophagus, a muscular tube connecting the mouth to the stomach. Discusses sphincters, surgical considerations, and various disorders including motility issues and achalasia. Common symptom is dysphagia.